Peter Sandman and Jody Lanard Risk Communication

CDC's new estimate of flu vaccine efficacy: 50-70% in healthy adults... A risk communication comment

 

Brief analysis of a risk communication error:

The CDC reports its newest estimate of influenza vaccine efficacy: 
50-70% in healthy adults under 65

By Jody Lanard M.D. (posted on October 25 2011, 1:30 pm EDT)

On October 12, the U.S. CDC updated its estimate of influenza vaccine effectiveness (written for health care professionals), based on randomized controlled studies published in 2009 and early 2010. 

The most notable datum in the update:

Flu Vaccine Effectiveness: Questions and Answers for Health Professionals (October 12 2011)

>How well do inactivated influenza vaccines work in randomized control trials?

>As noted above, effectiveness varies with vaccine match and the age and immune function of the recipient. In general, the greatest benefits of influenza vaccines have been reported in randomized controlled trials (RCTs) conducted among healthy adults. For example, recent RCTs of inactivated influenza vaccine among adults under 65 years of age have estimated 50-70% vaccine efficacy during seasons in which the vaccines' influenza A components were well matched to circulating influenza A viruses (Beran et al., 2009, 2006-2007 season; Jackson et al., 2010, 2005-2006 season; Monto et al., 2009, 2007-2008 season). As vaccine efficacy from a randomized clinical trial is the gold standard for how well a vaccine actually works, vaccine effectiveness estimates obtained from observational studies can equal, but not exceed, estimates of efficacy.<

This updates the CDC’s previous estimate of 70% to 90% efficacy, based on older studies.

Here's the risk communication error:

The October 12 2011 update does not mention the previous estimate, or highlight that “50-70%” in healthy adults under 65 is a rather dramatic downward change. The update only notes that the estimate is based on “recent RCTs”.

And the CDC did not issue a heads-up to journalists highlighting the new, much lower estimate of efficacy.

As of noon on October 25^th, no medical or other journalists appear to have reported this new information.

One excellent news scan that I follow, from the Center for Infectious Disease Research and Policy (CIDRAP) at the University of Minnesota, reported on the CDC’s new update, in an item entitled “CDC backgrounder helps health providers interpret flu vaccine effectiveness”, without mentioning the updated estimate of flu vaccine efficacy.

On October 13, CDC updated its parallel page for general readers:
Vaccine Effectiveness - How Well Does the Flu Vaccine Work? (October 13, 2011)

The update for general readers does not mention the new estimate at all.

Until February 2011, the update for general readers stated:

"Past studies have shown in years when the vaccine viruses and circulating viruses are well-matched, the vaccine can reduce the chances of getting the flu by 70% to 90% in healthy adults.” (see this version of the page as it appeared in December 2010 on the CDC website.)

On February 25, 2011, CDC eliminated that datum from the update for general readers, and stated:

“CDC is currently reviewing recently published studies on VE to update existing estimates." (see this version of the page, updated on February 25 2011, as it appeared in April 2011 on the CDC website.)

And on October 13 2011, one day after updating the report for health professionals, the CDC updated its flu vaccine effectiveness page for general readers without including any efficacy estimates for healthy adults under 65: not the old “70-90%”; not the new “50-70%.”

Comment:

From my perspective as a risk communication analyst, I hypothesize that the CDC did not want to draw attention to its new lower estimate of flu vaccine efficacy – or to the fact that CDC’s experts have known about the new studies behind the new estimate for almost two years.

My ongoing study of influenza vaccine communication over the years – particularly analysis of annual flu vaccine promotion campaigns every year in both hemispheres – strongly suggests to me that many public health officials, at the U.S. CDC and other national health agencies, routinely convey the impression that influenza vaccine is more effective than it is.

I believe they convey this mis-impression for pro-social, pro-public health reasons – including their fear that if people learned that the flu vaccine is not very effective (compared with most other vaccines in common use), they would be even less inclined to get vaccinated.

But as a risk communication expert, I think they are wrong to do this.

I hypothesize – but cannot prove – that overstating the benefits of any vaccine exacerbates the atmosphere of vaccine skepticism and distrust that so worries those of us (myself included) who strongly support the CDC’s recommended use of vaccines.

For more risk communication analysis related to vaccine communication, see:

Convincing Health Care Workers to Get a Flu Shot – Without the Hype! (January 2009)

And 

Trust the Public with More of the Truth (October 2009)

 

 

 

Haiti Cholera Outbreak:

 

How many Nepalese soldiers would probably have had diarrhea
in their first two weeks in Haiti?

Applying previously-published person-month data regarding 
incidence of diarrhea in travelers and deployed soldiers

         by Jody Lanard M.D.[5]

Originally posted as a Google knol ("a unit of knowledge"), December 15, 2010. Google knols will be discontinued on May 1, 2012.

