# Presentation: 169141

## Communications

## A Brief Situation Analysis

- Confirmed case will be an international health emergency.
- Will also overwhelm all levels of government in the country where it happens.

**Notes:**
A confirmed case of smallpox will be an international health emergency, regardless of where it happens.
-AND-
A confirmed case of smallpox will become an emergency at all levels of government.

## What Can You Expect?At the Higher Level

- Immediate and intense concern.
- Community will be focus of worry.
- Community and national health agency will be flooded with media.
- Flooded area hospitals and health departments.
- Reactions, responses, messages, and actions rapidly will come from everywhere.

**Notes:**
A confirmed case of smallpox will generate immediate, intense, and sustained concern.  There will be a demand for information from everywhere around the globe.  The community in which the first case takes place will rapidly experience a tremendous amount of media interest and coverage.  The medial will flock to the first community, as well as the national health agency.  The public will likely flood area hospitals and health departments.

Reactions, responses, messages, and action will come from everywhere, quite quickly.

## Press and media are everywhere.
Inaccurate news stories.
Politician statements are inconsistent or contradictory.
Government and public health responses are being severely criticized.

- Inaccurate news stories.
- Politician statements are inconsistent or contradictory.
- Government and public health responses are being severely criticized.

**What Can You Expect?****At the Local Level**

**Notes:**
What can a local area expect if a case is diagnosed?
The press and media will be everywhere, trying to follow the response teams in their activities.  Every vaccination site will be surrounded by cameras.  Satellite dishes will be set up everywhere.
Numerous TV and cable news stories will be broadcast and many of these will be inaccurate.
The public statements of politicians at all levels will be inconsistent and contradictory.
The government and its public health response will be severely criticized.

## Communication Reality

-    Demand for information will quickly exceed  capacity.

**Notes:**
Should there be a confirmed case of smallpox, the demand for information will quickly exceed any one organization’s capacity and systems for supplying it.  This will be true whether we’re talking about handling media calls, assisting healthcare providers, responding to public inquiries, or providing spokespeople.

## The General Approach

- Start in planning and preparation phases.
- Develop—and test—now.
- Identify and train spokespeople now.
- Risk and crisis communication.
- Develop contacts and connections before a crisis.

**Notes:**
In order to be effective at communicating during a crisis, communications experts should be brought into the planning and preparation phases so that they’re familiar with the approach to be taken.  They will need to develop and test their plans and materials before a crisis occurs.  They’ll need to identify and train spokespeople now who are well-versed in the questions they can expect to receive.  They should incorporate the principles of risk and crisis communication.  And they should make contacts and connections with the media now so that they can learn and collaborate before a crisis hits.

This is not only effective in preparing for a smallpox case, but will also improve communications around other health issues.

## Communication Objectives Overall

- Maintain public confidence in public health system.
- Minimize public panic and fears.
- Rapidly provide accurate, consistent, and comprehensive information.
- Address rumors, misperceptions, and inaccuracies.

**Notes:**
Instill and maintain public confidence in the nation’s public health system – and its ability to respond to and manage a smallpox outbreak – by providing accurate, rapid, and sufficient information.
Minimize, as much as possible, public panic and fears related to smallpox.
Rapidly provide the public, healthcare providers, policy makers, and the media access to accurate, consistent, and comprehensive information.
Address, as quickly as possible, rumors, misperceptions, and inaccuracies.

## National Guidance

- Help lower levels prepare.
- Educate Key Players:
- Public
- Health Care Professionals
- Policy Makers
- Media
- Topics for Training:
- Smallpox disease
- Smallpox Immunization Issues
- Containment Strategies

**Notes:**
National health agencies should assist their counterparts at the different levels of government in preparing for their communications needs.

They should help their partners effectively educate the public, health care professionals, policy makers, partners, and media about smallpox disease, smallpox immunization issues (including vaccine safety), and the health strategies that may be used prior to a confirmed case or outbreak (such as, isolation and quarantine).

## 1. Communications is more than writing good sound bites:
Requires resources and effort.
Involve communications experts in planning early on.

- Requires resources and effort.
- Involve communications experts in planning early on.

**Communication Reality #1**

**Notes:**
Communications requires good writing, but it’s more than being able to “wordsmith” messages or craft short sound bites.

Providing effective communications isn’t as easy as it appears.  It requires resources and effort.  If communications is going to play a central role, communications people need to be involved in discussion and decisions that involve them.

## Communication Preparation

- Create/Update Media and Communication Plans.
- Create/Update websites on the disease and your response.
- Develop education and information materials.
- Develop training courses for healthcare and first responders.
- Develop a communications research plan.

**Notes:**
There are some preparations that can be done beforehand to be ready for smallpox:
Create or update your written smallpox media and communication plans.
Create or update websites with information about smallpox and how public health will respond.
Develop smallpox-related education and information materials.
Develop training courses for healthcare providers and first responders.
Develop a communications research plan to ascertain how your messages would be received.

## Providing media/communication training: 	
Local public health officials.
Spokespeople.
Developing materials for use with the media  and public, including “message boxes” for:
Pre-event / Pre-outbreak.
Isolation and quarantine.
Vaccine benefits and risks.
Handling unconfirmed reports.

- Local public health officials.
- Spokespeople.
- Developing materials for use with the media  and public, including “message boxes” for:
- Pre-event / Pre-outbreak.
- Isolation and quarantine.
- Vaccine benefits and risks.
- Handling unconfirmed reports.

