I hope and trust that the bill will pass. I am particularly supportive of the legislation as it addresses the health needs of both volunteers and the general public impacted through their work in the 9/11 response. (Further, a number of the victims are suffering with Leukemia likely a result of the aftermath.)

In supporting the bill, New York City Mayor Michael Bloomberg underscored the reasons I think it is important to help this group of Americans:

“It’s time that the country stood up to do the right thing,” he said. “There are people who rushed into what started as a rescue and wound up to be a recovery mission. They put their lives on the line. They are suffering greatly,” he said.

“Supposing there’s another disaster. You don’t want people sitting back and saying, ‘I’m afraid to go in and save somebody’s life, because when it comes to my life, the public’s not going to be behind me,’” he continued. “That will be my message to both the parties.”

It asks the public to do five things: get a flu vaccination and other recommended immunizations, create a family communications and evacuation plan, have an emergency preparedness kit, protect their pets, and encourage their community to get ready. APHA is encouraging citizens to organize preparedness events on Get Ready Day, September 21st, as part of National Preparedness Month.

The APHA’s Audrey Pernik told me that the “promise” concept has worked before for other Association campaigns so it decided to use the idea for preparedness this year. The hope is that by getting individuals to take the first step online it will encourage them to take family readiness stepss. Asking more and getting more is similar to the philosophy of Orange County READYOC’s “Promise To Prepare” campaign that I wrote about last month. Pernik said that 1600 people have already made the pledge in the first week it has been on the web.

An interesting aspect of the APHA preparedness initiative is that it includes immunization as a part of preparedness, which is central to the group’s work but is not normally part of emergency management’s standard outreach message (other than last year when the H1N1 flu was a major focus). Though it is an extra step, I see how including immunization in public preparedness recommendations might be useful because it is a more pedestrian, non-disaster action which could be a good way to get citizens into emergency preparedness in a less threatening way.

You can make your preparedness promise here.

The APHA’s Get Ready campaign video, “Ant & Grasshopper”

As the unprecedented offshore oil drilling disaster in the Gulf of Mexico unfolds and extraordinary measures are being taken to protect vulnerable coastal and marine environments from the toxic fuel, the question arises: Is the health and safety of responders being protected as well? Over the past week, I’ve been investigating this question for The Pump Handle, but answers to my questions have not been forthcoming. On May 3, Occupational Safety and Health Administration (OSHA) head David Michaels visited the Gulf and profile of responder health and safety issues began to rise, but many questions remain unanswered…

…A pressing question is how to ensure the health and safety of response workers – a question being asked with the specters of the Exxon Valdez, World Trade Center, and Hurricane Katrina looming large. Concern is real that in the rush to protect beaches, sensitive wetlands, and wildlife – and to contain the massive oil flow – health and safety of those on the front lines is receiving scant attention.

Obviously, the health and safety of all rescue workers should be a top priority (though this blog will be focused on the thousands of citizens who volunteer for the cleanup — Grossman says there have 14,500 involved so far.) It’s a topic that we’ll continue to keep an eye on as the situation develops. Grossman’s full post can be found here.

The proclamation, which Obama signed Friday night, will make it easier for U.S. medical facilities to handle a surge in flu patients by allowing the waiver of some requirements of Medicare, Medicaid and other federal health insurance programs as needed, the White House said in a statement.

The U.S. Centers for Disease Control and Prevention said on Friday that H1N1 swine flu has become widespread in 46 of the 50 U.S. states, a level comparable to the peak of ordinary flu seasons but far earlier and with more waves of infection expected.

The White House statement said the declaration was intended to prepare the country in case of “a rapid increase in illness that may overburden health care resources” and was similar to disaster declarations issued before hurricanes hit coastal areas.

The City has currently signed up 500 “patients” so far, according to Anne Rinchiuso from the Health Department’s Bureau of Emergency Management, but she says they could use up to 2000 volunteers. “The more people in the drill the more practice and data we get.” During the drill, the volunteer patients will go through a POD, a mass dispensing site opened for the distribution of antibiotics or other medications in response to a public health emergency or outbreak.

Rinchiuso says the exercise was designed a year ago specifically for an anthrax response. However, it will also provide lessons for officials in case there is a need for a mass H1N1 vaccination program this Fall.

If you are interested in participating on Saturday, go to the Health Department’s Exercise website at www.nyc.gov/health/podexercise to fill out the short registration form. The drill will take place at a school on Manhattan’s Lower East Side and will run from approximately 1-5 pm. It is open to New Yorkers over 18 years old. More information will be provided once you register.

Although CERT team members are often asked to participate in emergency responder drills (and are doing so again on Saturday), this exercise is open to all New Yorkers. Rinchiuso notes that this an opportunity for individual members of the public to play a very helpful role in the City’s emergency preparedness planning. (On a personal note, I have participated in a number of these drills. I — and I think most of the other participants — have found them interesting, community-building and even fun events. You really do feel as if you are helping out your city in an unusual but important way. And maybe you’ll even make some new friends on the line for ‘medicine’.)

