The Importance of Communication Before and During a Public Health Emergency

In a public health emergency, communications are just as important as operations. According to the Centers for Disease Control and Prevention (CDC), “The right message at the right time from the right person can save lives.” Similarly, the wrong message at the wrong time can have disastrous consequences – or worse – what if you cannot get your message heard over the rest of the daily media clutter? Unfortunately, this aspect of public health preparedness does not always receive the level of attention it deserves. Here are important elements to consider in any communications strategy, and examples based on local experience.

Communication is more than just responding to media inquiries and deserves forethought and planning.

The first time you think about how you communicate to your audiences should not be when the crisis hits. If you do not have a written plan, you should at least have a policy as a starting point. The Division of Public Health (DPH) has an overarching communications policy. At the beginning it sets the tone for DPH communications, stating “The intent is to ensure communications are accurate, timely, and consistent…” The policy covers both internal and external communications with the media, as well as stakeholders, clients, customers, and legislators. It defines what information may and may not be released, who has the authority to decide who may speak on behalf of the Division, provides the process for responding to media inquiries, and clearly establishes the authority for who makes the final decision on what information can be released.

DPH is fortunate to have a fully staffed Office of Communications, which consists of a team of seven individuals with clearly defined roles including a lead spokesperson, someone who manages day-to-day media inquiries, and a social medial coordinator. In the event of a public health emergency that necessitates the opening of the State Health Operations Center (SHOC), each of these positions may play a primary or a backup role but are dedicated to the communications function. This means they will not be diverted to other tasks.

Emergency and crisis communications should be a natural extension of your everyday communications activities.

How you say something, what channels and tactics you use to communicate, and what you say (and who you say it to) are all critical elements of a communications strategy. Outside of crisis or intense risk communication periods, as much as possible at DPH we like to do proactive communications regarding a variety of topics ranging from drinking water and food safety, to infectious disease prevention and animal welfare.

We use multiple channels for our communication efforts. Not everything requires issuing a press release. Increasingly, communications are posted to our social media channels as we can see and quantify the amount of reach and interactions our messages are generating. We also have both internal and external newsletters that we publish to share information.

Importantly, know your message and know your audience. Not all of our messages require reaching the general public. When we want to reach health care providers, we may issue a Health Alert/Advisory Notice (HAN), send email communications through various associations such as the American College of Emergency Physicians, or directly through our major primary partners including the Medical Society of Delaware, the Delaware Healthcare Association, or the Delaware Academy of Medicine. A recent example of this was when we sent a HAN to providers to share recommended CDC actions for reporting vaping associated pulmonary illnesses, which is not a required reportable disease. That action resulted in DPH receiving reports of potentially related illnesses.

Our partners are important to helping us spread our messages, both in non-emergency and emergency situations. That is why the DPH Communications Office works to cultivate these relationships in calmer times, as well as relationships with our counterparts at each of the hospital systems in the state. We are also willing to share their messages with our staff and cross-post topics important to them on our social media channels. If you have not established those partner relationships, and don’t have solid interaction and a willingness to assist each other when it’s calm, you may not get much help when you must get a critical message out. Very recently, the benefits of our established relationships with our hospital communications partners became evident when DPH began investigating a potential infectious disease in a patient who presented to one of the hospitals. Within an hour of learning of the incident, two of my counterparts from hospitals involved in the investigation response, were calling me to initiate conversations around media statements and investigation process. DPH closely communicated with them throughout the day including sharing draft statements and responses to multiple follow-up questions by media. DPH also communicated with non-involved hospital spokespersons to advise them of the situation. Ultimately, all communications colleagues expressed gratitude for our open and ongoing dialogue and spirit of collaboration.

While proactive messaging is fun, we do a great deal of risk communication as part of our everyday work. Risk communication may not rise to the level of crisis communication but it is more involved than everyday communication activities. The CDC’s Crisis & Emergency Risk Communications (CERC) guidelines highlight six important steps in risk communications¹:

Be First, Be Right, Be Credible, Express Empathy, Promote Action, and Show Respect.

For us at DPH the first three items go hand-in-hand and really can be summed up like this: The two most important overarching themes in communications strategy – whether it is your standard plan or a risk or crisis communications plan – are trust and accuracy. These are your currency – and are as valuable as gold – with the public, your stakeholders, and the media. It is vital to build a good relationship with the media during calmer periods. For sure, the first contact you have with a media outlet should not be when you need to push out crisis messaging. You should have an ongoing established relationship with reporters and editors. It is important to be responsive to their questions during non-emergency periods so that when you really need them, they trust where the information is coming from, and they also trust that you will answer what questions you can.

