Development of the FlagIt Report and Response System for Concerning or Harassing Messages Related to Public Health Work.

In response to growing reports of concerning/harassing messages and backlash related to public health work, the Johns Hopkins Bloomberg School of Public Health established the FlagIt report and response system. The system uses a dedicated FlagIt email inbox for faculty and staff to report harassing or concerning messages related to public-facing work and has an autoreply message sharing available institutional resources. The Johns Hopkins University public safety investigators review, inventory, and investigate the reported messages and share their findings with the reporter within 2 business days. In addition, the Johns Hopkins Bloomberg School of Public Health faculty FlagIt team volunteers reach out to the reporter to check in on how they are doing and offer additional supports if needed The FlagIt system was developed with existing institutional resources and did not require additional funding. Given the continued backlash against public health, other public health institutions and agencies may consider implementing similar report and response systems.

Fighting the infodemic: the 4 i Framework for Advancing Communication and Trust.

BACKGROUND: The proliferation of false and misleading health claims poses a major threat to public health. This ongoing "infodemic" has prompted numerous organizations to develop tools and approaches to manage the spread of falsehoods and communicate more effectively in an environment of mistrust and misleading information. However, these tools and approaches have not been systematically characterized, limiting their utility. This analysis provides a characterization of the current ecosystem of infodemic management strategies, allowing public health practitioners, communicators, researchers, and policy makers to gain an understanding of the tools at their disposal. METHODS: A multi-pronged search strategy was used to identify tools and approaches for combatting health-related misinformation and disinformation. The search strategy included a scoping review of academic literature; a review of gray literature from organizations involved in public health communications and misinformation/disinformation management; and a review of policies and infodemic management approaches from all U.S. state health departments and select local health departments. A team of annotators labelled the main feature(s) of each tool or approach using an iteratively developed list of tags. RESULTS: We identified over 350 infodemic management tools and approaches. We introduce the 4 i Framework for Advancing Communication and Trust (4 i FACT), a modified social-ecological model, to characterize different levels of infodemic intervention: informational, individual, interpersonal, and institutional. Information-level strategies included those designed to amplify factual information, fill information voids, debunk false information, track circulating information, and verify, detect, or rate the credibility of information. Individual-level strategies included those designed to enhance information literacy and prebunking/inoculation tools. Strategies at the interpersonal/community level included resources for public health communicators and community engagement approaches. Institutional and structural approaches included resources for journalists and fact checkers, tools for managing academic/scientific literature, resources for infodemic researchers/research, resources for infodemic managers, social media regulation, and policy/legislation. CONCLUSIONS: The 4 i FACT provides a useful way to characterize the current ecosystem of infodemic management strategies. Recognizing the complex and multifaceted nature of the ongoing infodemic, efforts should be taken to utilize and integrate strategies across all four levels of the modified social-ecological model.

Operationalizing Community Assessment Results to Enhance Preparedness for a Radiological Emergency.

OBJECTIVE: A radiological emergency such as the detonation of a radiological dispersal device would have catastrophic health, environmental, and economic consequences. Community assessments can provide useful information about radiological and other emergency preparedness at the household level. Tools such as logic models can be applied to link data collected in a community assessment to planned activities and targeted outcomes. This study sought to answer how public health departments can use the results of a community assessment to improve preparedness for radiological and other types of emergencies and to present a sample logic model demonstrating how questions asked in a community assessment can be used to drive intended outcomes. DESIGN: Surveys were fielded in 2019 to professionals with experience in radiological emergency preparedness, state and local health and emergency management, and journalism. Questions included the role of health departments in radiological emergency preparedness, the operationalization of results from a community assessment for preparedness, and information sharing in a radiological emergency. Descriptive statistics and a modified framework approach were used for open-ended questions. RESULTS: Nearly three-fourths of state/local officials reported that it would be at least somewhat difficult (73%; 11 of 15 state/local officials) for a local health department to operationalize the results of a community health assessment for radiological emergency preparedness. Potential barriers included competing priorities, lack of funds, and limited staff. Resources such as pretested communication materials, tailored messaging, and technical tools and training can assist health departments and emergency management agencies in using the information collected from a community assessment. CONCLUSIONS: To address implementation challenges in operationalizing the results of a community assessment, officials can use tools such as logic models to illustrate how the information gathered from a community health assessment will create an intended preparedness outcome and to advocate for funds for this type of assessment.