Summary: The United Nations reports that none of the 454 Nepalese troops deployed to Haiti had diarrhea between their arrival and the start of Haiti's cholera outbreak in October 2010. Published data about the incidence of diarrhea in travelers suggests this is extremely unlikely.

The United Nations reports that none of the 454 Nepalese soldiers deployed to Haiti in October 2010 had diarrhea during the time between their arrival and the confirmation of Haiti’s cholera outbreak.[1] [2] There were approximately two weeks between the arrival of the soldiers and confirmation of the outbreak.[2] [3] 

To assess whether this was unusual – no cases of diarrhea among 454 newly-arrived soldiers during a two-week period – I applied data from a literature review of the “Incidence, etiology, and impact of diarrhea among long-term travelers”[4] to that number of soldiers and that time frame. The review found studies documenting an incidence range between 6 episodes of diarrhea per 100 person-months and 29 episodes of diarrhea per 100 person-months.

454 soldiers in Haiti for two weeks yields approximately 225 person-months.

In 225 person-months, we would expect 2.25 times as many episodes of diarrhea, compared with 100 person-months.  

Thus we would expect there to have been between 13.5 and 65 episodes of diarrhea among the 454 Nepalese soldiers during their first two weeks in Haiti. It would be highly unusual for none of the soldiers to have had diarrhea during that period. 

References

1. “We have also tested soldiers among the Nepalese all the tests that we have done have been negative. And we have checked also that none of the Nepalese soldiers have been sick or have been shown any sign of diarrhea.” (13:30 minutes into the press conference.) December 15 2010 UN press conference by Alain LeRoy, UN Under-Secretary General for Peacekeeping Operations        
2. Protesters Blame U.N. Base for Cholera in Haiti  Associated Press, October 28 2010   
3. Epidemiological report by Renaud Piarroux, December 10 2010 Rapport de mission sur l’épidémie de choléra en Haïti Professeur Renaud Piarroux    
4. Riddle MS, Sanders JW, Putnam SD, Tribble DR. Incidence, etiology, and impact of diarrhea among long-term travelers (US military and similar populations): a systematic review. Am J Trop Med Hyg. 2006 May;74(5):891-900  
5. Author contact information: Jody Lanard M.D. jody[at]psandman.com The Peter Sandman Risk Communication Website www.psandman.com 

Addenda added March 28 2012: 

1. Excerpt from Nepalese origin of cholera epidemic in Haiti, Frerichs R., Keim P., Barrais R., Piarroux R. In: Clinical Microbiology and Infection, DOI: 10.1111/j.1469-0691.2012.03841.x, accepted manuscript online March 14, 2012 (accessible online at http://crofsblogs.typepad.com/files/supporting-information.pdf )

The first Nepalese troops arrived at the Meille MINUSTAH camp near Mirebalais in the Centre Department of Haiti on October 9, 2010 [S7]. Another Nepalese group arrived on October 12, and still another on October 16 [S7, S8]. Most of the troops from Nepal were stationed at Meille, a small hamlet located in the Centre Department of Haiti, two kilometers south of Mirebalais. Other Nepalese soldiers were assigned to MINUSTAH camps at nearby Hinche or Terra Rouge [S5]. The UN Panel wrote that they reviewed dispensary clinic data at the Meille MINUSTAH camp and found “no cases of severe diarrhea and dehydration” during this initial period [S5]. No mention was made, however, of mild or moderate diarrhea cases, nor did they review the medical records of Nepalese troops assigned to either the Hinche or Terra Rouge MINUSTAH camps.  

2. Excerpt from Cholera -- Symptoms, Mayo Clinic

Most people exposed to the cholera bacterium (Vibrio cholerae) don't become ill and never know they've been infected. Yet because they shed cholera bacteria in their stool for seven to 14 days, they can still infect others through contaminated water. Most symptomatic cases of cholera cause mild or moderate diarrhea that's often hard to distinguish from diarrhea caused by other problems.

Only about one in 10 infected people develops the typical signs and symptoms of cholera, usually within a few days of infection.

Jody Lanard Buenos Aires April 13 2011 risk communication overview slides

 

Risk Communication: difficult, counter-intuitive
strategies for Public Health and other Ministries

Presented at the request of the Ministerio de Salud de la Nación, República Argentina, and the Pan American Health Organization 

by Jody Lanard M.D.
Buenos Aires, April 13 2011

Download Jody Slides April 13 argentina 2011

This set of slides (downloadable from the link above) is a brief overview of risk perception, risk = hazard + outrage, and the three main kinds of risk communication: precaution advocacy, outrage/fear management, and crisis communication.

