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.

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.

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.

Developing an instrument to measure household radiological emergency preparedness using the Community Assessment for Public Health Emergency Response (CASPER) methodology: An evidence-informed approach.

INTRODUCTION: Community assessments to measure emergency preparedness can inform policies, planning, and communication to the public to improve readiness and response if an emergency was to occur. Public health and emergency management officials need an effective assessment tool to measure community preparedness for a radiological emergency. METHODS: The authors created a survey instrument to collect data on household radiological emergency preparedness that could be implemented using the Community Assessment for Public Health Emergency Response (CASPER) methodology, developed by the U.S. Centers for Disease Control and Prevention. To inform the development of the tool, the authors examined existing CASPER surveys, focusing on identifying best practices for creating a survey instrument, as well as analyzing the results of a survey of radiation preparedness experts and state/local health and emergency management officials. RESULTS: The developed survey tool includes 32 questions covering four domains: communication in an emergency, preparedness planning, physical/behavioral health, and demographics. The instrument captures information related to identified barriers in communicating in a radiological emergency as well as self-reported behaviors that could potentially be influenced through awareness and education. DISCUSSION: Using the proposed survey instrument and following the existing rapid assessment methodology provided by CASPER, public health and emergency management agencies can collect valuable information on the radiation preparedness needs of their communities, which can then be used to improve household readiness for an emergency.

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.

Prioritizing Communication About Radiation Risk Reduction in the United States: Results from a Multi-criteria Decision Analysis.

OBJECTIVES: The lack of radiation knowledge among the general public continues to be a challenge for building communities prepared for radiological emergencies. This study applied a multi-criteria decision analysis (MCDA) to the results of an expert survey to identify priority risk reduction messages and challenges to increasing community radiological emergency preparedness. METHODS: Professionals with expertise in radiological emergency preparedness, state/local health and emergency management officials, and journalists/journalism academics were surveyed following a purposive sampling methodology. An MCDA was used to weight criteria of importance in a radiological emergency, and the weighted criteria were applied to topics such as sheltering-in-place, decontamination, and use of potassium iodide. Results were reviewed by respondent group and in aggregate. RESULTS: Sheltering-in-place and evacuation plans were identified as the most important risk reduction measures to communicate to the public. Possible communication challenges during a radiological emergency included access to accurate information; low levels of public trust; public knowledge about radiation; and communications infrastructure failures. CONCLUSIONS: Future assessments for community readiness for a radiological emergency should include questions about sheltering-in-place and evacuation plans to inform risk communication.

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.

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.

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%).

Vector control in Zika-affected communities: Local views on community engagement and public health ethics during outbreaks.

Aerial spraying of products to kill larvae or adult mosquitoes is a public health measure used to control vector-borne diseases. In some outbreaks, the intervention has evoked controversy and community resistance. This study evaluated how local opinion leaders in US localities affected by Zika think about community engagement in public health policies for outbreak response. In December 2017 through March 2018, 4 focus groups were convened in Houston, TX, New Orleans, LA, Miami, FL, and Brooklyn, NY. They discussed a hypothetical scenario that featured vector control by aerial spraying. Participants (N = 20) more readily accepted this vector control method under 4 conditions: They were informed of alternatives, benefits, and risks for human health and the environment. Public health claims were backed by objective evidence and an authority figure genuinely working in the community's interests. They received timely notice about how to mitigate toxin exposure. And, aerial spraying helped to protect vulnerable individuals. The community engagement requirements of the local opinion leaders resonate with core principles of recent public health ethics frameworks: namely, personal autonomy, transparency, reasonableness, and solidarity. Participants foresaw problems with community consent in an era of growing social media use and mistrust in governmental and scientific authority. They also debated whether health authorities should use moral-based arguments, in addition to science-based ones, to communicate aerial spraying's risks and benefits.

Influencing Factors in the Development of State-Level Movement Restriction and Monitoring Policies in Response to Ebola, United States, 2014-15.

During the 2014-15 domestic Ebola response, US states developed monitoring and movement restriction policies for potentially exposed individuals. We describe decision-making processes and factors in the development of these policies. Results may help health officials anticipate potential concerns and policy influencers in future infectious disease responses. Thirty individuals with knowledge of state-level Ebola policy development participated in semi-structured interviews conducted from January to May 2017. Interviewees represented 18 jurisdictions from diverse census regions, state political affiliations, and public health governance structures as well as the US Centers for Disease Control and Prevention (CDC). Limited and/or changing guidance and unique state-level public health, legal, and operational environments resulted in variation in policy responses. Federal guidance developed by the CDC was an important information source influencing state-level policy responses, as was available scientific evidence; however, other external factors, such as local events, contributing experts, political environment, public concern, news media, and the influence of neighboring states, contributed to additional variation. Improvements in timing, consistency, and communication of federal guidance for monitoring and movement restrictions at the state level-along with balanced approaches to addressing ethical concerns, scientific evidence, and public concern at the state level-are considerations for policy development for future disease responses.

Clade X: A Pandemic Exercise.

Clade X was a day-long pandemic tabletop exercise conducted by the Johns Hopkins Center for Health Security on May 15, 2018, in Washington, DC. In this report, we briefly describe the exercise development process and focus principally on the findings and recommendations that arose from this project.

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.