Using prediction polling to harness collective intelligence for disease forecasting.

BACKGROUND: The global spread of COVID-19 has shown that reliable forecasting of public health related outcomes is important but lacking. METHODS: We report the results of the first large-scale, long-term experiment in crowd-forecasting of infectious-disease outbreaks, where a total of 562 volunteer participants competed over 15 months to make forecasts on 61 questions with a total of 217 possible answers regarding 19 diseases. RESULTS: Consistent with the "wisdom of crowds" phenomenon, we found that crowd forecasts aggregated using best-practice adaptive algorithms are well-calibrated, accurate, timely, and outperform all individual forecasters. CONCLUSIONS: Crowd forecasting efforts in public health may be a useful addition to traditional disease surveillance, modeling, and other approaches to evidence-based decision making for infectious disease outbreaks.

Zika Inquiries Made to the CDC-INFO System, December 2015-September 2017.

We examined Zika-related inquiries to CDC-INFO, the national contact center for the Centers for Disease Control and Prevention, to identify potential communication gaps. The most frequently asked questions related to travel or geographic location of Zika (42% of all inquiries), information about laboratory testing (13%), or acquiring a Zika test (11%).

Misinformation and the US Ebola communication crisis: analyzing the veracity and content of social media messages related to a fear-inducing infectious disease outbreak.

BACKGROUND: The Ebola communication crisis of 2014 generated widespread fear and attention among Western news media, social media users, and members of the United States (US) public. Health communicators need more information on misinformation and the social media environment during a fear-inducing disease outbreak to improve communication practices. The purpose of this study was to describe the content of Ebola-related tweets with a specific focus on misinformation, political content, health related content, risk framing, and rumors. METHODS: We examined tweets from a random 1% sample of all tweets published September 30th - October 30th, 2014, filtered for English-language tweets mentioning "Ebola" in the content or hashtag, that had at least 1 retweet (N = 72,775 tweets). A randomly selected subset of 3639 (5%) tweets were evaluated for inclusion. We analyzed the 3113 tweets that meet inclusion criteria using public health trained human coders to assess tweet characteristics (joke, opinion, discord), veracity (true, false, partially false), political context, risk frame, health context, Ebola specific messages, and rumors. We assessed the proportion of tweets with specific content using descriptive statistics and chi-squared tests. RESULTS: Of non-joke tweets, 10% of Ebola-related tweets contained false or partially false information. Twenty-five percent were related to politics, 28% contained content that provoked reader response or promoted discord, 42% contained risk elevating messages and 72% were related to health. The most frequent rumor mentioned focused on government conspiracy. When comparing tweets with true information to tweets with misinformation, a greater percentage of tweets with misinformation were political in nature (36% vs 15%) and contained discord-inducing statements (45% vs 10%). Discord-inducing statements and political messages were both significantly more common in tweets containing misinformation compared with those without(p < 0.001). CONCLUSIONS: Results highlight the importance of anticipating politicization of disease outbreaks, and the need for policy makers and social media companies to build partnerships and develop response frameworks in advance of an event. While each public health event is different, our findings provide insight into the possible social media environment during a future epidemic and could help optimize potential public health communication strategies.

Analysis of sectoral participation in the development of Joint External Evaluations.

BACKGROUND: The Joint External Evaluation Process (JEE), developed in response to the 2014 Global Health Security Agenda (GHSA), is a voluntary, independent process conducted by a team of external evaluators to assess a country's public health preparedness capabilities under the 2005 International Health Regulations (IHR) revision. Feedback from the JEE process is intended to aid in the development of national action plans by elucidating weaknesses in current preparedness and response capabilities. METHODS: To identify gaps in sector participation and the development of national action plans in response to public health emergencies, all English-language JEE reports available on March 31, 2018 (N = 47) were systematically reviewed to determine sectoral backgrounds of key host country participants. RESULTS: Overall, strong representation was seen in the health, agriculture, domestic security, and environment sectors, whereas the energy/nuclear and defense sectors were largely under-represented. CONCLUSIONS: While strong participation by more traditional sectors such as health and agriculture is common in the JEE development process, involvement by the defense and energy/nuclear sectors in the JEE process could be increased, potentially improving preparedness and response to widespread public health emergencies.