It also includes introductory stories illustrating officials' tendency to say "Don't panic," and "The situation is under control." 

The principles are generic, but the examples are mostly related to pandemic and avian influenza.

The slides are mostly in English, but the three main kinds of risk communication are illustrated with slides in Spanish. 

 

Jody's slides for Guangdong meeting. Chinese and English versions.

Here are links to my English and Chinese main slide sets for Guangzhou, in case you did not get them via email.

I haven't tried this system of uploading before; I hope you can download both sets from this page:

Download English Lanard template Guangzhou 151

Download CHINESE Lanard Guangzhou template August 2010

Unedited recording (Peter's end only), interview by Dick Knox (NPR), Dec 4 2009

For the final version of Richard Knox's report on the severity of the H1N1 Pandemic as of November 2009, see:  http://www.npr.org/templates/story/story.php?storyId=121184706

The download below goes to the unedited recording of Peter's end of the interview, taped December 4 2009.

Download 20091204 162152

Correcting the record -- a note from Jody Lanard

[Correction published July 29, 2009. Addenda (see below) published August 3, 2009 and January 1 2010]

The following articles do not accurately capture statements by me at a recent risk communication workshop.

Jamaica among Most "Open and Honest" In Dealing With Influenza A Pandemic

US consultant says Jamaica's H1N1 pandemic [sic] among the best in the world

Jamaica among most open in dealing with swine flu

I stated at the risk communication workshop that "Jamaica, in my view, has been in the middle of the pack for risk communication about the pandemic among democratic countries that have a free press.”

The same day, in an interview via email with a reporter who attended the workshop, I wrote: “In terms of public health officials' communication, Jamaica is right in the middle of the pack of free countries with a free press -- not worse, not better -- in terms of communicating about the flu pandemic.”

Addendum added August 3, 2009:

Several people have helped me see that I did say something at the workshop that could lead a reasonable smart reporter to interpret the statement as meaning that Jamaica was “among the best” in its pandemic influenza risk communication.  It was probably something like this, although I only have my notes, and not a tape-recording:

 

Among democratic countries, among countries with a free press – in other words, among countries with the best possibility [meaning chance] of being open and honest, Jamaica is in the middle of the pack in being open and honest about H1N1 in Jamaica.

 

However, I did not intend to say that Jamaica was “among the best” or “the best in the world” regarding its pandemic influenza risk communication.  

 

I am so sorry that I conveyed that misimpression – entirely my fault, as the communicator -- and subsequently caused embarrassment to others due to my explicit disavowal of the statement as it was reported in several newspapers and media services in Jamaica and the Caribbean region.

Addendum added January 1 2010

In a Jamaica Information Service "Year in Review" article a couple days ago, the misquotation was recycled again. I am grateful to the reporter, Latoya Pennant, for immediately removing the misleading paragraph at my request. Unfortunately, Google had "cached" the incorrect version before the error was corrected. Since the cached version lives on, I wanted to once again correct the record.

 

Chinese, Japanese, and Korean translations

Several handouts from The Peter Sandman Risk Communication Website have been translated into Chinese, Japanese, Korean, Khmer, Lao, Vietnamese, and Spanish, courtesy of the World Health Organization's Western Pacific Regional Office (WPRO) and the Pan American Health Organization (PAHO).

The Chinese, Korean, and Japanese translations are posted here. The rest will be posted later.

My  attempt to convert these translated documents may have led to all kinds of formatting problems -- I can't tell for sure. But I hope the materials are useful to people trying to learn or train others in risk communication around the world.

Advice about formatting errors (and any other comments) are greatly welcomed!

Jody Lanard

Swine Flu Risk Communication: The end of the "containment" phase

 

Here is a general comment that applies to countries which are focusing (publicly at least) on initial “containment” of swine flu.

 

 

Many are not preparing their people for the likely failure of “containment.” The more they celebrate their successful “catches” of incoming travelers and contacts, the more the public will perceive the later failure of “containment” as the government’s failure. The public will also be more surprised – less emotionally prepared – when community spread becomes obvious.

 

So it might be wise for countries to warn now about the eventual failure of containment, and how policies and strategies will change once that happens.

 

 

Yesterday (June 7), New Zealand health officials did some excellent "tell people what to expect" risk communication about this:

 

New Zealand Herald, June 7 2009

>In a message titled "Pigs can't fly but flu can", public health boss Mark Jacobs has warned family doctors that community transmission here is a matter of "when rather than if"...

>The latest edition of the College of GPs newsletter, ePulse, carries a message from Dr Jacobs, the Health Ministry's director of public health.

>"The recent rapid increase in cases in Australia in particular emphasises that community transmission in New Zealand is a matter of when rather than if.

