Over the course of its 2-year existence, the SNS Standing Committee frequently discussed SNS communication strategies targeting a range of audiences. This session offered committee members a final opportunity to share their insights on this topic, and for Greg Burel, as DSNS director, to pose questions for the committee’s consideration.
A panel discussion including Burel, Lewis Rubinson, Skip Skivington, and Paul Petersen, and facilitated by Laura Runnels, opened the session. As the panelists reintroduced themselves, each identified his or her position in the public health response supply chain, as shown in Figure 2-1: Burel, directing DSNS, as a “purchaser/assembler;” Rubinson, a hospital medical officer, and Petersen, a state public health officer, as “service personnel;” and Skivington, through his role at managed care consortium Kaiser Permanente, representing “supporting facilities.” The discussion initially focused on the demand end of the supply chain, relative to the SNS.
According to Burel, DSNS has set three main goals for strategic communications: to identify key audiences to receive preparedness information in advance of an emergency and craft appropriate information for each such audience; to enhance outreach efforts so as to raise awareness and understanding of the SNS across the supply chain; and to engage effectively with policy makers whose decisions influence the function of the SNS. Discussion throughout the session focused primarily on the first and most complex of these goals.
Burel asked panelists to help answer these linked questions: Who are the key audiences for advance information—those individuals or groups who need to connect with the SNS when disaster strikes? What does DSNS need to tell them? As reflects the composition of the panel, most of the responses he received addressed communications with health care providers: public health officials, hospital administrators, clinicians, and emergency responders.
Guidance from a Single, Trusted Source
Recalling Sheldon Jacobson’s observation that people tend to value advice and guidance over factual information alone, several participants commented on the source of the information that DSNS seeks to impart. Tara O’Toole noted that CDC is mandated by law to provide guidance on the contents of the stockpile and how to use it, but she questioned whether the federal government is an effective source of such information. “The question, I think, becomes how do we organize, in advance, the clinical community so that it can learn in real time and push that knowledge out, whether it is about how to use Tamiflu during an epidemic under conditions of shortage, [or] whether it is how to use the new biologics that nobody has much clinical experience with?” she observed.
To get there, O’Toole insisted, the various layers of the health care system must create some kind of decision-making or advice-giving mechanism, and it must be explicitly acknowledged that the SNS is not responsible for providing such guidance. In a disaster, she said, health providers are looking for authoritative recommendations and professional advice. She suggested that professional societies take on this role, rather than the federal government.
Rubinson agreed, noting that the SNS’s strength is delivering products to the necessary locations. Providing expertise on the use of each of the stockpile’s assets under a wide range of emergency and patient scenarios is well beyond the agency’s purview. Currently that responsibility defaults to CDC, but their limited, information-based approach does not qualify as guidance for clinicians, he observed. Just as CDC has the Advisory Committee on Immunization Practice (ACIP) (CDC, 2018), established under the Federal Advisory Committee Act (FACA) (GSA, 2018), he proposed an advisory committee on clinical practice to provide guidance during an emergency event.
How effectively clinicians use MCMs in an emergency will depend on the quality and detail of the guidance they receive, Rubinson observed. For example, he asked, how many physicians know that the countermeasure for
anthrax was approved through the Animal Rule,1 and therefore has never been tested on humans? Clinicians will accept that and other “third-rail” realities associated with using SNS assets in emergency response, he said, but these facts need to be communicated.
Karen Remley agreed that ACIP provides an appropriate model for a clinical advisory committee that would enable “important conversations with people who can speak to the science, can speak to the clinical setting, and can speak to the public health and the individual health perspective.” Clinicians need to produce guidance for SNS assets, and to be accountable for its quality, she insisted.
