Understanding the Public’s Response to a Possible Scenario Involving Inhalation Anthrax
Moderator:Leticia R. Davila
Presenters:Dr. Laura Ross, PhD and Dr. Gillian SteelFisher, PhD, MSc
Date/Time:July 23, 2013 2:00 pm ET
NOTE:This transcript has not been reviewed by the presenter and is made available solely for your convenience. A final version of the transcript will be posted as soon as the presenter’s review is complete. If you have any questions concerning this transcript please send an email to firstname.lastname@example.org
Welcome and thank you for standing by. At this time all participants are on a listen-only mode until the question and answer session of today’s conference. At that time to ask a question, please press Star 1 on your touch-tone phone and record your name at the prompt. This call is being recorded. If you have any objections you may disconnect at this time. And I would now like to turn the call over to this Leticia Davila. Ma’am you may begin.
Thank you (Susan). Good afternoon I am Leticia Davila and I’m representing the Clinician Outreach and Communication Activity (COCA) with the Emergency Communications System at the Centers for Disease Control and Prevention. I am delighted to welcome you to today’s COCA Webinar Understanding the Public’s Response in a Possible Scenario Involving Inhalation Anthrax.
We are pleased to have with us to today Dr. Laura Ross from CDC and Dr. Gillian SteelFisher from Harvard School of Public Health. They will discuss the results from public opinion polls which assessed how people would respond to a possible release of anthrax spores in an unidentified area.
You may participate in today’s presentation by audio only, via Webinar, or you may download the slides if you are unable to access the Webinar. The PowerPoint slide set and the Webinar link can be found on our COCA Website at emergency.cdc.gov/coca. Click on COCA calls. The Webinar link and slide set that are located under the call in number and call passcode.
At the conclusion of today’s session the participant will be able to: (1) describe the process used by Harvard’s Opinion Research Program for the public opinion polling, (2) discuss planning strategies emergency response planners can use to encourage adoption of recommended behaviors during a medical countermeasure response, and (3) identify perspectives that may be different for racial, ethnic minority groups and can enhance both communication and planning in such communities.
In compliance with the continuing education requirements all presenters must disclose any financial or other associations with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters as well as any use of an unlabeled product or products under investigational use.
CDC our planners and the presenters for this presentation do not have financial or other associations with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters with the exception of Dr. Gillian SteelFisher who would like to disclose that her spouse receives a consulting fee from Eli Lily. This presentation does not involve the unlabeled use of a product or products under investigational use. There is no commercial support for this activity.
At the end of the presentation you will have the opportunity to ask the presenters questions. On the phone dialing Star 1 will put you in the queue for questions.You may submit questions through the Webinar system at any time during the presentation by selecting the Q&A tab at the top of the Webinar screen and typing in your question.
Our first presenter, Dr. Laura Ross, currently serves as the Lead Health Communication Specialist for CDC’s Division of State and Local Readiness. In this role she provides technical assistance to state and local public information personnel who are planning to respond to a large scale medical countermeasure response. She has worked on the development of 12 previous Division of Strategic National Stockpile satellite broadcasts, and has served as a content editor for CDC’s Public Health Workbook to Define, Locate, and Reach Special Vulnerable and At-Risk Populations in an Emergency. She has written the public health - the public information and communication section of the operational guidance that state and local project areas use while planning for a medical countermeasure response. Her previous research also includes national polling to determine the public’s likely response to a widespread aerosolized anthrax attack and further investigation into the balance of fear and efficacy messaging in emergency preparedness.
Our second presenter, Dr. Gillian SteelFisher, is a research scientist and the Assistant Director of the Harvard Opinion Research Program at the Harvard School of Public Health. She directs Harvard’s Opinion Research Program on biological security and the public, which involves a series of polls at the international, national, and state levels to understand public response to threats of health emergencies including emerging infectious illnesses, foodborne illness, and bioterrorism. Dr. SteelFisher also directs complementary polls of public health professionals including physicians and pharmacists in these same areas. She has published articles on public health topics in the New England Journal of Medicine, MMWR, Bioterrorism and Biosecurity, and the Journal of Food Safety, and also lectures regularly on the role of public opinion health policy and the use of mixed methods to study public health problems.