“These results suggest Americans are likely to support public health officials in prioritizing preparations for the possibility of a serious H1N1 outbreak in the fall or winter,” said Robert J. Blendon, Professor of Health Policy and Political Analysis at the Harvard School of Public Health.

Despite a majority believing that a serious outbreak is likely, more than half of Americans (61%) are not concerned about their personal risk — that is, that they or their family members will get sick from influenza A (H1N1) in the next year. This level is unchanged since the previous poll conducted May 5-6, 2009.

The current survey further suggests that the World Health Organization (WHO)’s decision to raise the worldwide pandemic alert level to Phase 6 did not dramatically impact Americans’ level of concern about their personal risk. Only 22% of Americans knew that the WHO had raised the level, and only 8% of Americans said it made them more concerned that they or their family would get Influenza A (H1N1) in the next 12 months.

One approach that has been used in the recent outbreak as a means to slow the spread of Influenza A (H1N1) is the closing of schools. In this survey, substantial numbers of parents who have children in school or daycare report that two-week closings in the fall would present serious financial problems for them. About half (51%) of these parents report that if schools/daycares closed for two weeks, they or someone else in their household would likely have to miss work in order to care for the children. Forty-three percent of these parents report that they or someone in their household would likely lose pay or income and have money problems; 26% of these parents report that they or someone in their household would likely lose their job or business as a result of having to stay home in order to care for the children.

The situation is likely to be worse for minority parents. More African American and Hispanic parents of children in school/daycare indicate that they are likely to lose pay or income and have money problems (56% and 64% respectively), as compared to whites (34%). And, more African American and Hispanic parents of children in school/daycare report that they or someone in their household would likely lose their job or business (40% and 49% respectively), as compared to whites (14%).

If the outbreak in the fall or winter is serious and leads to large-scale workforce absenteeism, the survey suggests the possibility of substantial difficulties for many people and the economy as a whole. If people had to stay home for 7-10 days because they were sick or because they had to care for a family member who was sick, 44% indicate that they would be likely to lose pay or income and have money problems, and 25% reported that they would be likely to lose their job or business.

“The findings highlight the important role that employers would play during a future outbreak. Flexibility in their employee policies may help minimize some of the problems identified in this survey,” said Blendon.

At the time of this survey, 27% of Americans reported that there had been cases of influenza A (H1N1) among people in their community, and 18% reported that schools in their community had closed due to influenza A (H1N1). Since the beginning of the outbreak, roughly two-thirds of people report that they or someone in their household has washed their hands or used sanitizer more frequently (62%).

“Handwashing was a major focus of public health education during the recent outbreak. The results of this survey show that these efforts helped people protect themselves,” said Blendon. This is the third in a series of polls about Americans’ response to the H1N1 flu outbreak.

Administration officials announced that an H1N1 vaccine is expected to be ready in October and that more vulnerable populations, such as school age children, pregnant women and individuals with underlying illnesses will be the first in line for vaccination. There was also an announcement of increased federal funding for state and local preparedness initiatives and the launch of a one-stop government website, Flu.Gov. Particularly interesting for this blog was that much of the discussion focused on getting the public ready and informed — whether it be family preparation, school/workplace policies, mass vaccination and risk communications.

I thought it would be helpful to outline some of the key issues/questions regarding the public that were discussed during the Summit. In addition to attending the panels, I spoke to officials to find out what they want the public to do as well as their concerns, obstacles and challenges in getting Americans prepared by the Fall. (I videotaped a few interviews and include them below.) This is a long post; I hope it’s useful.

At the Summit, federal officials offered a clear message to the public to start preparing for a possibly more lethal H1N1 outbreak in the Fall. However, they are still working out the policy and logistical questions that citizens would face in the event of a serious outbreak. The gathering was an opportunity for local officials to ask questions, provide input, and relay on-the-ground concerns to the feds as they will ultimately be responsible for implementation in their communities. The Summit addressed many of the concerns raised by the experts that I spoke to and blogged about earlier this month, though the answers are still being worked on.

Cabinet secretaries Arne Duncan, Janet Napolitano and Kathleen Sebelius listening to their boss, President Obama, speak to the Summit via phone from Italy.

To get an overview of the Summit (in addition to this blog post), you can check these articles: New York Times‘  “Obama Warns Of Return Of Swine Flu In The Fall”, the Associated Press’ “Swine Flu shots at school: Bracing for a Fall return”, or for a state/local perspective the Rutland Herald’s “State Officials Attend H1N1 Summit”. You can go to Flu.Gov for the Summit press release and panel schedule. The Health and Human Services’ (HHS) social media Twitter feed, FluGov, live tweeted the Summit with a guest blogger, David Hale. Heidi Splete of Medical News Net also tweeted the proceedings. You can also check the #09fs Twitter tags to read about activity both at the conference and in the blogosphere. There was also a conference call during the day in which top officials answered some good questions from bloggers around the country, including Greg Dworkin from Flu Wiki and Daily Kos, Mike Coston of Avian Flu Diary, and Sharon Sanders of FluTrackers.com. A transcript can be found here. Videos of the sessions are available here.