Frequency of Risk-Related News Media Messages in 2016 Coverage of Zika Virus.

News media plays a large role in the information the public receives during an infectious disease outbreak, and may influence public knowledge and perceptions of risk. This study analyzed and described the content of U.S. news media coverage of Zika virus and Zika response during 2016. A random selection of 800 Zika-related news stories from 25 print and television news sources was analyzed. The study examined 24 different messages that appeared in news media articles and characterized them using theories of risk perception as messages with characteristics that could increase perception of risk (risk-elevating messages; n = 14), messages that could decrease perception of risk (risk-minimizing messages; n = 8), or messages about travel or testing guidance (n = 2). Overall, 96% of news stories in the study sample contained at least one or more risk-elevating message(s) and 61% contained risk-minimizing message(s). The frequency of many messages changed after local transmission was confirmed in Florida, and differed between sources in locations with or without local transmission in 2016. Forty percent of news stories included messages about negative potential outcomes of Zika virus infection without mentioning ways to reduce risk. Findings from this study may help inform current federal, state, and local Zika responses by offering a detailed analysis of how news media are covering the outbreak and response activities as well as identifying specific messages appearing more or less frequently than intended. Findings identifying the types of messages that require greater emphasis may also assist public health communicators in responding more effectively to future outbreaks.

Public Health Resilience Checklist for High-Consequence Infectious Diseases-Informed by the Domestic Ebola Response in the United States.

CONTEXT: The experiences of communities that responded to confirmed cases of Ebola virus disease in the United States provide a rare opportunity for collective learning to improve resilience to future high-consequence infectious disease events. DESIGN: Key informant interviews (n = 73) were conducted between February and November 2016 with individuals who participated in Ebola virus disease planning or response in Atlanta, Georgia; Dallas, Texas; New York, New York; or Omaha, Nebraska; or had direct knowledge of response activities. Participants represented health care; local, state, and federal public health; law; local and state emergency management; academia; local and national media; individuals affected by the response; and local and state governments. Two focus groups were then conducted in New York and Dallas, and study results were vetted with an expert advisory group. RESULTS: Participants focused on a number of important areas to improve public health resilience to high-consequence infectious disease events, including governance and leadership, communication and public trust, quarantine and the law, monitoring programs, environmental decontamination, and waste management. CONCLUSIONS: Findings provided the basis for an evidence-informed checklist outlining specific actions for public health authorities to take to strengthen public health resilience to future high-consequence infectious disease events.

Media Messages and Perception of Risk for Ebola Virus Infection, United States.

News media have been blamed for sensationalizing Ebola in the United States, causing unnecessary alarm. To investigate this issue, we analyzed US-focused news stories about Ebola virus disease during July 1-November 30, 2014. We found frequent use of risk-elevating messages, which may have contributed to increased public concern.

Public Health Preparedness Funding: Key Programs and Trends From 2001 to 2017.

OBJECTIVES: To evaluate trends in funding over the past 16 years for key federal public health preparedness and response programs at the US Department of Health and Human Services, to improve understanding of federal funding history in this area, and to provide context for future resource allocation decisions for public health preparedness. METHODS: In this 2017 analysis, we examined the funding history of key federal programs critical to public health preparedness by reviewing program budget data collected for our annual examination of federal funding for biodefense and health security programs since fiscal year (FY) 2001. RESULTS: State and local preparedness at the Centers for Disease Control and Prevention initially received $940 million in FY2002 and resulted in significant preparedness gains, but funding levels have since decreased by 31%. Similarly, the Hospital Preparedness Program within the Office of the Assistant Secretary for Preparedness and Response was funded at a high of $515 million in FY2003, but funding was reduced by 50%. Investments in medical countermeasure development and stockpiling remained relatively stable. CONCLUSIONS: The United States has made significant progress in preparing for disasters and advancing public health infrastructure. To enable continued advancement, federal funding commitments must be sustained.

US State-Level Policy Responses to the Ebola Outbreak, 2014-2015.