Again the PowerPoint slide set and the Webinar link are available from our COCA Webpage at emergency.cdc.gov/coca. At this time, please welcome our first presenter, Dr. Laura Ross.
Dr. Laura Ross:
Thank you Leticia and hi everyone. It’s really a pleasure to be here. It’s really exciting to get to talk about the polling that we’ve done to determine the public’s response to an anthrax scenario. So, I’m going to do just a very quick overview presentation to warm you all up for Gillian to talk about some of our data and the results of this polling, but I just wanted to provide some context for the polling.
So, for those of you who aren’t familiar with it, the Strategic National Stockpile or SNS, is a large cache of pharmaceuticals and other lifesaving medical materiel and equipment that’s designed to supplement state and local medical supplies in an emergency, in which the state or local supplies run out or even if it looks like they’re going to run out.
The Strategic National Stockpile was originally designed with the threat of Category A agents in mind particularly those that could be mitigated somewhat with early antibiotic prophylaxis or antimicrobial prophylaxis such as anthrax, plague, tularemia.
It’s since been very much expanded. We’ve taken on the threats of a flu and pandemic flu as well as we’ve got burn blast kits and some other countermeasures for other things as well.
And some of you might also be familiar with the terminology 12 hour push package and managed inventory and these are some of the ways that we from the federal government are able to get these materials out to the state and local jurisdictions in need.
So you’re thinking by now at this point that’s great, but how does it actually get to the people who need it? And so, this is kind of our medical countermeasures operation diagram here that’s on the screen now.
So the SNS assets are maintained, you know, year round in these warehouses located across the country where the federal government stores them. And we’re responsible for the operations, logistics, and maintenance of these things so that when they are requested by the state who is having such an emergency, we from the federal government get them delivered to the state.
And we’ll usually deliver it to what we refer to as an RSS site, but really you can just think about it as a big warehouse site where we turn this stuff over.
So then from that point the state then takes these assets and they would then deliver them to the local health jurisdiction to open and operate what we refer to as Points Of Dispensing, or PODs.
And so you see this pretty picture here, but keeping in mind that if we have something like an anthrax attack we might only have such a short amount of time to get all these medical supplies into the hands of the people who need them most.
So generally our planning scenario, based on epidemiologic data, has been about 48 hours. So mind you that it takes a little time for us to get it to the state level, and then from then on we really have this planning job of getting these pills into people’s hands within the rest of that amount of time. So it’s a very, very heavy lift on getting our public to the PODs in addition to getting the medicine all the way to that point as well.
So when we look at our main goal here, you know, we talk about getting pills into people. And this is the idea that I was just talking about. We’re really trying to mobilize the public to get to our PODs, our dispensing sites, but also providing them the information that they need while they’re there to help get them through in a quick - in a quicker manner encouraging them to take the pills as they’ve been directed and answering their questions all along the way, before, during, and after this process so it’s definitely a big heavy lift on the public information side.
So when we start to think, you know, from my position at the federal government providing technical assistance to the state and local jurisdictions on this type of plan, you know, a whole lot of questions come to mind with this.
And we start to think well, you know, if we’re trying to develop the best messages possible to get the public to do what we’re asking them to do, we come up with all these questions.
Well wouldn’t it be nice to know what the public does already know about anthrax. And would they be believing in its severity and their own susceptibility? So essentially how concerned are they about this type of an attack?
And if we do - on that unfortunate day actually have to go through something like this, will the public get their pills in this recommended time frame that we are saying that they need to get their pills in? So are they going to act on our recommendations?
And if they do say go and get their pills at the POD are they going to take their pills? And what about the children? Are the children going to be able to swallow the pills even if we do get them into their hands?
And here we’ve got all this planning on opening up PODs in the affected jurisdictions by the anthrax attacks, what if people start leaving that jurisdiction? So these are other planning considerations that we needed to start coming up with.