Not only should the source of guidance on the use of SNS assets be trusted, it should be exclusive, several workshop participants noted. Skivington recalled that during the H1N1 epidemic, he received conflicting information regarding contraindications and patient eligibility for the vaccine Kaiser Permanente received—a problem he ascribed to the existence of multiple sources of information, none of them authoritative. Irwin Redlener noted that when crises occur, he is deluged with information from sources including CDC, the New York State and New York City Health Departments, and AAP. Instead, clinicians should be able to access emergency information from an outlet that is “narrow and clear and identified as the final resource,” he stated. General information about the purpose and organization of the SNS could also be filtered through this source, he added.
Albert Romanosky, while supportive of the notion of a single source of SNS information for clinicians, was also skeptical of its potential impact. Noting that CDC’s recent guidelines on the Zika virus have been questioned by both state and local health departments, he predicted that clinicians may eschew emergency guidance from the proposed advisory committee. “If it is contrary to how they operationalize or how they perceive the problem, they are not going to accept it,” he stated.
Redlener said that medical specialty societies can play a role in this process by evaluating emergency measures performed, for example, by pulmonologists, intensive care physicians, or pediatricians. He also emphasized coordination between DSNS and other federal partners, such as ASPR, who also prepare for and respond to disasters. Rubinson, however, warned that some medical professional societies may not move quickly enough to assemble the hoped-for advice, so responsibility for providing it should rest with a FACA-established clinical advisory committee.
1 Also known as the Animal Efficacy Rule, FDA’s Animal Rule governs the development and testing of drugs and biologicals against lethal or permanently disabling CBRN agents in cases where human efficacy trials are not feasible or ethical. See https://www.fda.gov/EmergencyPreparedness/Counterterrorism/MedicalCountermeasures/MCMRegulatoryScience/ucm391604.htm (accessed October 8, 2017).
Rubinson mentioned the National Ebola Training and Education Center (NETEC, 2017) a consortium of Ebola treatment units, as a potential adjunct to medical specialty societies, and also as a model of collaboration among clinicians for crisis response. Skivington predicted that NETEC is poised for, and would be receptive to, such roles.
Lewis Grossman urged that workshop discussion be extended beyond clinicians to include communication with emergency responders who may not have medical training. Rubinson noted that “clinicians” include pharmacists, who play a crucial role in administering MCMs. On the other hand, he continued, the majority of disaster-related medical care—which can extend long beyond a crisis—is provided by hospitals.
Burel, however, acknowledged the need for general public guidance on the use of SNS assets. He noted that for some MCMs, such information already exists, although much of it will not be released until a disaster occurs, so as not to create undue panic. Nevertheless, he continued, DSNS is concerned primarily with improving communications with clinicians, ensuring their confidence in using SNS assets, including novel drugs and biologics.
Designating a “Point Person”
Some health care organizations have identified staff members to receive and respond to communications from the SNS. Skivington, who serves in that role at the national level for Kaiser Permanente, acknowledged that even he does not have a deep understanding of the contents of the SNS. Rather, he expects to learn on a “need-to-know” basis about particular events as they occur, and to distill and quickly disseminate critical information relevant to decision making within his organization.
O’Toole wondered whether health care organizations of a certain size should be required to identify a point of contact for the SNS, and to maintain regular communication about SNS policies and overall operations, as well as about shortages in the medical supply chain. Skivington assented, but within limits: there is, he said, a point of diminishing returns, given the size and complexity of the supply chain within which the SNS exists.
Information for Health Care Providers
Communications from the SNS to health care providers should be tailored for specific audiences and be concise and focused, Rubinson insisted. The SNS is not part of a clinician’s daily toolkit, he noted. Typically, when shortages occur—whether or not they are associated with an emergency—clinicians generally query the private industry operating in the commercial supply chain, not the SNS.
Rubinson noted that clinicians must be aware that the SNS can provide unusual or novel countermeasures, such as CHEMPACKs, which contain antidotes for specific chemical exposures. CHEMPACKs are pre-positioned locally to allow rapid response, but for security reasons, the SNS does not disclose their contents and locations. Unfortunately, this means potential end users of CHEMPACKs are unaware of their availability, and therefore cannot use them effectively. Burel acknowledged the difficult balance between CHEMPACK use and security. “How do we make sure the right people know about those things?” he asked.