CONTEXT: The 2014-2015 Ebola epidemic in West Africa raised concerns about the potential occurrence of an Ebola outbreak in the United States. The federal government and individual states developed guidance and policies to determine how to manage individuals within the United States who may have been exposed to Ebola. DESIGN: A total of 139 documents describing state policies for individuals considered at risk for Ebola and the requirements, as well as restrictions these individuals may be subject to, were systematically identified and analyzed. RESULTS: A wide range of policy responses and variations on quarantine, movement restrictions, exposure categories, and monitoring were found. While the majority of states reflected US Centers for Disease Control and Prevention guidance, some states enacted aggressive quarantine policies and movement restrictions, developed unique categorization strategies, and established more frequent monitoring procedures. CONCLUSIONS: Findings may help public health practitioners and policymakers anticipate what policies could be implemented in response to future infectious disease threats. Furthermore, practitioners and policymakers should assume that some variation in response policies will occur at the state level.

News media coverage of U.S. Ebola policies: Implications for communication during future infectious disease threats.

The Ebola outbreak of 2014-2015 raised concerns about the disease's potential spread in the U.S. and received significant news media coverage. Prior research has shown that news media coverage of policy options can influence public opinion regarding those policies, as well as public attitudes toward the broader social issues and target populations addressed by such policies. To assess news media coverage of Ebola policies, the content of U.S.-focused news stories (n=1262) published between July 1 and November 30, 2014 from 12 news sources was analyzed for 13 policy-related messages. Eight-two percent of news stories mentioned one or more policy-related messages. The most frequently appearing policy-related messages overall were those about isolation (47%) and quarantine (40%). The least frequently mentioned policy-related message described dividing potentially exposed persons into distinct groups based on their level of Ebola risk in order to set different levels of restrictions (5%). Message frequency differed depending on whether news sources were located in an area that experienced an Ebola case or controversy, by news sources' political ideological perspective, and by type of news source (print and television). All policy-related messages showed significant increases in frequency after the first case of Ebola was diagnosed in the U.S. on September 30, 2014, with the exception of messages related to isolation, which showed a significant decrease. Results offer insight into how the news media covers policies to manage emerging disease threats.

Common Sense or Gun Control? Political Communication and News Media Framing of Firearm Sale Background Checks after Newtown.

Gun violence is a critical public health problem in the United States, but it is rarely at the top of the public policy agenda. The 2012 mass shooting in Newtown, Connecticut, opened a rare window of opportunity to strengthen firearm policies in the United States. In this study, we examine the American public's exposure to competing arguments for and against federal- and state-level universal background check laws, which would require a background check prior to every firearm sale, in a large sample of national and regional news stories (n = 486) published in the year following the Newtown shooting. Competing messages about background check laws could influence the outcome of policy debates by shifting support and political engagement among key constituencies such as gun owners and conservatives. We found that news media messages in support of universal background checks were fact-based and used rational arguments, and opposing messages often used rights-based frames designed to activate the core values of politically engaged gun owners. Reframing supportive messages about background check policies to align with gun owners' and conservatives' core values could be a promising strategy to increase these groups' willingness to vocalize their support for expanding background checks for firearm sales.

Emergency Preparedness in the 10-Mile Emergency Planning Zone Surrounding Nuclear Power Plants.

OBJECTIVES: Each of the nuclear power plants in the US is encircled by an Emergency Planning Zone (EPZ). Within each EPZ, government officials, utility professionals, emergency managers, and public health practitioners collectively conduct extensive planning, exercises, and outreach to better protect their communities in the event of a nuclear accident. Our objective was to conduct a cross-sectional study of off-site public health preparedness within EPZs to better understand the dynamics of nuclear preparedness and uncover lessons for all-hazards preparedness. METHODS: Using a qualitative, interview-based method, we consulted 120 county emergency managers, state health preparedness officers, state radiation health officials, and industry officials from 17 EPZs in ten different states. RESULTS: Interviewees reflected that EPZ emergency preparedness is generally robust, results from strong public-private partnership between nuclear plants and emergency management agencies, and enhances all-hazard preparedness. However, there exist a few areas which merit further study and improvement. These areas include cross-state coordination, digital public communication, and optimizing the level of public education within EPZs. CONCLUSIONS: This first-of-its-kind study provides a cross-sectional snapshot of emergency preparedness in the 10-mile EPZ surrounding nuclear power plants.

Analyzing Social Media Messaging on Masks and Vaccines: A Case Study on Misinformation During the COVID-19 Pandemic.