The day began with cabinet secretaries Kathleen Sebelius, Janet Napolitano and Arne Duncan along with White House Homeland Security Advisor John Brennan speaking to a standing room crowd at NIH’s Natcher Conference Center. President Obama called in from Italy where he was attending another summit, the G-8. (Ironically, he was in the town of L’Aquila, the site of a recent natural disaster, last year’s earthquake). After the initial plenary, there were panels and smaller breakout sessions largely focusing on schools, work place issues, vaccine distribution and communications. The focus was on examining the lessons and experiences from the Spring — what worked and what didn’t — in a largely open, self-critical manner.

Federal officials outlined their initial plans and raised the questions that they are currently trying to figure out (e.g. what should school closing policy be?); it was both a briefing for state and local officials and a way to bring them all into the planning process. In addition, the day served as somewhat of a pep rally for health leaders across the nation who have had a challenging spring and may have an even tougher autumn and winter. It was also a way to get media and public attention that H1N1 was not going away as a problem, and that the government was still on the case.

I thought I would highlight a few of the overarching themes I heard throughout the day regarding public preparedness for H1N1:

* Preparing Not Scaring — In his remarks, President Obama said: “We want to make sure that we are not promoting panic, but are promoting vigilance and preparation.” And throughout the Summit, speakers looked for ways to underscore the seriousness of the potential situation (”We’re planning for the worst case scenario”, “It’s a deadly threat”, “Time is of the essence” were some of the phrases used), but in the same breath emphasize that to date the illness has largely displayed only mild virulence. The hope is that the public is able to hold  that balance in their minds going forward. One of the goals of the Summit was to get Americans’ attention that H1N1 was a threat (and underscore their responsibility to prepare) without frightening them. Towards the end of the day, Sebelius summed up the message: “It’s not about panicking people or striking fear but motivating Americans to prepare.” That approach is useful not only for pandemic preparedness but emergency preparedness in general.

* Giving The Public An Information Inoculation: “Be Prepared To Be Surprised” – Secretary Sebelius said that when it comes to this flu we should all “be prepared to be surprised.” It was a phrase repeated throughout the day. New Centers for Disease Control (CDC) Director Thomas Frieden noted in his remarks that influenza is among the most unpredictable of illnesses. As an example, many speakers mentioned that in most of their pandemic plans there was the expectation that the flu (most likely Avian) would come from another part of the world rather than just south of the border. And as a result, we would have more time to prepare. John Brennan called it a “very dynamic situation” with a lot still unknown. I think there is great value in putting that word out in advance to the citizenry in order to sensitize them to expect — and not be shocked — by change, and that we need to be prepared for whatever eventuality and be able to turn on a dime. It is almost as if this Summit was the first round of an information vaccination protocol which hopes to build up resistance and resilience in each of us by the Fall.

* Help Wanted: Leading & Listening – Officials repeatedly said that they did not have all the answers and would need to engage all aspects of society, including the public, to help them in preparing and responding to an H1N1 outbreak in the Fall. “We can’t do this alone,” Sebelius said. Brennan offered an honest but reassuring “we don’t have all the answers, but we’re committed to finding them.” Obama ended his remarks by saying: “If there are any issues we haven’t raised, please let us know.” I think that this kind of leading and listening — we’re doing all we can but we can use your help and input — is a winning communications strategy. As part of that approach, Sebelius urged state and local officials in the audience to convene ‘mini-summits’ at home; that sounds like a good forum to engage and involve the public.

The National Institutes of Health, site of the H1N1 Summit

* Top-Down & Bottom-Up — Most of the decisions in a pandemic are made by local and state authorities, but they need clear guidance on tricky issues that have far reaching effects (e.g. when to close schools) from the federal government. One of the goals of the Summit was to get everyone in public health on the same page. To me, this top-down and bottom-up approach echoes the optimal manner of dealing with other emergency preparedness challenges: most disasters are local responsibilities but there are things that only the federal government can do and say in a crisis. In the case of the Spring H1N1 outbreak, information was coming not only from feds but also from other governments and even an international body, the World Health Organization. In this era of unfamiliar, potentially serious threats as well as a new media environment, local officials cannot do it alone. It needs to be both the grass roots and tree tops working together.

* You Can’t Spell TEAM Without DOE, DHS, HHS, ASTHO, ETC. – One of the challenges I have found in the area of emergency preparedness is that it tends to blend different disciplines — emergency management, health, public safety, critical infrastructure — that have different languages, approaches and org charts but which must work together on challenging issues, sometimes in a crisis situation. Having the three top Cabinet officials jointly oversee this Summit underscored the need to deal with H1N1 across agencies and stove pipes at all levels both vertically and horizontally. Brennan called it a “team approach,” and you did feel that spirit in the Natcher building on Thursday.

* Not A Waste No Matter What Happens In The Fall – Secretary Napolitano made the important point that the preparation that government, business, schools and the public undertake for H1N1 will be useful even if the flu turns out to be not to be severe. Preparing for a pandemic will only increase the public’s (and in turn the nation’s) resilience going forward for other emergencies. Again, this is an idea — preparation is worth the time because it will come in handy sometime for something — that is the rationale for all citizen emergency preparedness. I would suggest that H1N1 citizen preparation be integrated into activities for the Department of Homeland Security’s National Preparedness Month this September. In fact, I would urge federal agencies involved in citizen preparedness to consider tying their communications to the public in this area more closely together. For example, many of the same preparation and response recommendations for a pandemic would be made for a bioterrorism attack (obviously, there are differences: washing your hands may be effective for the former but not the latter.)