As well as, you know, as we’ve progressed over the years in our planning on a national level for getting pills into people in this very quick manner there’s been lots of exploration into ways that are not these traditional points of dispensing in order to get pills into people.
So we’ve talked a lot about using private institutions, large corporations, maybe university systems to act as what we call closed PODs or closed Points of Dispensing where they would dispense to maybe their employees or their employees families after that.
And we’ve also talked about, you know, partnerships with the United States Postal Service of an option for possibly delivering medications to people’s houses in this amount of time.
So given these other options that we’ve seen coming out there, we thought it would be fair enough to also investigate if the public considers these alternates fair when they might only be enacted for certain segments of the population.
So with all those questions in mind, this is when we decided to partner with Gillian and her group at Harvard to try and help us find out the answers to those questions.
We really wanted to obtain information about how the public at least thinks they’re going to react during this type of doomsday scenario that we provide them.
And trying to figure out if they’re not going to go to the PODs or they’re not going to pick up their medicines, why? Because once we’ve gotten this information it can help us improve our own messaging to make it better. And also we can use this data to develop informed plans at all levels.
So our general approach to doing this we’ve now conducted three rounds of national telephone polling, both land lines and mobile.
We started this off in December 2009. This is our first go at the polls. So we had a lot of baseline knowledge that we wanted to collect to see where the public was.
We also wanted to see, you know, just in a very basic sense are they going to go to the POD if they’re being told to go to the POD.
And we wanted to see what they considered their trusted sources of information during such a scenario.
Roughly a year later we were able to ask many of those same questions that we asked the first time around. That enabled us to get some trend data on what the public was thinking. We were also able to add a couple of new questions to our polling where we asked about people’s perceptions of the U.S. Postal Service delivery option that I just mentioned as well. And we were also able to do some different sampling so we could look at differences between racial and ethnic groups as well.
So then we were able to do a third round of polling and that’s really what the focus of the data that Gillian will be sharing with you in just a minute but we were again able to continue trending our data.
We started looking at if people are going to flee that - evacuation likelihood. We started picking up some pediatric issues on if people - if children in particular, would be able to swallow pills but we also expanded it to find out about adults ability to swallow pills.
And then again we wanted to scan the public’s perceptions of the close PODs as another alternate modality for dispensing this.
So with that set up I want to turn it over now to Gillian SteelFisher to talk about really what we found in all this polling.
Dr. Gillian SteelFisher:
Thank you so much Laura. This is Gillian here. I’m so glad to be with you all today and to share this important information.
It’s been a pleasure to be part of this project for several years now. And I’m going to try to present to kind of a synthesis by focusing on the third wave of the data.
We’ll cover kind of some key areas. And I’ll take about half an hour or a little more to do that. And then we’ll have time for some questions and answers at the end.
So the key issues is how do we go about this and why for goodness sake did the CDC partner with the Harvard Opinion Research Program?
Well essentially we’re kind of a unique research group. We’re a very applied group. And our primary focus is trying to support public health leadership with insights to help enhance our outreach and communications.
And we do this by conducting rapid polls. Now of course most of you will have heard of polls in the context of elections.
And essentially what we’re doing is applying that same technique they use in politics and major media organizations and we’re applying it to public health emergencies.
So we essentially go out and do quick short surveys of people to find out their response to an issue and in some cases their baseline reactions to something even before an event occurs. And that’s kind of the style that we’re talking about here.
We do find out much of the same information that they do in a public opinion poll in a political context though.
We need to understand well what’s the public baseline awareness of the issue already? What do they come to the table with so we know how to address that in communications?
What knowledge do they have or think they have that might shape their intake of new information?
What are their general attitudes both to the concerns, you know, the public health issue on the table and to some of the strategies that public health officials might be recommending? What are they actually doing? And where are they getting their information?
With all of that kind of general information about the public’s response we can really provide much better strategic guidance to communications and outreach that can help motivate the public to take actions that will help protect themselves and their families.