Misinformation and disinformation during infectious disease outbreaks can hinder public health responses. This analysis examines comments about masks and COVID-19 vaccines on Twitter during the first six months of the COVID-19 pandemic. We conducted a content analysis of 6,600 randomly selected English-language tweets, examining tweets for health, political, of societal frames; inclusion of true information, false information, partially true/misleading information, and/or opinion; political components; risk frames; and use of specific types of rumor. We found false and partially false information in 22% of tweets in which we were able to assess veracity. Tweets with misinformation were more likely to mention vaccines, be political in nature, and promote risk elevating messages (p<0.5). We also found false information about vaccines as early as January 2020, nearly a year before COVID-19 vaccines became widely available. These findings highlight a need for new policies and strategies aimed to counter harmful and misleading messaging.

Lessons learned during dengue outbreaks in the United States, 2001-2011.

Since 2001, three autochthonous dengue fever outbreaks have occurred in the United States: in Hawaii (2001); Brownsville, Texas (2005); and southern Florida (2009-2011). We sought to characterize and describe the response to these outbreaks from the perspectives of public health and vector control officials. By conducting a medical literature review through PubMed and news media searches through Google, we identified persons involved in managing each outbreak; 26 persons then participated in qualitative, semistructured interviews. After analyzing the 3 outbreaks, we found the following prominent themes in the response efforts: timely detection of illness; communication of up-to-date, correct information; and development of a rapid response that engages the community. We therefore recommend that public health authorities involve the clinical and laboratory community promptly, provide accurate information, and engage the local community in vector control and case identification and reporting.

Public Health Implementation Considerations for State-Level Ebola Monitoring and Movement Restrictions.

OBJECTIVE: This article describes implementation considerations for Ebola-related monitoring and movement restriction policies in the United States during the 2013-2016 West Africa Ebola epidemic. METHODS: Semi-structured interviews were conducted between January and May 2017 with 30 individuals with direct knowledge of state-level Ebola policy development and implementation processes. Individuals represented 17 jurisdictions with variation in adherence to US Centers for Disease Control and Prevention (CDC) guidelines, census region, predominant state political affiliation, and public health governance structures, as well as the CDC. RESULTS: Interviewees reported substantial resource commitments required to implement Ebola monitoring and movement restriction policies. Movement restriction policies, including for quarantine, varied from voluntary to mandatory programs, and, occasionally, quarantine enforcement procedures lacked clarity. CONCLUSIONS: Efforts to improve future monitoring and movement restriction policies may include addressing surge capacity to implement these programs, protocols for providing support to affected individuals, coordination with law enforcement, and guidance on varying approaches to movement restrictions.

Longitudinal Risk Communication: A Research Agenda for Communicating in a Pandemic.

In this paper, we present a research agenda for longitudinal risk communication during a global pandemic. Starting from an understanding that traditional approaches to risk communication for epidemics, crises, and disasters have focused on short-duration events, we acknowledge the limitations of existing theories, frameworks, and models for both research and practice in a rapidly changing communication environment. We draw from scholarship in communication, sociology, anthropology, public health, emergency management, law, and technology to identify research questions that are fundamental to the communication challenges that have emerged under the threat of COVID-19. We pose a series of questions focused around 5 topics, then offer a catalog of prior research to serve as points of departure for future research efforts. This compiled agenda offers guidance to scholars engaging in practitioner-informed research and provides risk communicators with a set of substantial research questions to guide future knowledge needs.

The Promise of Disease Detection Dogs in Pandemic Response: Lessons Learned From COVID-19.

One of the lessons learned from the coronavirus disease 2019 (COVID-19) pandemic is the utility of an early, flexible, and rapidly deployable disease screening and detection response. The largely uncontrolled spread of the pandemic in the United States exposed a range of planning and implementation shortcomings, which, if they had been in place before the pandemic emerged, may have changed the trajectory. Disease screening by detection dogs show great promise as a noninvasive, efficient, and cost-effective screening method for COVID-19 infection. We explore evidence of their use in infectious and chronic diseases; the training, oversight, and resources required for implementation; and potential uses in various settings. Disease detection dogs may contribute to the current and future public health pandemics; however, further research is needed to extend our knowledge and measurement of their effectiveness and feasibility as a public health intervention tool, and efforts are needed to ensure public and political support.