* Using Viral Media To Take On A Virus (Thanks for that headline to Chris Thoman) – Social media played an important role in the government’s H1N1 public education efforts in the Spring and that will only increase in the Fall. In addition to the comprehensive Flu.Gov site, Secretary Sebelius announced a new H1N1 video PSA contest (YouTube announcement below) with a prize of $2500, hoping to tap the “creative ideas of average citizens and young Americans.”

HHS Secretary Kathleen Sebelius announces new 2009 Flu Preparedness PSA Contest.

Between sessions I spoke to Richard Besser who, as Acting Director of the CDC, earned widespread praise for his leadership during the Spring outbreak. I asked him what the public should be doing now to prepare for the Fall (n.b. the button on my Flip camera was sticking so the video continues a little bit beyond the end of the actual interview, and I haven’t yet learned how to edit — but I will soon):

Dr. Richard Besser advises the public what to do regarding the H1N1 Flu.

As Dr. Besser, who heads the CDC’s Coordinating Office for Terrorism Preparedness and Emergency Response, says on the video, officials are now reassessing school policy. It is one of what are called “community mitigation” steps. One of the nation’s leading public health policy analysts, Jeff Levi of the Trust for America’s Health, told me last month that the U.S. does not have in place the social and economic policies that can support the significant public health recommendations which might be necessary in a serious outbreak. During the Spring, there were numerous reports of citizens with flu symptoms who went to work because they would not be paid or feared losing their job. Similarly, the costs of closing schools — in child care needs or school lunches — turned out to be more significant than expected (in Chicago, for example, 80% of public school children are eligible for a federally subsidized meal at school).

I thought I would take a shot below at outlining the big policy and implementation questions that the public should know about:

Do School Closings Work? — “We’re reassessing” was a reoccurring comment when it comes to the decision on schools and H1N1. There was a consensus among most speakers that the school closing policies need to be clearer in the Fall than they were in the Spring. Typical was the comment of Belinda Pustka, superintendent of Texas’ Schertz-Cibolo-Universal City Independent School District, during one of the panels which was addressed to the feds: ”What I need from all of you is an idea of when it is best to close, when it is necessary to close and when it’s not.” New York City Assistant Health Commissioner Marci Layton said her department is currently surveying schools to determine the economic impact of the closings and see what kids did with their free time (going to the mall wasn’t going to help stop the flu). On another panel, a Chicago school official said the city only closed two schools but instead focused on “exclusion” (ie. keeping sick students home) rather than closing while a Texas educator  said he felt that their district shutdowns were effective in slowing the flu’s spread. Federal officials are now, in the words of Secretary Napolitano, “working the problem.”

One thing I think that needs to be part of the approach is that the public should be included in the discussion over the effectiveness of school closings and other community mitigation steps, such as preventing large gatherings and distributing masks. It is my sense that most Americans believe that closing schools and other mandates were effective in slowing the virus. If that is not true, then the mythology should be debunked so in the Fall there will not be public calls and pressure from political leaders for measures that are really useless and disruptive.

Another goal of the Summit was to bring in grass roots practioners to offer feedback from the spring. One speaker, Mary Pappas, the school nurse at St. Francis Prep in Queens, New York, diagnosed the Big Apple’s first H1N1 case in April. In her comments, she highlighted the value of student cellphones in quickly alerting their parents about the news from school (and recommended every school have a registry of the mobile numbers of all parents). And she drew laughs when she offered this ‘from the trenches’ tip on what she told students: “If it’s wet and not yours, don’t touch it.” (By the way, the often unsung school nurse received a lot kudos during the day.)

Will Workplace Plans Work? — While the H1N1 did not have as much impact on business as it did in schools this Spring, that might change this Fall. At the Summit press conference, I asked Napolitano about what the government was doing in regard to businesses and their employees, and what citizens should be doing and asking in their workplaces. Her answer is below:

Secretary Napolitano answers a question I asked at the Summit press conference about business/employee preparedness for H1N1.

While bigger companies often have contingency plans, will smaller companies be able to cope? You could never expect a seamless private sector net, but it seems as if there might be significant holes which could be very problematic during a major outbreak. In addition to reaching out to big companies and trade groups, I think the government will have to use a robust bully pulpit, putting societal pressure on the private sector that in the event of a significant crisis sick leave and telecommuting, where possible, is the norm.

Another potential vulnerability in the planning was raised during one of the sessions by Paul Jarris, executive director of the Association Of State & Territorial Health Officers (ASTHO): undocumented workers (a worry in other disaster responses as well) not wanting to volunteer to participate in a vaccination program and how that could impact the H1N1 public health effort.