**Communication Preparation**

**Notes:**
Other activities you can undertake to prepare for your communications need include:
Media/Communication training for local public health officials.
Media/Communication training for your designated spokespeople.
Develop materials for the media to use on various smallpox topics.  This should be developed as both pre-and post-event messages.

## Communication Realities #2a and #2b

- 2a.  Intense interest also brings intense scrutiny.
- 2b.  Science will not be all that matters.

**Notes:**
Another reality we must deal with is that, regardless of what we do or don’t do, there will likely be criticism, second guessing and questioning from some, and perhaps many, places.

Science will not be all that matters.  Public opinion and “politics” will play significant roles and can alter your communications plans.

## A Better– and Achievable-- Scenario

- Establish a joint information center.
- Provide the media with information:
- Regular and frequent briefings.
- Websites.
- Access to experts.
- Other tools to match specific needs.
- Develop and share key messages among the agencies and organizations involved in the response.
- Inaccuracies are minor– major messages are consistent.
- Public health response will be criticized.

**Notes:**
So how do we deal with this reality?  Be consistent.
Establish a joint information center for all government agencies immediately after a case is found.
The press and the media will be “all over” the story trying to get their own unique spin on the case.  After the initial shock of the story breaking, this can cause them to turn to people who will critique the response.  Regular and frequent briefings, websites, managed access to experts, and other tools are used to manage their interest and meet their needs.
Key messages should be developed and shared among the agencies and organizations involved in the response.  And these messages are crafted from the perspective of the organization and their audience.
Inaccuracies are a minor thing if the major messages are consistent.
But no matter what you do, the government and its public health response will be criticized.  It’s the nature of media.

## Communication Realities

- Build and utilize a pool of smallpox experts.
- Develop a portfolio of messages and materials.
- Improve existing websites / Prepare an “Emergency Response” Website.
- Expand and prepare communication capacity.
- Expand and prepare local capacity.
- Work with a range of partners on communications coordination and response.
- Develop operational plans for Communications Command Posts and for response teams.

## Critical Issues and Activities

## Effectively and Consistently Addressing Communication Challenges

- Pre-event smallpox vaccination likely to be interpreted as indication of increased threat.
- Difficult to communicate/educate people about pre-event.
- Must avoid:
- a) increasing perceived disease threat.
- b) fostering concerns about vaccine safety.
- Effectively address the benefit-risk concerns.

**Notes:**
Implementing and broadening your pre-event smallpox vaccination recommendations is likely to be interpreted by some (perhaps many) as an indication of increased threat, or a likelihood of a smallpox outbreak or attack.  It may become difficult to communicate and educate people about pre-event immunization priorities.

Public and provider education must avoid increasing perceived disease threat and fostering concerns about the safety of currently recommended vaccines.  Your messages and materials must effectively address the benefit-risk concerns of potential vaccinees.

## Recommended Pre-Event Communication Goals

- Develop needed materials and strategies now.
- Instill and maintain public confidence.
- Provide access to accurate, consistent, and comprehensive information.
- Involve communications people now.

**Notes:**
When forming your communications in the pre-event period, you should minimize communication problems, as much as possible, by developing needed materials and strategies now.

Instill and maintain public confidence in local public health systems – and their ability to respond to and manage a smallpox outbreak – by providing accurate, rapid, and sufficient information.  Rapidly provide the public, health care providers, policy makers, and the media access to accurate, consistent, and comprehensive information.  Involve your communications people now in any discussions and decisions that will require or involve effective communications.  Remember, if communications is expected to be critical to success, communications people must be involved early on.

## Pre-event Communication NeedsLocal Level

- “Local” communication plans that:
- Identify key messages, partners, and message delivery plans.
- Prepare for local media interest.
- Prepare for vaccine adverse reactions or vaccine adverse events.
- “Local” portfolios of communication and education materials, resources, and spokespeople.
- Established communication channels, networks, and information clearance procedures.

**Notes:**
The effort doesn’t end at the national level.  Local public health agencies need to be ready to respond.

Each local public health agency should have a local plan that:
Identifies key messages, partners, and message delivery plans.
Prepares local official and health authorities for the local media interest likely to be generated by smallpox.
Prepare local officials to effectively handle vaccine adverse reactions and vaccine adverse events.

The local agency also should have portfolios of communication and educational materials, resources, and spokespeople who can speak the same messages, but geared towards the audience of the local community.  And the local agency should work out ahead of time how this information will be disseminated, as well as how new messages can be cleared at the local level and coordinated with the national level.

## CDC Efforts to Date include. . .

- Research on smallpox knowledge and beliefs.
- Identifying “likely to be asked” questions.
- Training courses to improve state and local capacity.
- Developing a “portfolio” of messages and materials.

**Notes:**
Like many other countries, the Centers for Disease Control and Prevention in the United States has begun to prepare communications messages.  These efforts include:
Formative research with clinicians and members of the public to identify smallpox-related knowledge, beliefs, and concerns.
Identifying “likely to be asked” questions and then preparing answers and “Q&A” (Question and Answer) documents.
Developing and testing tools that expand and prepare state and local communications capacity and skills.  This includes things such as live training courses, satellite courses, and interactive CD-ROMS.
Developing a “portfolio” of messages and materials for health care providers, prospective vaccinees, and partners. 

## Slide 20

**Notes:**
Here you see the CDC’s first attempt at creating a pre-event message map.  This contains all the points to be emphasized in pre-event communications.

## Harvard Public Opinion Survey

- Nationally representative sample of 3,011 adults.
- Conducted in three waves (May 8 – May 21).
- Margin of error was ~ 2%.
- Survey was third in a series on “Americans’ Response to Biological Terrorism.”
- October 2001.
- November – December 2001.