Rubinson replied by describing his hospital’s more successful communication with the SNS when obtaining ventilators from the stockpile. DSNS collaborated with several critical care societies, making stockpile devices available for local demonstrations that informed health care providers about what types of ventilators the SNS could provide without disclosing how many units the SNS owned or their locations.
“At times, CDC can overcommunicate,” Petersen observed, from the perspective of state public health. “We have to be able to take all of this information in, distill it, and make sure it is relevant to health care partners that maybe don’t have the time to do that,” he observed. Instead, he suggested CDC (and by association, DSNS) present concise, focused information on the SNS through a single source, to which health care providers know they can turn when the need arises.
Rubinson agreed. For example, he said, it is not efficient for DSNS to tell clinicians how to use a device such as a ventilator; they do, however, need to know which ventilators can or cannot be used for small children, and how to triage ventilation patients in an emergency. Lengthy FDA package inserts for novel countermeasures are useless, he continued; instead, clinicians need essential directions, clearly delivered—such as not to divide antitoxin doses, because neither recipient is likely to survive. “That is the kind of information we need from the stockpile, or else, as clinicians, we are going to get creative,” he warned. “The information we need is to keep us on point.”
Because DSNS cannot—for both practical and security reasons—tell every health care provider all of the information about every MCM the stockpile holds, their goal is to identify the four or five most important pieces of information for clinicians who need to know them, as well as to make available more detailed information (e.g., package inserts, device manuals), Burel stated. He suggested that such information could be made available in advance to “trusted agents” such as medical professionals charged with providing guidance to clinicians in the event of a disaster.
Several participants discussed the potential use of modeling to inform clinicians’ expectations of interactions with the SNS during emergencies and its crucial role in organizing the stockpile. The content of the SNS and the
choice of countermeasures under development are founded on modeling, O’Toole pointed out.
Romanosky suggested that DSNS present models of disaster scenarios in locations around the country to enable local and state public health, as well as health care providers, to anticipate requirements for medical materiel and plan how to meet those needs through the SNS and the commercial supply chain. Burel stated that DSNS bases its inventory requirements for each asset on model data supplied mainly by BARDA, and that much of that information is available to inform decision making by public health and health care institutions. Rubinson also noted that much of those data are open-access, and useful for general planning, but that each emergency presents unique factors that cannot be predicted. Most crises, he noted, continue to affect communities for weeks or months beyond the initial disaster; ongoing assessments of a response throughout the follow-up period can improve response capacity. Operationally engineered models to prepare institutions to distribute or deliver a novel SNS asset to patients would be very useful, Rubinson observed, but they would not qualify as a communication strategy.
In light of the session’s focus on strategic communications for health care providers, Grossman urged DSNS to also consider communications with patients, who today are increasingly active and informed in their health decisions. For instance, should patients—on either ethical or practical grounds—be made aware of the Animal Rule? “Patients are really used to knowing a lot about their medicines now,” he observed. “I think we can’t ignore that.”
Means of Communication
Building on the concept of brief, focused communications to prepare health care providers to interact with the SNS during a crisis, Remley suggested a visual format for these messages. Increasing numbers of clinicians are likely to prefer a novel MCM from a video prepared by a medical professional deemed a “trusted agent” over a one-pager such as those produced by CDC, she said. DSNS should not overlook the opportunities that video and other technology and social media platforms afford for rapid, effective, credible communication, she advised.
Runnels asked participants to distinguish between information that the SNS should routinely provide to clinicians or their representative “point people,” and what they should provide “just in time” to address a crisis. Petersen said his office strives to keep all of its public health partners in Tennessee informed and current on the use of CHEMPACKs, as well as how to request supplies from the SNS. Due to high personnel turnover, this is a continual process, he noted—and a challenge to keep the message fresh
despite repetition. Skivington also said he struggles to reinforce generic information on the SNS among his staff, in part because the stockpile’s mission continues to expand.