So in this case and in many of our others we do a telephone poll. As Laura mentioned both landline and cell phone so we include the entire population as a statistically representative sample.
We conducted this third phase between December 17, 2012 and January 11, 2013.
And in the end we had a nationally representative random sample of adults. We had 1,509 total responses - respondents. And, we did it oversample of parents so we could address some of those pediatric issues. There were 676 total parents including 158 Hispanic parents and 171 African- American parents.
So I think Laura gave you a pretty good sense of kind of the major issues that we were trying to tackle in each of the waves, but let me just reiterate how this really happened.
What we do in the poll is we walk the respondents through a possible scenario. In this case we tell them that they are going to see in the news that there’s been illnesses among people and a couple of deaths and that officials think there may have been an anthrax attack but no one is sure of the precise location.
And so then we walked them through the reactions to this scenario. And then we outline what PODs are, what they’ll be asked to do, what they think they would do, and do as much sort of a mockup of the situation as we can understanding the limits that people haven’t really thought about this much before they get on the telephone with us. So we try to walk it through them pretty slowly.
We try to get their baseline understanding of issues, their baseline predictions about their responses, whether or not they think they’d be willing or able to follow recommendations, and how they perceive response operations again so we can guide them strategically.
And what we try to do is provide really overarching guidance. We don’t rely like gosh 26% of people say they’re going to do this so we’re going to take that number, you know, as, you know, as written in stone.
We’re saying okay what does this tell us about what people think now and how can we put all this data together to kind of make sense of it strategically? And this is really the way that polls and political strategy are done as well.
So let me now walk you through the data itself and try to tease out some of the implications as we go so you can think about what are the takeaways for folks who might be involved in response whether you’re a public health communication specialist someone who may be involved a physician who might have an office or might be involved in the response yourself.
Okay. So let’s start at the beginning here. How knowledgeable is the public about “inhalation anthrax” and prevention after exposure?
So looking at the basic core elements of this that they know about and don’t know about and how might that shape our kind of first foot out the door in such a terrible event?
Okay. So we first asked people gosh have you ever heard of the term “inhalation anthrax?” And what we see here -- I’m going to try to use this little checkbox here to try to point us to -- is that about 20% of people said they were very familiar with the term, and another 42% said they were somewhat familiar.
So right here and here which means a little more than half about 62% said they’re familiar with the term inhalation anthrax.
Now what this means up front is actually not an unsubstantial number of people actually are not familiar with it.
So when you kind of combine those you’re looking at a little more than a third of the public who says they’re not very familiar or not at all familiar.
So that’s kind of the first piece. This isn’t going to be - some people think they know what it’s about but there’s still substantial share who actually really aren’t familiar with it.
Okay. Now we then asked them well do you think that actually inhalation anthrax is contagious that is can it be passed from person to person?
And what we found is that among those who are familiar with inhalation anthrax, 29% gave the wrong answer essentially. They said it was contagious.
And then an additional 54% said no it’s not contagious that’s the correct answer and an additional 17% don’t know.
So these are kind of the two groups that are kind of at risk, this yes they’re contagious or don’t know, because they don’t actually have the correct information that is they think they know what inhalation anthrax is about and yet they have some misperceptions and why might that be important?
Well right out of the box and we’ll see this kind of drawn out to the data people may be reluctant to follow instructions that require them to get close up to other people if they think those other people might make them sick.
So having them stand in line down in the POD might be a challenge for people who think that they’re actually putting their family a greater risk from that.
And so you want to make sure you have communications right up front to try to dispel that misinformation and actually have people get in line at those PODs and make the safest decision for their family.
So in total what we see is actually it’s pretty substantial. Forty four percent of the public are familiar with inhalation anthrax and know that it’s contagious but more than half the public has missing or misinformation that is they’re familiar with the term but they believe it’s contagious that incorrectly. They’re familiar with it but they don’t know if it’s contagious or they’re not at all familiar with it. Okay. So now we’re talking about baseline knowledge. Now what about whether or not they know that there is a vaccine? Okay. We thought this might be important because people might sort of the clamoring for the vaccine if they thought if they were aware of it.