**Notes:**
The Harvard Public Opinion Survey is a nationally representative sample of 3,011 adults.  This survey was the third in a series on how Americans have been responding to biological terrorism.  Previous surveys were done following the anthrax attacks in the eastern United States in the fall of 2001.

## Harvard Survey Interest in Smallpox Vaccination

- “As you may know, a vaccine for smallpox exists, but it may produce serious side effects in a small number of cases.  If such a vaccine were made available to you, would you go get vaccinated as a precaution against a terrorist attack using smallpox, or wouldn’t you get such a vaccination?”
- 	Would get vaccinated			59%
- 	Would not get vaccinated		33%**
- 	Don’t Know				  7%
- ** of these, 81% indicated they would go get vaccinated if there was a smallpox case reported in their community

**Notes:**
One of the questions in this ongoing series is the public’s interest in smallpox vaccination.  The public was asked if the vaccine for smallpox had serious side effects in a small number of cases, would they get the vaccine as a precaution.  Fifty-nine percent indicated that they would.  However, of the 33% that stated they would not get vaccinated, 81% indicated they would do so if a case of smallpox was reported in their community.

## Harvard SurveyOther Results

- 56% believe they have been vaccinated for smallpox.
- About 8% of respondents believe it is likely they or a family member may contract smallpox during the next 12 months (vs. about 70% likelihood of getting the flu).
- 43% are “worried” about the possibility that terrorists may use smallpox in attacks (with 8% “very worried” and 35% “somewhat”).
- 40% believe there is a cure for smallpox.
- 84% are “confident” their physician can recognize the symptoms of smallpox (with 45% being “very” confident) [but only 3% have discussed BT-related issues with their physician].

**Notes:**
These other results from the survey indicate a certain level of concern in the American public regarding future bioterrorism attacks.  These results can help to create pre-event messages to deal with those fears and can also be used to craft messages if a pre-event vaccination policy were instituted.

## Physician and Public Perceptions NIP Study Objectives

- Beliefs about smallpox disease, vaccine, and risks.
- Assess understanding and reactions to:
- a smallpox disease fact sheet.
- a smallpox vaccine fact sheet.
- Beliefs regarding quarantine.
*Identify what people are thinking vs. how many people may hold that belief.*

**Notes:**
In the study conducted by the National Immunization Program at the CDC, researchers hoped to learn what physicians and members of the public believe about smallpox disease; smallpox vaccine; smallpox vaccine benefits and risks; and pre- and post-event immunization strategies.  They also wanted to learn what misperceptions these groups had.

The study also asked participants to indicate their level of understanding and reactions to a smallpox disease fact sheet, as well as a smallpox vaccine fact sheet.  And finally, the researchers hoped to identify physician and public beliefs regarding quarantine.

The ultimate goal was to identify the range, types, and depths of beliefs; that is, what people are thinking versus how many people may hold that belief.

## Qualitative Study Methods

- Philadelphia, Chicago, and San Francisco.
- 17 one-on-one, in-depth physician interviews:
- ID specialists, ER, pediatricians, family/general practitioners (about half male, half female).
- Under 35 and over 35 years old.
- Twenty public focus groups (~8 people/group):
- Caucasian, African, Asian, and Hispanic Americans.
- 10 groups female, 10 groups male.
- Two groups under 35 years of age (mixed ethnicity).

**Notes:**
The research was conducted in Philadelphia, Chicago, and San Francisco.

The physicians were interviewed one-on-one and consisted of infectious disease specialists, emergency room physicians, pediatricians, and family practitioners. These were almost equally divided between male and female, as well as under and over 35 years of age; the time when regular smallpox vaccine was stopped in the United States.

To ascertain public perceptions, twenty focus groups were conducted with various mix of races, gender, and age.

## Smallpox Knowledge/Beliefs Physicians

- Limited knowledge about smallpox disease.
- Many misperceptions.
- Some believed that smallpox still occurred naturally in the developing world.
- Many questions related to disease transmission:
- What is “prolonged exposure”?
- Virulence?  /  Contagiousness?

**Notes:**
Physicians, overall, exhibited a limited knowledge of smallpox disease and had many misperceptions about its natural course and modes of transmission.  There were some physicians who were unaware that smallpox has been eradicated.

## Smallpox Vaccine Knowledge and BeliefsPhysicians

- Little knowledge about smallpox vaccine and  administration.
- Assumed to be effective because smallpox was eradicated.
- Assumed to be as safe as routine childhood vaccines.
- Could effectively screen for contraindications and for severe vaccine adverse reactions.

**Notes:**
Overall, physicians understood very little about smallpox vaccine and its administration.  A few were surprised to learn how it was administered.  They assumed it was effective and as safe as routinely recommended childhood vaccines because the disease had been eradicated.  Physicians believed they could screen well for contraindications.

## Beliefs Regarding Current ACIP RecommendationsPre-attack

- Existing policy was understood.
- General support for limited, pre-attack use.
- Those with higher personal threat perceptions:
- Expand to include “first responders” and/or some physicians.
- More willing to be vaccinated pre-attack.

**Notes:**
In discussing the current US policy of limited, pre-attack use of the smallpox vaccine, physicians were fairly supportive.  However, those who had a higher perception of personal threat were more in favor of expanding the vaccine’s use and were more willing to be personally vaccinated.

## Beliefs Regarding Current ACIP RecommendationsPost-attack

- Little knowledge of ring vaccination, especially among younger physicians (i.e., <40).
- Strategy was counter-intuitive.
- Ring vaccination would be needed or helpful, but not sole strategy.
- Most supported supplementing ring vaccination with rapid, broader access to vaccine.