Will A Mass Vaccine Distribution Work? – Officials say that they hope to have a vaccine in October (though it may take longer) and will embark on a voluntary vaccination distribution program. A big concern among some experts I spoke to is the scope. How will such a mass vaccine be distributed? Will the public have concerns about participating? Will there be ample supply? Will October be early enough? Federal officials acknowledged that the logistics of the vaccination program will be a Herculean challenge with schools, medical facilities and other retail locations possibly having to dispense both 100 million-plus doses of regular winter flu vaccine – and H1N1 shots. “We know a mass vaccination program of even modest scale will involve extraordinary effort on your part,” Sebelius told the Summit.

I spoke to Anne Schuchat, director of CDC´s National Center for Immunization and Respiratory Diseases, after a breakout session about what the citizens need to know about the vaccination program. (My camera stuck on this video as well so the end runs on a bit beyond the interview.)

Dr. Anne Schuchat talks about what citizens should know about the H1N1 vaccination.

Can Public Risk Communication Work As Well Again? — Though the federal government’s communications throughout the Spring outbreak was widely applauded, there were some issues being discussed at the Summit for the Fall. In her remarks, New York City’s Marci Leyton said that improvements were needed in getting messages out to the “non-afffected” (ie. the ‘worried well’ who jammed hospitals); reaching citizens in higher risk groups (e.g. pregnant women, asthma sufferers) who required treatment; as well as better explaining policy differences between local/state government actions and CDC  recommendations (whether that be on schools, N95 masks or public gatherings). It is a challenge: one local official said that the key for health officers in the field and the public is “communication, communication, communication” from federal officials, but that the communication needs to be “meaningful, quick, accurate”.

In the day’s last panel, Barbara Reynolds, a CDC communications adviser and Dr. Besser offered some very interesting communications advice for the state and local officials based on the experiences of the Spring. Among their recommendations: be first; be right: don’t be afraid to give out information in chunks (Reynolds said Twitter had made it more acceptable to parcel out information in stages since you only get 140 letters); be credible;  be empathetic; give people things to do; don’t give out mixed messages; don’t be paternalistic. Don’t treat people like children (”invite public into the process”) counter rumors and don’t turn down media requests. Besser, a pediatrician by training, said he spoke at press conferences as if he was talking to a parent in his office. He said you should acknowledge the public’s fear and uncertainty but then turn it into planning and action.

I had met Dr. Besser last year in Atlanta during a pandemic training session at NIH, and I had participated in a mock press conference as a reporter to test officials like him who might have to brief the media in the event of a pandemic. And in fact, one of the stakeholders that will be central to the communications challenge but did not get mentioned much during the Summit is the media (both mainstream and ‘new’). There is obviously no way to fully coordinate or manage the press’ coverage of H1N1. But the more knowledge and information the media has, the less likely it will stoke panic among the public. I imagine that officials will be briefing them soon on the same issues that were discussed at the Summit.

I asked Rear Admiral W. Craig Vanderwagen, who has been the HHS Assistant Secretary for Preparedness for the past three years, for his take on how citizens should be preparing for the Fall:

Dr. Craig Vanderwagen speaks about how the public and its institutions should be dealing with H1N1.

I also asked Paul Jarris, who oversees the state health officers association, what he recommended to the public in advance of the Fall. He said it should begin with some extra supplies:

Paul Jarris from ASTHO talks about making sure Americans are prepared for a possible H1N1 outbreak.

The value of the Summit may have been best summed up to me by California Public Health Officer Dr. Mark Horton (below) who said he had come across the nation with low expectations thinking that it would be just a bunch of public health officials talking to each other but he was struck by how much he learned.

Dr. Mark Horton, California’s Public Health Officer discusses the H1N1 Summit.

The challenge going forward, however, is not only to educate and persuade the public to prepare but it is to make sure that the institutions — ie. schools, businesses, public health and other government areas — are set up to make it easy for the public to do so. One way will be to have the kind of discussion with the American people that occurred at NIH on Thursday. This blog will continue to cover this unfolding story and the work being done on the federal, state and local level on behalf of the public. If you have comments or questions, I’d love to hear them.

The combination of Twitter and epidemiology presents an interesting opportunity: What if doctors twittered about symptoms they observed and diagnoses they made? What if that information was aggregated in a way that helped track disease outbreaks in real-time, share treatment plans, and save lives?

Combining health data with social media tools to track disease outbreaks is a simple concept. Executing this in the real world, however, is extremely difficult. Dr. John Snow, the father of epidemiology, tracked the 1854 Broad Street Cholera outbreak in London’s SoHo district. Dr. Snow recorded the locations of the 600 cases of Cholera on a spot map, spoke with SoHo residents to learn more about how the disease spread, and finally concluded based on the locations of the cases and personal encounters that the Broad Street water pump was the main agent responsible for spreading Cholera.

Fast forward to 2009. How can we combine social media tools with electronic medical records (EMRs) to help track disease outbreaks like the Swine flu?

Today, Dr. Snow’s interaction with SoHo residents could theoretically have been done via his Twitter feed. The modern day equivalent of Dr. Snow’s spot map may look something like this Google Map/Twitter “mash up”, which combines the visual affect of a digital map with the real time tweets from Twitter users talking about the Swine flu. However, when looking at that mash up, you’ll see that there is no filtering of the tweets’ relevance to an epidemiologist’s needs. Any communication referencing Swine flu, from jokes to local news stories, appears on the map.