Well it turns out at least right upfront today that only 22% of the public said yes there is a vaccine for anthrax, 42% believe there is actually not a vaccine, and more than a third say they don’t know.
So while this information will certainly change in the context of an emergency -- and you may see the people suddenly become aware of vaccine as media brings up the issue -- what it means is that baseline there’s no - there’s not a huge percentage of the public that’s aware of this.
And so if you are the first to present information you want to be careful about how you present that information especially when it’s going to be a prophylaxis that’s offered rather than a vaccine as a first step.
So it’s going backwards sorry about that. So we also wanted to ask okay well is their knowledge of the medicine besides vaccine to prevent illness or death from exposure to anthrax? And of course here we’re talking about the prophylaxis that we hope to be offering people.
And what we see is that there’s actually not much familiarity with this either. So 22% say there is a medicine, 40% say no there isn’t a medicine, and 38% said they don’t know.
So when you actually want to present people yes there is such a medicine you may have to combat some disbelief about it and try to make people aware of that.
And so again if you’re the first out of the box with the information which we hope to be in the context of a response this will be important to address upfront that there actually is a medicine because people aren’t going to know about it before you get to them.
So when we they first hear about news of anthrax cases in their city or town how are they likely to respond?
We want to find this out because this will help us determine whether or not they’re actually going to be concerned enough to be motivated to follow some of the recommendations or whether they’re going to think it’s going to apply to someone else but not themselves.
The general rule of research around public motivation is that until people feel that it is personally a threat to them they do not get off the couch.
And once they do they are much more highly motivated. And we see this across behaviors, across illnesses, across other kinds of risks, and natural disasters, and other risks that might be close to themselves and their family.
So first I want to ask okay well how worried are they about becoming seriously ill or dying if they saw or heard in the news there were anthrax cases in their city or town?
And what you see here is that just about half the public said they’d actually be very worried, and another third said they’d be somewhat worried.
So it’s actually a pretty sizable number here that we’re going to see some concern in the public. People are going to be nervous about this. And this is pretty consistent with other data we’ve seen about the public’s response to anthrax in general.
We then asked well what else are they going to do I mean we’re talking about PODs here but is this all, you know, is all for not are people actually going to leave even before we can tell them about the PODs?
And what we see is actually there’s a bit more of a risk of this then maybe some folks thought. We said well okay you’re going to be concerned. Do you think you’re going to be likely to stay or are you going to be likely to leave when you first get this information?
And what we see is that 40% of the public say they’re going to be definitely or likely to leave if they hear about these cases.
And so right upfront if the best thing and the safest thing for people to do is to go to PODs we have to anticipate an address this likelihood.
And I think some people said oh it will be difficult for people to leave and so forth but when you see that 40% of the public says yes they’d get out of town this is certainly something we need to think about as we prepare for PODs.
Now the key issue is okay well why are they actually going to leave because that’ll help us develop messages that would, you know, resonate and make them more likely to stay.
Now there’s been some concern that gosh people would just rush out to get the vaccine or get medicine
But in fact while that certainly may be an issue what we see is that the number one reason is that people think they could reduce the chance that they or their family be actually exposed to the anthrax that was still in buildings or other places 71% of people who would not definitely say - stay said this was a major issue for them.
Now another key issue right here is that what we see is they could reduce the chance that they or their family would be exposed to anthrax from other people who were sick with it right here.
Now remember we asked that first question upfront do you think it’s contagious? Well this really stems from people being confused about contagiousness.
So we can reduce this reason this motivation for doing something that’s unsafe which is leaving if we can make clear to people that they are not at risk from other people who may have been exposed to anthrax and who might be sick with it?
Some people would actually be worried about a second anthrax in their city or town. And so trying to develop messaging around, you know, we probably won’t be able to predict with certainty that there won’t be such an attack but tried to explain to people that they are safer if they stay even if there is another attack than if they leave and don’t get appropriate prophylaxis.