**Notes:**
When discussing a post-attack response, there was little knowledge of understanding of the concept of ring vaccination.  They felt the strategy was counterintuitive.  They felt that ring vaccination could be helpful, but shouldn’t be the only strategy used in the event of an outbreak.  They supported broader access to vaccination, in addition to the ring vaccination strategy.

## Physician Concerns Ring Vaccination

- “Much has changed since 1960s”:
- Low levels of population immunity.
- Greater numbers of immune-compromised individuals.
- More mobile societies.
- Disease will be artificially introduced.
- Concern that we will be unable to identify all the people who have been potentially exposed.

**Notes:**
Part of the physician’s concern about ring vaccination was that there aren’t the high levels of population immunity today that may have enabled ring vaccination to succeed in the 1960’s.  There are also greater numbers of immunocompromised individuals and our society is more mobile than it was.  And since the disease will be artificially introduced, it may be hard, if not impossible, to identify the index case to make this work.

## Physician ConcernsRing Vaccination

- Anthrax “dated” strategy experience:
- Are current medical/public health assumptions valid?
- How we can be confident old approaches will work today? And in a bio-terrorism attack?
- Public will demand vaccine.
- Mass vaccination more attractive, more feasible.

**Notes:**
The anthrax attacks in the fall of 2001 seem to have engendered skepticism regarding the use of any “dated” strategy.  Can we be sure the current medical and public health assumptions are still valid?  How can we be confident that old approaches will work today? And in a bioterrorism attack?

The public will demand the vaccine.  Trying to limit access to that vaccine will be impractical.  Mass vaccination was considered a more attractive, feasible strategy than using large-scale quarantine.

## Other Key FindingsPhysicians

- Concern about liability issues pre-attack.
- Little support for pre-attack permissive vaccination:
- Rapid access to smallpox vaccine.
- Based on personal beliefs and social concerns, not science.
- An “unfocused” or “random” approach, not a public health strategy.
- Smallpox and bioterrorism are remote compared to the immediate demands of daily practice.

**Notes:**
Of additional note, physicians were very concerned about liability issues; particularly if doing pre-attack public vaccination.  As a result, there was little support for pre-attack permissive vaccination.  Physicians preferred rapid access to smallpox vaccine, post-attack.  They felt that pre-attack permissive use was based on personal beliefs and social concerns, rather than science.  Some noted it was an “unfocused” or “random” approach, and not a public health strategy.

Smallpox and bioterrorism are remote compared to the immediate demands of daily practice.  This could change quickly, if needed, but didn’t need to complicate things, right now.

## Smallpox Knowledge/BeliefsPublic

- Not very knowledgeable about smallpox disease.
- Many misperceptions:
- Much uncertainty about symptoms.
- Exposure nearly always results in death.
- Can be transmitted via casual contact.
- Many also believed that smallpox still occurred naturally in the developing world.

**Notes:**
Overall, the public focus groups were not very knowledgeable about smallpox disease, and there were many misperceptions.  They had a lot of uncertainty about the symptoms of smallpox.  Many believed that exposure nearly always resulted in death.  And they believed that the disease can be transmitted via casual contact.  Many also believed that smallpox still occurred naturally in the developing world.

## Smallpox Vaccine Knowledge and BeliefsPublic

- Little or no knowledge about vaccine and administration.
- Vaccine is safe and provides lifetime protection.
- Children still receive the vaccine.
- Wanted the vaccine if there was an outbreak in the U.S. or in their state.

**Notes:**
When it came to the vaccine itself, most participants had little or no knowledge about smallpox vaccine and its administration.  Many assumed the vaccine was safe and provided lifetime protection.  Some believed that children still received the vaccine.  Most people expressed a desire to receive the vaccine if there was an outbreak in the United States or in their state.

## Smallpox Vaccine Benefits and RisksPublic Beliefs

- Desire to get vaccine strongly related to threat perception.
- Frequency of serious adverse events seen as very small and unlikely to happen to them.
- Fact sheets and pictures of vaccine adverse events had little impact on desire for vaccine:
- Those interested in vaccine still wanted vaccine.
- Those not interested in vaccine expressed reluctance even in the event of an outbreak.

**Notes:**
The pre-attack desire to receive the vaccine was most strongly related to the person’s perceived level of threat.  Most perceived the frequency of serious adverse events as very small and unlikely to happen to them. 

Fact sheets and pictures of vaccine adverse events had little impact on their desire for vaccine.  Those interested in the vaccine still wanted it.  Those not interested in the vaccine still expressed a reluctance, even in the event of an outbreak.

## Vaccine Use Public Beliefs

- Most participants supported very limited, pre-attack use of smallpox vaccine.
- Pre-event permissive vaccination appealed.
- Nearly everyone favored broad (“required”) access in the event of an outbreak.

**Notes:**
When explained to them, the existing policy was understood and accepted.  Most participants generally supported very limited, pre-attack use of the smallpox vaccine.  Pre-event permissive vaccination did have some appeal because it provided a freedom of choice.

Nearly everyone favored broad and “required” vaccination in the event of an outbreak.

## Ring Vaccination Public Beliefs

- When the concept was explained:
- Still hard to understand approach.
- Concerns about equity and social justice.
- Ring vaccination would be insufficient:
- “Vaccination” equates to broad or mass vaccination.
- How could health authorities know who had been exposed?
- Anthrax perceptions engendered skepticism.