Bio-surveillance company Veratect is trying to track diseases in a similar way by monitoring social media traffic on blogs and Twitter feeds talking about the Swine flu. Even though Veratect’s project is much more robust than the Swine flu map mash up, it still suffers from a high signal-to-noise ratio. What exactly constitutes evidence of a disease outbreak when you’re monitoring social media traffic? How can doctors and epidemiologists verify the information being sent in?

Imagine this. Doctors around the world are conducting their rounds and examining patients on electronic medical records, which document diagnosis codes. As the physician makes a diagnosis or documents symptoms, he has the option to “tweet” that observation. This allows other doctors to follow that feed and observe trends. Even better, epidemiology-specific analytics can be layered on top of the feeds to recognize patterns as they develop.

Thoman, whose company Software Advice is a computer consultancy, offers a fictionalized scenario if doctors used Twitter during a disease outbreak. And he adds:

This adoption by doctors would need include a verification system that only allows trusted or authenticated users to tweet about information contained in the EMRs. What we’re trying to avoid is aggregating a whole mess of data related to a particular disease. Authenticating users to make sure they are who they say they are avoids this problem.

With a uniform set of diagnosis codes and a proper authentication system, suddenly the trending data sent out by these verified doctors’ tweets goes from speculative to extremely reliable.

Unique diagnosis codes could also be translated into other languages, making worldwide tracking of diseases a reality. Personal communication between doctors and epidemiologists would still be hampered by language barriers but at least every user of this system would have access to the same reliable information in their native language.

Twitter users employ “hash tags” to help group their tweets together. By using the # symbol before a word, that word becomes a hash tag and links each tweet of said tag together. Twitter groups these hash tags together as trending topics, allowing anyone to click on a hash tag and bring up every tweet that references it. Epidemiologists could aggregate disease data coming from doctors in a similar way, substituting the Twitter hash tag search for a diagnosis code search.

During any disease outbreak, time is of the essence. Many government and health agencies around the world aggregate their data on potential outbreaks but do so on a weekly or semi-weekly basis at best. The technologically primitive nature of the vast majority of the world’s health care systems prohibits catching most outbreaks in their infancy. Even if a disease outbreak is discovered, that outbreak may only be realized at the local or regional level. When you’re talking about potentially killer diseases – Swine flu as a recent example – an advance warning of even a couple of days could mean thousands of lives would be saved.

The real time nature of a Twitter EMR system would allow epidemiologists to get a jump on disease outbreaks. Much like the trending topics section of Twitter, symptoms and diagnoses could be tracked by their frequency as they’re submitted by doctors. Algorithms can be developed to push relevant diseases and their diagnosis codes to the top of epidemiologists’ tracking lists.

Naturally, there are going to be privacy concerns about doctors tweeting patient information out into the digital world. However, no personal identifying information is required to track diseases in this scenario. The only name associated with the posting of this health information would be the doctor’s. Even that may be an alias.

The combination of social media and EMRs, in some form or another, will undoubtedly be part of the future of tracking disease outbreaks. The how and when of that process remains complicated, dependent on health agencies, governments and the doctors themselves to implement the appropriate systems. However, the “viral” spread of Twitter leads us to believe that physicians may not have to wait around for bureaucracies to organize an epidemiological social network. Like the Iranian opposition party, they may organize it themselves with Twitter.

After the U.S. government declared a public health emergency in April, 46 of 50 state health departments posted some information about the H1N1 outbreak within 24 hours of the federal announcement, according to Rand Corp. researchers. However, only a third of the 153 local health departments included in the study posted information on their Web sites within 24 hours of the federal announcement.

The researchers also found wide differences in performance among local health departments in the five states with confirmed swine flu cases at the start of the outbreak — California, Kansas, New York, Ohio and Texas. About 73 percent of counties in California quickly provided some information on their Web sites, compared with 18 percent of counties in Texas and eight percent of counties in Kansas.

The study also found that content posted by most state health departments was of high quality. Forty-three of 47 state health departments provided information about how people could protect themselves or their family, 36 of 47 offered information about when to seek treatment and 27 of 47 explained who should take antiviral drugs.

Among the other findings:

* 30 states provided information for health-care providers, with 14 posting their own information and 16 linking to information posted by the U.S. Centers for Disease Control and Prevention.
* Just over half of state health departments posted a news release, and nine provided information in languages other than English.
* Of the 34 percent of local health departments that posted information on their Web site within 24 hours of the federal announcement of a public health emergency, 54 percent did this by linking to the CDC or their state health department Web site.

“We found that the capability to conduct basic crisis and emergency risk communication is quite good at the state level, but there remains significant variation at the local level,” the study’s lead author, Jeanne Ringel, a senior economist at Rand, said in a news release. “We concluded there is room for improvement at all levels, particularly in the area of providing information in languages other than English.” The study appears online in the journal Health Affairs.