During both crisis and non-crisis situations, accuracy is also of paramount importance. It can be easy to get caught up in the sense of urgency some reporters may throw at you when things are moving fast and conditions are changing rapidly. They need it now, now, now. “We need to inform our viewers/readers/listeners as soon as possible,” they say. However, if you share information before it is fully vetted, and have to explain that you were wrong earlier, then how are they or the public going to trust what you say going forward?

Some messages may be appropriate for fluid or emergent situations:

• “This is an evolving situation and we will update you when we have more information.”

• “We have just learned of this situation; let me get some information and get back to you.”

• “I’m not the authority on this subject, so let me see if I can set you up with someone who is in the best position to answer your questions.”

If you fall into the ‘we need it now’ trap, and share either personal health information, HIPPA (Health Insurance Portability and Accountability Act of 1996) protected information, or sensitive security-based information, you not only lose trust with the public, but also with any partners on whose toes you stepped. Always remember that in an emergency, we need people to trust us and do exactly what we ask of them in order to protect their health and their safety. You only get one chance to get it right.

Let me share an example where we worked hard to be first, be right, be credible, express empathy, promote action, and show respect. In 2018, we identified the first case of rabies in a human in decades. As soon as rabies was confirmed, we knew we needed to announce it, and knew that this would generate a significant amount of media interest. Instead of subjecting our leadership to multiple requests for interviews, we organized a media call (Be First). In the room where we hosted the call, we had not only our Public Health Director, but also our Medical Director, State Epidemiologist, partners from the Delaware Department of Agriculture, and even federal partners on the phone. Everyone who had relevant expertise was available to answer questions in one place (Be Credible). After introductions and announcing the purpose of the call, the first statement our Director made was, “First, on behalf of the entire Division of Public Health, let me express my heartfelt sympathy for the victim’s family. Our thoughts are with them during this extremely difficult and emotional time.” (Express empathy)

Our talking points, which were prepared before the call, included letting the media know that the general public was not at risk and human-to-human transmission is very rare, preventive measures that everyone can take, and an honest assessment of what we could tell the media. Said DPH Director Dr. Karyl Rattay,

“Let me tell you what we know about the victim and what we can share. I think it is important for members of the media on this call to know that we as the Public Health agency while protecting the health of the public are also bound to protect this woman’s identity. Failing to do so would be a violation of HIPPA laws. You will always want to know more than we are able to share, because even the deceased have a right to have their medical information protected. The geographic area in which she lived is small enough, that when you continue to add in what seem like innocuous details, would make it easier for someone to identify her.” (Promote Action, Show Respect, and Be Right).

When it comes to risk communications, know that you will have different plans for each situation and you need to consider different audiences. During our rabies response, in addition to notifying the public, we needed to advise the victim’s neighbors to stay away from unfamiliar animals.

Also in 2018, we needed to generate awareness of potential exposure to Tuberculosis (TB) among staff, patients, and visitors to a long-term health care facility in Wilmington. Our communication audiences and tactics were different than those within our rabies response. Our TB risk communications plan included a press release and a media call, as well as letters to current and former patients and staff of the facility, the announcement of testing days, and the opening of a call center. The call center was used both to field questions from the public and also to make outgoing follow up calls to potentially affected individuals to ensure they received the letter that was mailed to them. To get our call center up and running, we needed to identify and train volunteers, and write scripts for the call center operators. A fully detailed procedure for standing up a Call Center is part of DPH’s 89-page communication plan called the Crisis and Risk Communication Annex, which is part of the overall State Health Operations Plan.

The plan outlines roles and responsibilities of each member of the communications team, identifies a variety of resources and communication channels to be used, includes a template for message development and provides examples, ensures we are thinking about audiences with access and functional needs, and identifies procedures for communicating during a power outage.

In the event of an emergency when the SHOC is activated, the Office of Communications Section Chief functions as the lead spokesperson (Public Affairs Officer - PAO) and is embedded in the SHOC with Operations. Other staff are utilized as needed. All public health media inquires are directed to the SHOC and are answered by the PAO or designee. Depending on the scale of the emergency, the PAO may work with the spokesperson for the Delaware Emergency Management Agency to request assistance in setting up a Joint Information Center (JIC). The JIC can be located anywhere there is access to phone lines and computers, and consists of trained spokespeople from other state or county agencies who function and respond on behalf of one central agency, under the coordination and guidance of the PAO.

Whether handling crisis or everyday communications, these are my top recommendations for being successful:

• Develop your three top messages and repeat them often.

• Stay on message. Do not be diverted by off-target questions. Circle back to your top three messages.

• Be expressive – show compassion and empathy.

• Be conversational and avoid jargon and acronyms.

You should be able to scale your communications plan up or down, depending on the nature of the situation. Successful communications are about not only what you say, but how you say it. To make sure your messages are on target, visit the CDC at https://emergency.cdc.gov/cerc/resources/index.asp for additional guidance.