**Notes:**
When the concept of ring vaccination was explained, most still had a hard time understanding the approach.  This “selective” vaccination raised concerns about equity and social justice.  They were concerned it could lead to bias among races, cultures and socio-economic levels.  Like the physicians, most felt that ring vaccination would be insufficient in the event of an outbreak.

For the public, “vaccination” means broad or mass vaccination, as occurs with other vaccines.  They wanted to know how health authorities could ever know who had been exposed.  And their perceptions of the handling of the anthrax attacks provoked skepticism that the government could adequately do this.

## Finding #1

*   **The public and physicians do not know much about smallpox-related issues.*
- Implications:
- Education can reduce perceived threat and anxiety.
- Current knowledge levels limit understanding of pre-event and post-event strategies.
- Public health perspectives and scientific views will face strong competition from other views.

**Notes:**
In looking at these results, we can clearly see that neither the public nor physicians know much about smallpox-related issues.  So what can we learn from this?
Education can reduce perceived threat and anxiety, help demystify smallpox, and increase vaccine-related knowledge.
The current knowledge levels of physicians and the public will limit the understanding of pre- and post-event response strategies, including vaccine recommendations.
Public health perspectives and scientific views will face strong competition from other views and should be anticipated when developing communications messages.

## Recommendation #1

- Educate selected disciplines on smallpox.
- Maintain public education efforts:
- Internet.
- Provider Education.
- Local Partnerships.
- Avoid Pitfalls:
- Increasing perceived disease threat.
- Fostering concerns about safety of current vaccines.

**Notes:**
So how will we use this knowledge?
Selected disciplines — such as infectious disease specialists and primary care physicians — need more information, education, and training on smallpox diagnosis, vaccine, and immunization strategies.
Public education efforts need to be maintained.  We can do this by getting information out on the Internet, making sure their healthcare providers can speak knowledgeably about the topic, and using our state/local partnerships to create messages tailored to the specific cultural groups in the area.
Both public and provider education must avoid increasing the perceived disease threat and fostering concerns about the safety of currently recommended vaccines.

## Finding #2

*Assuming adequate vaccine supplies, neither physicians nor the public appear to support reliance on focused vaccination approaches as a primary post-event immunization strategy (e.g., ring vaccination).*
- Implications:
- Considerable resources will need to be spent defending focused vaccination strategies.
- Any highly focused immunization strategy must address social equity and liability issues, and anticipate broad demand for vaccine.

**Notes:**
Assuming adequate vaccine supplies, neither physicians nor the public appear to support reliance on focused vaccination approaches – such as ring vaccination – as a primary post-event immunization strategy.
The implications of this finding are:
Considerable resources will need to be spent defending focused vaccination strategies. 
- and -
Any highly focused immunization strategy must address social equity and liability issues, and anticipate broad demand for vaccine.

## Recommendation #2

- Identify and address the social equity and liability.
- Consider complementing focused vaccination with other strategies (e.g., mass or permissive vaccination).
- Have plans in place for “mass” immunization.

**Notes:**
Current planning efforts need to identify and address the social equity and liability issues associated with ring vaccination or other highly focused immunization strategies. 
Assuming adequate vaccine supplies in the event of an outbreak, consider complementing focused vaccination with other strategies – for example, mass or permissive vaccination.
It would be very helpful to have plans in place for “mass” immunization, including education and communication strategies and materials.

## Finding #3

*Broadening of pre-event smallpox vaccination recommendations is likely to be interpreted as an indication of increased threat or likelihood of smallpox.*
- Implications
- It may be difficult to communicate/educate people about pre-event immunization priorities (e.g., why one group versus another group).
- It may quickly become difficult to limit pre-event access to smallpox vaccine.

**Notes:**
Broadening of pre-event smallpox vaccination recommendations is likely to be interpreted as an indication of increased threat or likelihood of smallpox.
Therefore:
It may be difficult to communicate and educate people about pre-event immunization priorities. For instance, why one group is vaccinated versus another group that is not vaccinated. 
- and -
It may quickly become difficult to limit pre-event access to smallpox vaccine.

## Recommendation #3

- If significant changes are made to the current pre-attack vaccination recommendations, then:
- Address the benefit-and-risk concerns of potential vaccinees.
- Undertake significant physician and public education efforts.

**Notes:**
If significant changes are made to the current pre-attack vaccination recommendations, then:
Be prepared to provide information that effectively addresses the benefit-and-risk concerns of potential vaccinees, such as tangible evidence of increased threat.
- and -
2) Be prepared to undertake significant physician and public education efforts, such as efforts that enable physicians to effectively discuss vaccine benefits and risks with patients.

## SummarySmallpox Knowledge Studies

- Smallpox disease and vaccine knowledge is quite limited.
- Clear recommendation on vaccine use.
- Pre-event use of vaccine will necessitate much provider and potential vaccinee education.
- Pre-event use of vaccine will likely be interpreted as a sign of increased smallpox disease threat.
- Supplement focused vaccination strategies (e.g., ring vaccination) with rapid, broad access to vaccine.

**Notes:**
In summary: 
Smallpox disease and vaccine knowledge is quite limited; and public and practitioner attention may be decreasing.
There are strong preferences for a clear recommendation with respect to vaccine use vs. adopting a “neutral” stance.
Expansion of pre-event use of vaccine will necessitate: 1) much provider and potential vaccinee education, and 2) effectively providing vaccine benefit-and-risk information.
Significant expansion of pre-event use of vaccine will likely be interpreted by many, including health care providers, as a sign of increased smallpox disease threat.
- and, finally -
There is much support for post-event vaccine use strategies that supplement focused vaccination strategies – such as ring vaccination – with rapid, broad access to vaccine.