What we see is that a little more than a third think they would try to leave to get medicine to prevent themselves from getting sick with anthrax or to get the vaccine.
Now I expected an actual response once you tell people that there is a vaccine a medicine, that’s going to be available, this number may jump up.
So, you know, I wouldn’t place too, too much weight on this but I think what’s important is that when they don’t know there is PODs yet that we see these other issues will even without having PODs and without the knowledge that they could get medicine at the PODs or somewhere else they’re still pretty likely to leave. So that we really do have a risk that we need to address in our communications right up front.
Then we described to them well they’re actually going to go they’ll be antibiotic pills available. And that we tell them they’re safe and effective.
And the key question is will the public actually believe public health officials? What’s our credibility on this because of course without credibility people aren’t going to be motivated to go?
So we described the prophylaxis medicine, antibiotics, and we asked them whether or not they thought antibiotic pills that used to treat anthrax would be safe to take?
What we see is actually we have more than half certainly saying it’s safe if we count the 34% who say it’s very safe and the 48% who say it’s somewhat safe.
Now in the world of political polling we lay a lot of credence actually in the very safe category. It turns out that in order to say very safe as opposed to somewhat safe people have to have much stronger beliefs and the issue is more salient for them.
And so I tend to look at that very safe bucket as well. And what we see here is actually a third is okay but not great numbers in terms of the folks who say it’s very safe.
These people are probably most protected from some misinformation. But those who say it’s somewhat safe are a little bit more vulnerable to rumors or other things that might discredit claims about safety at the time of an attack. So I do worry about that larger bucket in the somewhat to safe category.
We see similar numbers when we talk about effectiveness 25% saying it’s very effective and 57% saying it’s somewhat effective so again sort of messages around safety and effectiveness with the pills will be critical.
In terms of credibility we’re also talking about sort of confidence in the government’s ability to actually deliver the antibiotic pills to take action. Will this actually all occur?
We’re going to say to them hey, you know, they’ll be these PODs. And then they have to say like well really will there be?
They’re saying it there will be but a lot of people were sort of at the nadir the very lowest point of public confidence in the government overall.
And this is a concern not only for public health but for other areas. And so we felt it was important to assess in the context of this response.
So what we see here is that when we look at the again sort of the very confident and somewhat confident buckets together we have about 70% saying they are confident that the government actually has sufficient supply of antibiotic pills but again when I look at that sort of very confident bucket it’s only 24%.
So it’s important to get messages out there to bolster confidence so showing pictures of the supplies if you can.
Not only just stating it but actually showing people, you know, moving the product even as it begins its journey from SNS all the way to the PODs will help motivate people and assure them that these resources really are being deployed for their use.
We also asked them about the confidence in the ability of local and state public health agencies to deliver antibiotic pills to the public.
As Laura showed in that diagram the pills have to get from the federal government all the way to local and state in order to get them into people.
And what you see is actually sort of similar levels of confidence, 19% saying they are very confident, 48% saying they are somewhat confident, so there’s some concerns here that we probably need to address.
And finally sort of the in between which is can we actually get the pills from the federal agency to the state and local public health agencies. And again sort of similar levels of confidence that we need to address.
Okay. So now we’ve told them that they’re going to be these PODs. We’ve told them all that. We’ve asked about their belief in safety and effectiveness of the pills, their confidence in the government’s ability to actually set up these PODs and get pills to them.
And now the question is will they come? So are they actually going to come to PODs and pick up the pills? That’s one of the first critical steps.
The somewhat reassuring answer is actually that we have about 69% who say they’re very likely to actually come to the PODs and get pills for themselves.
We have an additional 21% saying their somewhat likely. And those are pretty good numbers. You can see that sort of my very bucket here my key criteria is a much larger and wider bar on this chart so I’m happier with that.
We also asked them - parents about getting the antibiotic pills for their children. And, you know, not surprisingly we see slightly greater percentage of people who say they’re very likely to get the pills for their children.
Now we can all feel good about this. But the key point of polling here is to find out actually where our risk points are and to try to mitigate those.
