1. Smallpox Immunization Communications: Approaches and Activities Glen Nowak, PhD Associate Director for Health Communication National Immunization Program

2. Overview Smallpox Immunization and Risk Communication Managing emergency and large-scale health communications (such as smallpox immunization) CDC Smallpox Immunization Resources

3. Smallpox Immunization: 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. The national smallpox vaccination policy will affect these various people in different ways– and at different times. Policy decisions will affect communication effects and effectiveness.

4. Immunization Policy Results in Four Groups of People The “Can’t Get Vaccinated” – people with contraindications and others who we would refuse to vaccinate The “Shouldn’t Get Vaccinated” – those we advise against, but would do if they insist (e.g., military personnel family members and perhaps many members of the public later this year) The “Should Get Vaccinated” – those we advise to get vaccinated, but they don’t have to (i.e., we’re requesting that they do so) The “Must Get Vaccinated” – some military personnel

5. The Communications Environment, I There are three relevant “risks” that must be recognized (and communicated about): – Risks associated with terrible vaccine adverse reactions – The risk of a smallpox attack – The risks associated with not being prepared for a smallpox attack

6. The Communications Environment, II The smallpox vaccination program is grounded in much uncertainty: – Likelihood of an attack – Frequency of adverse events – The best ways to treat adverse events – Liability (and injury compensation) – Hospital and healthcare facility participation – Public reaction and actions

7. The Communications Environment, III The scope of the smallpox vaccination program was– and still is– a difficult decision. It could change if: – The threat of an attack goes up or down – If the assessment of the frequency and severity of vaccine adverse effects goes up or down – If the availability of licensed vaccine goes up or down

8. The Communications Environment, IV A number of factors influence an individual’s vaccination decision: – Primary motivators are relatively intangible and/or emotional (e.g., “service to others,” “self fulfillment,” “role model,” “moral duty”) – Barriers are more tangible, and likely to be more significant in the decision making (e.g., concerns over vaccine adverse events, inadequacy of injury compensation, and pre-vaccination screening) – Impact on family and household members

9. CDC’s Smallpox Vaccine Policy 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; Provide accurate, consistent, timely, and comprehensive information and resources; Assist state, local, and health care professional communication efforts. Foster “informed smallpox vaccine decisions and decision making”

10. Some Important Smallpox Immunization Communication Principles (Sandman 2003) “Risk” = Hazard + Outrage formula Do “anticipatory” guidance Tolerate the uncertainty – and help others tolerate it too. Practice dilemma-sharing Recognize the risk communication “seesaw”

11. “Risk” = Hazard + Outrage Hazard = actual likelihood and seriousness of a risk Outrage = cultural perceptions regarding a risk There is a relatively low correlation between the two (i.e., between how many people are actually harmed by a risk and the number people who get upset– or how badly upset they get); Outrage has a far greater impact on risk perception than does hazard (e.g., when people are upset, they will think the risk is great, even if it isn’t).

12. Factors that Influence “Outrage” include... “Voluntariness” (vs. mandatory) Familiarity (vs. unknown) Chronic (vs. catastrophic) Knowable (vs. unknowable) Fair (vs. unfair) Trustworthy sources (vs. untrustworthy) Responsive process (vs. unresponsive) Sandman (2002)

13. “Risk= Hazard+Outrage” applied to Smallpox Vaccine Smallpox vaccination “outrage” will almost certainly focus on side effects and terrible vaccine reactions; Smallpox attack outrage may also focus on vaccine availability (or lack thereof); Communications need to recognize both: “If the threat of an attack weren’t so awful, we would never have recommended vaccination. If the side effects of the vaccine weren’t so awful, we would recommend even more people get vaccinated.”

14. Do “Anticipatory Guidance” Tell people in advance what to expect– including how they are likely to react (i.e., give people a chance to “rehearse”). Anticipatory guidance must extend to unanticipated events as well– i.e., warn people to “expect the unexpected”

15. Anticipatory Guidance and Smallpox Immunization The prospect of vaccine “adverse events” The prospect of serious or even fatal outcomes from vaccinia virus shedding How bad the ordinary reactions can be The inevitability of novel adverse events (and causality may be difficult or impossible to establish) The risks of facing a smallpox attack without having a trained cadre of vaccinated responders

16. Tolerate Uncertainty Acknowledge the smallpox vaccination program is grounded in uncertainty. – We must allow room for the possibility that we will sometimes be wrong. – “It’s not being wrong that kills you– it’s being wrong after sounding sure.”

17. Practice Dilemma-sharing Dilemma sharing is explicitly claiming that a decision is difficult, and the right answer isn’t obvious. It is acknowledging uncertainty about decisions you face- and asking for help. It builds credibility– because it is usually the truth, and thus has the ring of truth.

18. Risk Communication “Seesaw” When people (e.g., the public) see merit on both sides of an issue, they will emphasize whichever side the communicator fails to emphasize (Sandman). For example, – If you don’t want people to be excessively fearful, don’t be excessively reassuring. – If you take a particular risk very seriously, people will usually be less, rather than more, concerned. – If you want to calm fears, then share and express fears.

19. Key Communication Elements Continue to utilize the smallpox risk communication principles to address the concerns of each audience Develop, distribute, and expand smallpox immunization resources (e.g., depth, breadth, scope, type, languages) Continue to utilize partnerships to identify needs, refine materials, and reach members of affected populations

20. CDC Smallpox Immunization Communication: Management and Resources

21. Emergency Communications Audiences “Content” Channels People directly affected by event People who may be affected Government Agencies Hospitals Journalists Healthcare Providers Health Departments Policymakers General Public Outside Experts Professional Organizations Messages Information Recommendations Guidelines “Answers” Materials and Resources Websites Teleconferences Media MMWR Health Alert Network EPI-X Hotlines Partner Organization E-mail Meetings

22. CDC Emergency Communications Structure CDC Communications Leadership Team Content Team Web Team Communi- cation Monitoring and Research Team Hotline Team Commu- nity Health Education Team Public Health Communi- cations Team Media Team Clinicians Communi- cations Team Federal Govern- mental Communi- cations Team

23. Currently Available Web Resources Main Website: www.cdc.gov/smallpoxwww.cdc.gov/smallpox Smallpox Basics Index in Spanish: http://www.bt.cdc.gov/agent/smallpox/basi cs/espanol/index.asp http://www.bt.cdc.gov/agent/smallpox/basi cs/espanol/index.asp Smallpox Resource Kit for Health Professionals: http://www.bt.cdc.gov/agent/smallpox/refe rence/resource-kit.asp http://www.bt.cdc.gov/agent/smallpox/refe rence/resource-kit.asp

24. 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

25. Available CDC Materials for Clinicians and Health Care Providers Include... 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)

26. CDC Clinician Resources continued... 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)

27. Ongoing and Upcoming Activities Weekly teleconferences with state public health information officers; Public service announcement and additional materials on policy and its purpose; Mailing to clinicians; Media teleconferences and updates, including vaccine safety system, vaccination levels, vaccine adverse events, new or updated recommendations, etc.

28. Questions?