## Creating Your Pre-Event Communications

## A Brief Situation Analysis

- Smallpox vaccination preparedness programs will affect a wide range of people – from response team members to emergency responders to the general public.
- Most people, including health care professionals, have relatively little knowledge about smallpox and smallpox vaccination.

**Notes:**
Good communications planning begins with a brief situation analysis. In the case of smallpox, smallpox vaccination preparedness programs need to keep in mind they will affect a wide range of people, from response team members to emergency responders to the general public.  And we should also assume that most people, including healthcare professionals, have relatively little knowledge about smallpox and smallpox vaccination.  After all, smallpox and smallpox vaccination have not been things we’ve had to worry about for over 30 years. 

## CDC’s Smallpox Preparedness Communication Goals

- Increase awareness and understanding of smallpox preparedness activities, including vaccine recommendations.
- Help instill and extend public confidence in national, state, and local ability to respond to and manage a smallpox release or outbreak.

**Notes:**
At CDC when we developed our smallpox preparedness communication plans, we began by articulating what our goals were.  We have four primary goals.  The first goal with our smallpox preparedness communication plan is to increase awareness and understanding of smallpox preparedness activities, including the recommendations on who should be vaccinated. Our second goal is to help instill and educate the public -- or help instill and extend public confidence in national, state, and local ability to respond to and effectively manage a smallpox release or outbreak. 

## CDC’s Smallpox Preparedness Communication Goals

- Provide accurate, consistent, timely, and comprehensive information and resources.
- Assist state, local, and health care professional communication efforts.

**Notes:**
The third communication goal is to provide accurate, consistent, timely, and comprehensive information and resources.  We have learned that there are many audiences and these audiences need to have a wide range of materials.  Our fourth goal is to assist state, local, and health care professional communication efforts. 

## Developing Effective Smallpox Preparedness Communication Plans

**Notes:**
In terms of developing effective state smallpox preparedness communication plans, there are a number of steps and a number of things that need to be kept in mind.  I want to walk through a few of them right now.

## I.  What should you assume?

- When developing smallpox communications plans...

## Smallpox Communication Plans Should Assume. . .  

- 1. Most people, including health care providers, need more information about the disease, vaccine, and vaccination.

**Notes:**
At CDC we're making a number of assumptions that help us in our strategies and planning. The first assumption we’re making is that most people, including health care providers, need more information about smallpox disease, smallpox vaccine, and smallpox vaccination.  Again, you need to keep in mind that, for many people, these have not been topics that have been recently discussed. 

## 2. Smallpox vaccinations will generate interest and requests for information from many people, including the public, the media, and families of those affected. 

**Smallpox Communication Plans ****Should Assume. . .  **

**Notes:**
A second assumption that we're making here at CDC, and we recommend that others make, is that smallpox vaccinations will generate interests and requests for information from many people.  This includes the public, the media, and the families of those affected.  There will be a lot of people interested in what smallpox is, a lot of people interested in the specifics of smallpox vaccination, and we need to be prepared to answer and respond to requests from a lot of different sources. 

## Many systems will be needed to distribute messages, updates, and information (including partnerships and networks).

**Smallpox Communication Plans ****Should Assume. . .  **

**Notes:**
A third assumption we should make in developing communication plans is that we're going to need many systems to distribute our messages, to provide updates, and to provide information to a wide range of people.  One of the things that will probably be invaluable in this effort is developing partnerships and networks that can help get messages, updates, and materials to the intended target audiences. 

## 4.	The first serious adverse vaccine reaction, claimed or real, will generate much local and national media attention and public interest.

**Smallpox Communication Plans ****Should Assume. . .  **

**Notes:**
A fourth assumption that communication planners should make is that the first serious adverse reactions – whether they are claimed or real – will generate much local and national media attention and public interest.  People are going to want to know the specifics about what happened, why the person may have had the adverse reaction, and what is being done as a result of this report. 

## II.  Recognize and Prepare

- Smallpox communication realities

## Smallpox Communication Realities

- You need to anticipate the questions and concerns that different audiences will have regarding your smallpox preparedness efforts.
- The more messages, materials, and resources that are prepared and ready – before vaccinations begin or before a confirmed case of smallpox – the better.

**Notes:**
There are a number of things that we need to keep in mind about smallpox communications, but the ones I want to list here are probably the most important.  First, it is very helpful if you anticipate the questions and concerns that different audiences will have regarding your smallpox preparedness efforts.  One of the things we recommend doing is listing your specific target audiences. For each of the audiences, try to write down the kinds of questions, the kinds of interests, and kinds of concerns that those audiences may have. Then, try to formulate answers to those questions right now.  The second thing that people need to be prepared for is that it's helpful to have more messages, more materials, and more resources prepared in advance and ready before a smallpox vaccination begins or before there is a confirmed case or outbreak.  The more messages, materials, and resources that you have prepared in advance, the better you will be able to manage the communications needs.

## 3.	Different groups or audiences will have:
Different information questions, needs, and interests.
Different ways of being reached (e.g., sources, media interests, etc.).
Different education, cultural, and occupational backgrounds.

- Different information questions, needs, and interests.
- Different ways of being reached (e.g., sources, media interests, etc.).
- Different education, cultural, and occupational backgrounds.