So we focus in on people who said they were not very likely to go that is people in these other categories somewhat, not very, not at all likely and we asked them essentially why not?
Now one of the big key reasons the topmost reason is that they’re worried that officials will not be able to control the crowds.
So we’ve seen this in other major events. They’re nervous about going. They feel like they might be at physical risk for going down there.
And of course the media loved to show pictures of people having, you know, elbowing each other in lines, or worse, you know, scuffles in lines, or people getting out of control.
And we need to sort of combat that with a proactive images of people standing peacefully in line the security that would be in place and other efforts so local and state officials who are setting up these PODs need to have that in mind as they’re preparing.
We also see that although they told us that they believe that pills are at least somewhat safe again worried about the safety of the pills and side effects another top reason.
Worrying about being exposed to anthrax from other people sick with (it at site). There goes that same issue about contagiousness kind of rearing its head here again.
So if we can reduce this misinformation we can reduce this as a motivator for people to stay at home rather than come to the POD.
People also worried about getting exposed to anthrax left in the buildings, people or transportation.
And trying to explain to them that they’d be safer even with that exposure in getting the prophylactics will be important.
And also worried there won’t be enough antibiotic pills at the dispensing site for everyone who wants them. These are kind of the top issues here.
There are some other issues. We have a lot of reasons that we could develop effective messages. And I think some of these are really important to note.
This one in particular kind of comes up and we’ll see this in a moment is that people would want to wait to get the antibiotic pills until after they knew for sure or that their child had been exposed.
And this is critical for anyone on the phone who is a physician because what we’re trying to explain to people here is the idea of taking medicine proactively, prophylactically.
That is to prepare even if you don’t - you’re not sure you get sick or even if you’re not sure you have symptoms because as any folks who actually study anthrax from -- I’m not a clinician -- but from what I hear it turns out (that inhalation) anthrax is not a good thing to have.
And that from the time you actually are really diagnosed with having the illness or really having sufficient symptoms that you would - that you’d be able to diagnose it the disease of course is quite rapid and you have a very short amount of time. And once you get to that stage the treatment is much less effective in the prophylaxis.
But making this clear to the public who’s a little nervous about the pills this is something where physicians can really step in and make a difference in terms of enhancing their trust in the process and how they can protect themselves and their family.
They’re also worried about having allergic reactions to pills. So explain to people about the low prevalence of reactions.
There’s also another key issue here. They believe they will be able to get pills from someone else like their doctor.
So again for those of you physicians out there they may be coming knocking on your door. You may want to be prepared for having people kind of line up at your office.
So now I think some of these other - other issues we don’t have to go through in as much depth.
I’ll just note that we did ask about a logistics issue.
Here they’d be difficult to get there and back. And actually that wasn’t as strong a factor as some of these others.
So again this is attitudinal which gives us an opportunity to address things with communications as well as logistics.
Okay so now people say they’re going to go to the site. They’re going to put pills in their hands. And the question is actually going to put them in their mouth’s which is really the important thing?
And I’ll be honest with you when we first did this poll we thought this was a no brainer like right once they waited in line in our first poll we actually showed they would wait in line multiple hours to get the pills why wouldn’t they actually take them?
But it turns out that I was wrong. And a substantial share say they’re actually going to hold onto the pills for the foreseeable future about a quarter say that.
So this is quite shocking. We thought well maybe this is just people concerned about themselves. What about when they’re talking about their children?
But again we see some of the same results here that we have a 26% of parents saying they’re actually going to hold on to the pills instead of giving them to their children.
So again what’s the key issue? How can we find out more to kind of guide people while we try to find out why?
This issue of whether or not they would have symptoms already or they knew for sure they were at a place where the anthrax had been released they’re going to hold on to the pill and make sure of that.
And the truth is they will not have time. So getting them to understand that they need to take this whether or not they are sure that they were in a place that - where anthrax was released and whether or not they have symptoms is critical.