Thanks to HHS’ FluGov Twitter feed for the link. (The Los Angeles Times‘ Booster Shots blog also had a story on the report.)

“The internet is buzzing with tweets, diggs, podcasts, widgets, and avatars. With these new social media technologies emerging at such a fast pace, it can be a challenge to make sense of what these developments mean for public health, and to decide how to use them to increase emergency preparedness. However, with some planning, you can incorporate social media technologies into your communication plans to increase the impact of existing strategies, to reach new audiences and to enhance trust among existing ones.”

The guide is a helpful brief overview for any institution using or planning to use social media in public health and emergency preparedness. It’s also a good introduction for individuals who want to take advantage of these new applications in preparing themselves. The two-page piece can be found at http://publichealth.yale.edu/ycphp/newsletters/Social%20media_PH.pdf. Thanks to Robert Buzzerd, a paramedic and graduate student, for bringing this to my attention.

In the context of a global pandemic — where media networks are doing their best to spice up an already serious threat — having millions of people wrap up all their fears into 140 characters and blurt them out in the public might have some dangerous consequences, networked panic being one of them. If you think that my concerns about context are overblown, here are just a few status updates from random Twitter users that would barely make you calmer (or more informed) about what’s going on. [A couple examples: "I'm concerned about the swine flu outbreak in us and mexico could it be germ warfare?"/"Swine flu? Wow. All that pork infecting people....beef and chicken have always been meats of choice."]

For the past few days, I have been closely following the unfolding H1N1 situation on Twitter through organizations and people whose Twitter feeds I “follow” and have been distributing my blog posts through my own Twitter feed. I agree with Morozov that there is a potential for Twitter to spread misinformation and fear. However,  I would argue that thus far the platform has been largely self correcting and both the government and individual feeds have been good at directing users to reliable sources of information. Yes, it is true that if you search #swineflu on Twitter you get a melange of tweets that are not hugely helpful to someone looking for solid information or advice. But to me those are just innocuous messages which most Twitterers will read and ignore. And just as likely, they will find a tweet referring users to reliable government sources of info and guidance or a new headline. Morosov is also concerned that there is not enough solid information being distributed through Twitter: 

Here is a tough question to communication experts out there: how do we reach the digital natives out there, especially those who are only accessible via Facebook and Twitter feeds? The problem is that while thousands of concerned and misinformed individuals took to Twitter to ventilate their fears, government and its agencies were still painfully missing from the social media space; the Twitter account of Centers for Disease Control and Prevention was posting updates once in a few hours — and that was probably the only really trustworthy source people could turn to online.

Right now, I think there is enough information out there (see below). But to me a bigger concern is whether the current governmental social media capability — nationally and particularly locally — is robust enough to handle a major decentralized crisis such as if Swine Flu turns into a major pandemic here. To date, the important information for the public (H1N1 numbers, general instructions) has been relatively centralized and limited. But if it the flu spreads widely Americans will be going to social media applications like Twitter looking for more detailed information (as well as offering their own reports). These new methods of distribution offer both a challenge and an opportunity for officials. The question is whether they presently have the capability to deal with it. I expect that authorities at federal, state and local level are now trying to figure out how to use social media during a pandemic. One suggestion would be to engage bloggers to help them in getting information out to the public through their channels.

As far as getting the latest news and advice on the ongoing situation via Twitter, I am following the CDC Emergency Preparedness Twitter feed (which is tied to the CDC’s main Swine Flu/H1N1 site. I also follow the U.S. Health & Human Services’ Pandemic Flu feed, the U.S. Department of Homeland Security, the American Red Cross (and its prolific Portland, Oregon chapter) and the American Public Health Association, Veratect (a private company that tracks disease globally) as well as individuals like Greg Dworkin, co-founder of the FluWiki and David Stephenson, a social media/disasters/e-government expert. There is another popular Swine Flu information feed H1N1Info. You might add a reliable news media resource like CNN. If your local or state government has a feed, I would also subscribe to those (in addition to any text and email alerts they offer). And then you can find trusted internet experts such as Mashable which leads you to information on how to filter out noise on Twitter about  Swine Flu or how to best utilize web tools during the outbreak. Also helpful resources are the blog Homeland Security Watch and the daily reports on the Center On Biosecurity. Please tell me if you have other suggestions.

*Contrary to most disaster movies, “up to 50 years of social research show that people by and large do not panic, they creatively cope…people are reaching out, adapting to changing situations and putting others ahead of themselves.”

*We have to think more broadly about the citizen’s role in public health preparedness. Typically, we’re asking citizens to set aside an emergency stockpile of essential goods and asking them to tune to media in an emergency for instructions. Both are important. But don’t limit citizen role to private action.

*Involve citizens more in community action and decision making. Give people opportunities to volunteer and provide input to public health planning.

*Citizens offer complementary skills and resources to uniformed responders in a disaster.

*To promote community resilience, government should allocate some public health spending for community-based and faith-based organizations who can work along side authorities and medical personnel building up infrastructures to distribute information and mass amounts of medicines if necessary.