**Smallpox Communication Realities**

**Notes:**
It's also important to recognize that different groups and audiences will have different information questions, different information needs, and different interests.  And that one brochure, one pamphlet, or one fact sheet is not likely to serve all those different audiences.  Rather, you need to keep in mind that different groups will have different ways of being reached; will have different sources that they rely on for information; will use different media to learn about these recommendations; and, finally, will have different educational, cultural, and occupational backgrounds.  These backgrounds will affect the kinds of things they're interested in and will also affect the kinds of things we need to provide in order to reach their needs. 

## III.  Five key elements

- All smallpox communications plans should address

## Key State Communication Plan Elements

- Identify the primary populations or audiences for your messages and efforts, including:
- People for whom vaccination is now recommended.
- People for whom vaccination is now recommended, but who are contraindicated or not interested.
- People for whom the vaccination recommendation will or may be extended.
- The general public (including the media).

**Notes:**
The first element that your plan needs to address is the target populations or audiences.  You need to start by identifying the primary populations or audiences that you need to reach with your messages and your efforts.  There are at least four audiences that we think are important.  The first audience is the people for whom smallpox vaccination is now recommended.  This group of people is going to have a number of questions and a number of needs relative to communications and education.  A second group is people for whom smallpox vaccination is now recommended, but who are contraindicated or are not interested in receiving smallpox vaccine.  These people are going to want reassurances that they, too, are protected without being vaccinated. A third group is people for whom the vaccination recommendation will or may be extended. There are obviously some people who will be among the first to receive smallpox vaccination and others for whom smallpox vaccination is recommended, but they will not be part of the immediate vaccination efforts.  These people will have questions as to when will they be able to receive smallpox vaccine and why they will have to wait for a few weeks before they can get it.  A fourth group that you need to be prepared for is the general public.  And this includes the media.  You need to be thinking about the kinds of messages that you want to disseminate and provide to members of the general public about your program and about these recommendations. 

## Develop your primary communication messages:
Overall.
For each identified population or audience.

- Overall.
- For each identified population or audience.

**Key State Communication Plan Elements**

**Notes:**
The second important thing to do in terms of developing a communications plan is to articulate or develop your primary communications messages.  And you need to do this on two levels.  First, what are your overall communications messages?  What do you want to say to everybody?  After you've articulated or identified those messages, the next thing you need to do is identify the primary messages for each of your identified populations or audiences.  At CDC, we have a number of primary messages regarding smallpox vaccination.  I want to touch upon five of them. 

## CDC’s Primary Messages

- “The probability of an intentional release of the smallpox virus is low, but since the consequences of an outbreak would be great, we must be prepared.”

**Notes:**
One of our first messages is in regards to the likelihood of a smallpox release or outbreak.  And at CDC, our primary message is that the probability of an intentional release of smallpox virus is low, but since the consequences would be great, we must be prepared. 

## “Our recommendations strengthen national and state preparedness by making licensed vaccine available to those people who would be called upon to respond to a smallpox release or outbreak.”

**CDC’s Primary Messages**

**Notes:**
Our second primary message speaks to the need for these recommendations and the purpose of these recommendations. These recommendations strengthen national and state preparedness by making licensed vaccine available to those people who would be called upon to respond to a smallpox release or outbreak.

## “Smallpox vaccination before a confirmed smallpox case or outbreak provides response teams and other first responders personal protection from smallpox disease.”

**CDC’s Primary Messages**

**Notes:**
Our third primary message speaks to why it's important that these people receive smallpox vaccination. And the message there is that smallpox vaccination before a confirmed smallpox case or outbreak provides response team members and other first responders personal protection from smallpox disease. 

## “It thus enables them to rapidly take the actions necessary to protect the public, which includes identifying people who need to be vaccinated to control the outbreak as well as establishing public vaccination clinics.”

**CDC’s Primary Messages**

**Notes:**
Thanks to this personal protection from smallpox disease, it enables them to rapidly take the actions necessary to protect the public, which includes identifying people who need to be vaccinated to control the outbreak as well as establishing public vaccination clinics.  In other words, by vaccinating the people who would first be called upon to respond to a smallpox outbreak, we are strengthening our ability to quickly and effectively respond and in doing so, we are protecting the public.

## “By protecting those people who would be initially called upon to respond:
We further strengthen our ability to protect the public;
We increase the capacity and capabilities of the public health system and the nation’s hospitals to respond to, and control, a smallpox outbreak.”

- We further strengthen our ability to protect the public;
- We increase the capacity and capabilities of the public health system and the nation’s hospitals to respond to, and control, a smallpox outbreak.”

**CDC’s Primary Messages**

**Notes:**
In terms of summarizing the CDC's primary messages, this fifth message serves as “the bottom line” – by protecting those people who would initially be called upon to respond, we, one, further strengthen our ability to protect the public and, two, increase the capacity and capabilities of the public health system and the nation's hospitals to respond to and control a smallpox outbreak. 

## Get prepared to communicate about vaccine reactions, risks, and adverse events NOW.
Establish your systems and methods for getting messages, information, and materials to your identified populations and audiences.

- Establish your systems and methods for getting messages, information, and materials to your identified populations and audiences.

**Key State Communication Plan Elements**

**Notes:**
The third part of effective communication plans is to get prepared now to communicate about vaccine reactions, vaccine risks, and adverse events.  We have learned there's much interest among people when it comes to immunization, such as the kinds of reactions that are typical and the risks associated with immunization and vaccine adverse events — including how to recognize them, how to respond to them, and who to call if a person thinks that they may be experiencing an adverse event.  You need to have all that information ready to go right now in order to effectively communicate to people when they want that information.  In addition, you need to establish your systems and methods for getting messages, information, and materials to your intended populations today.