>"In the event of sustained community transmission, hospitals already entering the seasonal influenza period would soon be overwhelmed, most people will need to be cared for at home supported by telephone triage, probably through Healthline."<

 

And today, the Philippines started to make the transition as well:

[Secretary of Health] Duque readies DOH for shift towards mitigation

In his Swine Flu Pandemic Communication Update for June 4 , Peter wrote:

 

 

>Unrealistic expectations.

 

 

>In countries where swine flu is not yet known to be circulating widely, experts agree that it’s only a matter of time before it does so. That doesn’t mean it’s futile to try to “contain” the initial spread of the H1N1 virus. Although containment will ultimately fail, it can slow the spread of H1N1. That buys time – for the development of a vaccine, for example, and for teaching people about non-pharmaceutical interventions. And it flattens the curve so fewer people are sick all at once, which reduces workplace and school absenteeism and the pressure on hospitals and other medical resources.

 

 

>But instead of explaining that containment is a temporary strategy to slow the spread of the disease, many countries are allowing their people to imagine that they actually intend to stop it. When officials identify and quarantine their first incoming travelers with swine flu, for example, they typically issue self-congratulatory statements implying (or claiming outright) that they can keep the disease from spreading.

 

 

>This failure of anticipatory guidance – “containment will eventually fail, and then here’s what we will do…” – sets governments up for public perplexity and even outrage. People will feel blindsided when their government eventually announces that the virus is now firmly entrenched, and containment measures – screening travelers, tracing contacts, testing all people with flu symptoms, giving them all (and even their contacts) Tamiflu – are abandoned in favor of measures that make more sense once sustained community transmission is established.<

 

 

I  also  wish more countries would say, as some have: 

 

“The number of confirmed cases is probably the tip of the iceberg. We  very likely have far more cases. Most of them seem to be mild so far, but as the case numbers grow we expect to see some serious cases, and even some deaths.”

 

 

“Telling people what to expect”, when a situation is likely to get worse, is good risk communication, sort of like a partially-effective inoculation.

 

Best regards,

 

Jody

 

Peter's Swine Flu Risk Communication Update
http://psandman.com/col/swinecomm.htm

 

 

WHO’s “Outbreak Communication Guidelines” –

and calling a pandemic a pandemic

http://psandman.com/gst2009.htm#guidelines

 

 

Swine Flu Risk Communication articles, guestbook entries,

and media interviews

http://psandman.com/index-infec.htm#swineflu1

Jody Lanard's crisis communication slides as of October 2008

Here is a link to my crisis communication slides, with annotated notes for trainers who may wish to use some of them in their own trainings. 

Almost regardless of what type of risk communication training you are doing, I most strongly recommend the introductory section, which is entirely based on Peter Sandman's Risk = Hazard + Outrage, which in turn stands on the shoulders of Paul Slovic's risk perception work. It is very useful to introduce this frame early on in risk communication training.

The "Risk = Hazard + Outrage" section orients trainees to:

1.  How normal people perceive risk, and the outrage/fear factors which drive people to over-or-underestimate a hazard

2.  The types of risk communication needed in three situations:

• Precaution advocacy -- when people are under-reacting to a serious hazard, due to apathy, complacency, or ignorance.  "Watch out!"
• Outrage (or fear) management -- when people are over-reacting to a small or non-existent hazard. "Calm down!"
• Crisis communication -- when people are appropriately upset about a real hazard. "We'll get through this together."

Khmer Risk Communication Handouts

Khmer Crisis Communication handouts 1 through 8 (all in one file)
Download khmer_crisis_comm_handouts.pdf

Vietnamese Risk Communication Handouts 1 to 8

1.  A Quick Introduction to Risk Perception
Download 1_a_quick_introduction_to_risk_perception.pdf

2.  Map of Risk Communication
Download 2_Sandman_Risk_Comm_Map_Vietnamese__tmp4fddd546.pdf

3.  Four Kinds of Risk Communication
Download 3_Vietnamese_4_kinds_of_risk_communication_sandman.pdf

4.  List of 25 Crisis Communication Recommendations
Download 4_List_of_25_recommendations_Viet.pdf

5.  Crisis Communication 1: How Bad Is It? How Sure Are You?
Download 5_Vietnamese_Crisis_Communication_I_Sandman_Lanard.pdf

6.  Crisis Communication 2: Coping with the Emotional Side of the Crisis
Download 6_Vietnamese_Crisis_Communication_II_Sandman_Lanard.pdf

7.  Crisis Communication 3: Involving the Public
Download 7_Vietnamese_Crisis_Communication_III_Sandman_Lanard.pdf

8.  Crisis Communication 4: Errors, Misimpressions, and Half-Truths
Download 8_Vietnamese_Crisis_Communication_IV_Sandman_Lanard.pdf