The Centers for Disease Control and Prevention has directed 72 major American cities to devise plans to distribute anthrax antibiotics to all their residents within 48 hours of receiving them. So far, few of these cities are able to meet that goal. The traditional approach to dispensing medical supplies to a large population is to place the medicines in schools and other public places and instruct people to pick them up. The main shortcoming of this “PODs” approach (for “points of dispensing”) is labor: there are not enough public health workers to distribute the antibiotics quickly, and cities would have to rely largely on volunteers to perform unfamiliar (albeit simple) tasks in unfamiliar settings.

A better way is to let residents stay home and have mail carriers, escorted by police officers, go door to door delivering antibiotics. This can be done within eight hours, trials in Seattle, Boston and Philadelphia have shown. While the mail carriers (who have already taken antibiotics) distribute pills, public health workers can make bulk deliveries to special populations like universities, nursing homes, detention centers, homeless shelters and large hotels.

After the mail carriers have finished their routes, the next police shift can be assigned to PODs, opened up to serve anyone who may have fallen through the cracks and to supply additional antibiotics so that each citizen can ultimately be given enough for the full 60-day course of treatment.

Besides being faster, the postal approach can reach those people who, surveys suggest, might refuse to go to a dispensing point. It would also require fewer workers, and it would be much better executed – mail carriers cover their routes six days a week through rain, sleet and snow. And the elderly, the handicapped and those without cars could obtain their pills more easily.

The issue of preparing the public for a bioterrorism attack has been a focus on this blog. I am also interested as a CERT team member as we might be asked to help distribute medicine to citizenry after a bioterrorism incident. Whether or not mail carriers are the optimal method of distribution (I am also very interested in the use of in-home ‘Med Kits’ which is now being tested as well), I think it is important that the public knows more about this issue, and Wein’s article — and its prominent positioning on the Times Op-Ed Page — helps accomplish that.

In my interviews with policymakers and first responders, I have found that the public’s role in preparing and responding to bioterrorism is a major concern of them. Yet, it is something that most citizens have little idea about. So, I think it’s very important that the government start a dialogue on this topic which should include: a) asking and beginning to answer what we expect our government to be able to do to respond to the range of terror threats and b) a higher profile effort to familiarize Americans what they might need to do in such a situation. To me, the goal should not be that every citizen knows everything about every possible terror weapon, but that the first time every citizen hears about these weapons and what to do is not after an emergency occurs.

Created by a research software developer Clark Freifield and a professor of pediatrics John Brownstein from Boston’s Children’s Hospital, HealthMap ”brings together disparate data sources to achieve unified and comprehensive view of current global state of infectious disease and the effect on human health.” 

You can search the map in a number of ways, including by country and infectious disease. The map is fascinating for a number of reasons. Just browsing through it offers a vivid reminder of how fertile our world is for infectious diseases. Then, you can find out the situation in your home area (ie. when I clicked on New York state on the map, I found out that West Nile Virus has just been discovered for the first time this year in Long Island). Healthmap is also a helpful reference if you are travelling somewhere in the world and want to see what, if anything, is going on there.

And, it is yet another example of how preparedness 2.0 applications can repackage, present and distribute emergency information to the public in new and accessible ways. Hat tip to John Bowen at the Hometown Security blog where I originally found HealthMap.

The Florida “Refill Bill” partially addresses an impediment for citizens trying to fully prepare for disasters. Practically every government preparedness site recommends that people store an extra supply of the prescription medicines they use in case of an extended emergency. For example, the Department of Homeland Security’s Ready.Gov site suggests that every American, as part of their emergency home preparedness kit, have an extra supply of:

“Prescription medicines you take every day such as insulin, heart medicine and asthma inhalers. You should periodically rotate medicines to account for expiration dates.”  Ask your doctor about storing prescription medications such as heart and high blood pressure medication, insulin and other prescription drugs.

But the problem is that most insurance plans and HMO’s do not allow customers to purchase extra medicine. So, you have officials instructing the public to stock medicine that many cannot get even if they wanted to. Unfortunately, this kind of situation is too often typical of citizen preparedness information campaigns — telling people to do something that isn’t possible let alone cost or time effective for them and then not helping them in any significant way to deal with that obstacle. As a result, it should not be surprising that so few people are actually prepared.

It is good to see the Florida legislature addressing the medical refill obstacle for their residents, many of whom are elderly with significant prescription drug needs. As Bowen smartly notes, “simply telling people to ‘be prepared’ is not enough. Sometimes you’ve got to remove obstacles for them. This law is a good example of that.”  

This is something that needs to be addressed in other states and by the federal government. And, it should be part of a broader, more complete effort to better educate and equip civilians to deal with their own (and their family’s) health needs during major disasters. Another aspect of that issue is how civilians will be provided medicine in the event of a significant public health crisis (such as a bioterror event or a pandemic). One possibility, as discussed in my previous post, is distributing emergency in home medical kits in advance.

The refill issue also illustrates the need for government emergency preparedness officials to take a new look at all the obstacles the public faces in the preparedness process. And then they should work with various stakeholders, including the private sector (in this case the health care industry) and the public itself, to figure out ways to address them. I think we would find that dealing with the obstacles to public readiness is less a matter of more government money than it is focus, creativity and effort.