## Establish protocols for meeting the frequent, perhaps daily, information requests from the media and public (e.g., updates, status reports, number of people vaccinated, etc.) to protect your response staff from having to deal with them.

COMMUNICATIONS ACTIVITIES SHOULD NOT INTERFERE WITH RESPONSE ACTIVITIES

- COMMUNICATIONS ACTIVITIES SHOULD NOT INTERFERE WITH RESPONSE ACTIVITIES

**Key State Communication Plan Elements**

**Notes:**
Finally, can you also expect there's going to be a lot of interest and demand from the media, the public, and policymakers for information and it's important that you establish the protocols for meeting those demands so that your response staff can continue to do their work. You should assume there will be frequent, perhaps daily, information requests from the media and the public.  They will want updates and status reports.  They'll be interested in the number of people who are eligible to be vaccinated, the number of people you have vaccinated, and the number of people who have suffered reactions to the vaccine.  You need to have systems in place to get that kind of information on a regular and frequent basis and also have systems in place so that the media and members of the public know where to get that information.

## IV.  Use developed resources

- CDC smallpox-related resources that can be tailored for your use

## Currently Available Web Resources

- Main Website:  www.cdc.gov/smallpox
- Smallpox Basics Index in Spanish: www.bt.cdc.gov/agent/smallpox/basics/ espanol/index.asp
- Smallpox Resource Kit for Health Professionals:  www.bt.cdc.gov/agent/smallpox/ reference/resource-kit.asp

**Notes:**
At CDC, we have been working to develop a wide range of materials and our portfolio materials can be found on our main CDC website.  We have a specific address for smallpox resources:  www.cdc.gov/smallpox.  On the CDC website, you will also find a large number of materials available in Spanish.  We have also developed a smallpox resource kit for health professionals.  This resource kit contains a wide range of materials, including educational materials for perspective patients about smallpox and smallpox immunization. 

## Available CDC Materials for the Public

- Fact Sheets, including:
*Smallpox Overview*
*Vaccine Overview*
*Who Should NOT Receive the Smallpox Vaccine? *
*Reactions after Smallpox Vaccination*
*Information on Live Virus Vaccines and Vaccinia*
- Frequently Asked Questions & Answers.

**Notes:**
In terms of materials that are available for the public, the CDC is working to develop a portfolio of fact sheets.  We currently have fact sheets on smallpox disease, on smallpox vaccine, on who should not receive the smallpox vaccine, and on the reactions after smallpox vaccination.  We have information on live virus vaccines and vaccinia.  We have a list of frequently asked questions and answers.  These materials are not only available in English, but also are available in Spanish. 

## Available CDC Materials for Clinicians and Health Care Providers

- In-Depth Resources:
*Smallpox Response Plan & Guidelines, *including* *the* Smallpox Vaccination Clinic Guide*
- Medical Management of Smallpox (Vaccinia) Vaccine Adverse Reactions
- Smallpox: What Every Clinician Should Know Online Training (and CD-ROM)
- Images (including smallpox disease and reactions to smallpox vaccination).

**Notes:**
The CDC website also houses a wide range of materials for clinicians and healthcare providers.  The materials range from in depth resources to, again, one-page or two-page fact sheets. In terms of in-depth resources, people can find the Smallpox Response Plan Guidelines, which includes the Smallpox Vaccination Clinic Guide on the CDC website. We also have information on medical management of smallpox and vaccinia vaccine adverse events. In addition, we have a CD-ROM that is available, included on the website under the training section as What Every Clinician Should Know, about smallpox and smallpox immunization. You can also find an image library.  There are images on the CDC website that show what smallpox looks like as a disease, as well as reactions to smallpox vaccination, including vaccine adverse reactions. 

## Fact Sheets, including:
Adverse Reactions Following Smallpox Vaccination
Smallpox Vaccine Information Statement
Training tools and materials:
Webcasts.
Slide presentations (on the CDC website).
Smallpox vaccination and adverse events training module.
Telephone information service (i.e., “hotline”).

*Adverse Reactions Following Smallpox Vaccination*
*Smallpox Vaccine Information Statement*
- Training tools and materials:
- Webcasts.
- Slide presentations (on the CDC website).
- Smallpox vaccination and adverse events training module.
- Telephone information service (i.e., “hotline”).

**Available CDC Materials for Clinicians and Health Care Providers**

**Notes:**
We have fact sheets on adverse reactions following smallpox and we have fact sheets on smallpox vaccine. We also have the vaccine information statement for smallpox available on the CDC website. In addition, we have training tools and materials.  These include webcasts, slide presentations, and smallpox vaccination and adverse events training modules.  Finally, we have telephone information services for both the public and health care professionals. 

## Concluding Advice

- Remember – communication needs will be ongoing (e.g., before, during, and after smallpox vaccinations begin).
- Be prepared to respond to daily information requests from the media, public, and people for whom smallpox vaccination is now recommended.
- Get prepared for immediately and effectively responding to vaccine safety questions and issues.

**Notes:**
In terms of concluding advice, there are three points I would like to leave you with -- first, remember that communication needs will be ongoing.  There will be things that people will be interested in before smallpox vaccinations begin, during the program, and after smallpox vaccinations begin.  Communication needs are something that are going to have to be responded to regularly.  Second, be prepared to respond to daily information requests.  These requests are likely come from the media, the public, and from people for whom smallpox vaccination is now recommended.  And finally, get prepared for immediately and effectively responding to vaccine safety questions and issues. The more prepared you are today, the better prepared you will be should the need arise.