Staff education is one of the largest expenses for the University of Maryland health system, but SNS-related training represents an insignificant piece of that very large pie, Rubinson reported; they target information regarding the SNS to those likeliest to use it, such as purchasing staff, rather than clinicians. This is appropriate, he said, given the remote likelihood that any clinician would need to interact with the SNS, even during an emergency.
Just-in-time training as an emergency unfolds should provide responders with information specifically targeted to the event and the SNS assets to be employed, Skivington advised. This is not something that DSNS needs to invent, Rubinson observed; several industries that have mastered just-in-time training could advise the development of a health care model.
Addressing the second of his stated goals for strategic communication by the SNS, Burel said that DSNS’s recent partnership with HIDA would serve as a model for future outreach efforts involving other organizations representing the commercial supply chain, and possibly with professional medical organizations such as AAP, that significantly influence SNS programming. In light of the imminent disbanding of the Standing Committee, Burel announced that he would continue to seek advice on forging partnerships with key contacts within manufacturing, distribution, and medical groups. DSNS realizes that the federal government is not always their most effective lever of influence, he noted; for example, DSNS’s interactions with HIDA reveal the power of working with trade associations to accomplish mutually beneficial goals.
Redlener asserted that the most important line of communication connects the SNS with other operating functions in the federal government also involved in preparing for and responding to disasters. The relationship between the SNS and ASPR is absolutely critical, he said, and while sturdy, must be vigilantly maintained. The next “layer of communications” among SNS priorities should be clinicians, he advised, and he advocated exploration of the involvement of professional medical societies, as noted above, in crafting messages for health care providers.
O’Toole recalled that at a previous meeting, Burel had defined a straightforward message for the U.S. medical community and general public regarding cases of general supply shortage: “The SNS is not the answer.” Rather, O’Toole explained, the SNS serves as a bridge, facilitating the delivery of critical medical supplies to people who need them in emergen-
cies. That analogy, she added, might only ring true in communities actually experiencing disasters, and whose interactions with the SNS will be defined by a specific event such as a hurricane, a bioterrorism attack, or a novel emerging infectious disease.
Burel agreed that the role of the SNS is context-specific. He applied the bridge analogy to emerging infectious diseases; in those cases, the SNS mounts a first response, meanwhile alerting manufacturers of critical MCMs to surge, and distributors to shift deliveries to the affected area.
Skivington offered another analogy for engaging the SNS: breaking the glass, as if to set off a fire alarm. The SNS is less a bridge than a last resort, he argued, as the final option for obtaining MCMs that are stalled in the supply chain. That may be true in some cases, such as after an anthrax attack, O’Toole rejoined, but it does not fit the role of the SNS in providing insecticides to curtail the Zika virus in Puerto Rico. Moreover, she noted, many health care settings lack the “first resort” resources available to Kaiser Permanente when disaster strikes. But Skivington reminded the group that as Kaiser and other hospital chains move toward just-in-time inventories, their emergency response increasingly depends on the commercial supply chain.
Based on discussion throughout the workshop, and given “the vast creeping mission expanse that SNS operates in,” O’Toole recommended a two-pronged communications strategy, encompassing both prepared information and a mechanism for gathering facts on the ground in near real time during an emergency response—and quickly disseminating that information.
Taking a more expansive view of strategic communications, Rubinson encouraged the SNS and its federal partners routinely to engage in conversations involving representatives across the medical supply chain. In an emergency, he said, all relevant stakeholders need to be at the table. For example, manufacturers can tell clinicians coping with a critical shortage whether or not—and how soon—they can surge or shift inventory to make up the shortfall, or if SNS assets are needed.