We’ve talked about trying to deal with this operationally as well and that is having sort of messages right on site but also having things like water that people will take the first dose in their mouth as they walk out the door or hopefully before they walk out the door and sort of begin that process and commit to actually following the regimen.
So they also would want to hold on to the pills in case of a second attack. So they’d want to get them even if they don’t think they’ve been exposed but they might be in the future. And again trying to explain to them that they need to take it regardless is critical.
Okay. So in this round we also asked people about swallowing issues because people have the willing to put them in their mouth but there are some challenges around getting people - formulations that they can actually take.
And there are some limitations in terms of whether or not people can get the pill form and whether or not be enough liquid or suspension form.
So we wanted to find out if people get the antibiotics will they or their children have a problem swallowing the pill form?
And then we also wanted to find out kind of tangentially since a lot of children won’t actually be eligible to take the pills we wanted to find out do they have a scale at home and that would facilitate their being able to follow the pill crushing instructions that would be complementary in places where there wasn’t enough suspension for all the children.
So this is a little bit of a technical note here. We asked people about their ability to swallow the pills about the size of an aspirin at least two times a day for ten days. So that was our metric of whether or not you could swallow.
So again for those of your clinicians and focus on actual swallowing issues this is not a clinical assessment of swallowing.
This is people’s perception that they can actually get the pills down their throat in an emergency twice a day for ten days.
And this is actually going to drive their behavior whether or not they’ve ever been diagnosed with a swallowing problem so this is kind of the key metric that we’re after and why we had to ask in a poll as opposed to looking at kind of the medical literature on this topic.
We asked of all adults and we asked this of parents whose children meet the 90 pound weight criteria. So under 90 pounds actually there’s no federal support for FDA allowance for children to take the pill they’d actually have to take the liquid form and have it be adjusted to their weight.
So we focused on children who meet the 90 pound weight criteria. We asked about each child individually to maximize the respondents.
And the way we actually screened for weight was that we asked each child who is at least eight years old -- so that we didn’t actually have to ask people, you know, is your two year old 90 pounds or more -- and so this is how it was done.
Okay enough of the methods what are the results here? The first thing is actually about 91% of adults said they could actually follow the regimen. They could swallow pills. And 8% said they’d actually need a liquid form, about 1% said they don’t know.
And this isn’t a terribly huge number. But you’re talking about, you know, roughly a 10th of the adult population who said they’re going to have (to get) suspension, and pill crushing instructions are going to be a substantial portion of what’s going on at PODs.
Of eligible children that who meet the weight eligibility for pill prophylaxis regimen we found this kind of what the percentage is so you can understand here.
About 36% were eligible children that is the child weighs 90 pounds or more or the parent’s weight - they were unsure about their weight and their child was at least eight years old.
And it seems like oh if they’re not sure why did you really include them? But we asked them straight out, you know, is your child more or less than 90 pounds.
And so this was like people who were on the cusp. So we figured to be conservative here we would include them in terms of the eligible children.
We get actually not terribly different numbers here but probably more children who say they’d need a liquid form or whose parents believe their child would need a liquid form.
We have about 15% including that we definitely need or don’t know. And about 15, 85% sorry who say they could swallow the pills.
So what is needed in total in terms of children? About 70% of children are actually going to need the liquid form.
So again in terms of planning for PODs this is a pretty substantial portion of what we’re going to be involved in.
And for this reason it makes sense to ask about whether or not they had a scale, whether or not they can actually follow some of the pill crushing instructions, and here we have about 60% who say they have a scale at home, 39% parents who say they do not have a scale at home.
And so when you think about some alternatives to actually just weight by scale to help parents with their pill crushing instructions and I believe there’s a separate research going on the formulation of those instructions but hopefully this sort of background quantitative data will inform that.
So the last topic that we covered in this poll was the perception of Closed PODs. I know Laura had talked about this at the beginning about having Closed PODs meaning those that would be operational at either large corporations, or at universities, and be focused on the populations most directly affiliated with them employees, or students, or related family.
So we first asked whether or not they thought they the public thought they would be fair? And we found out about 64% of the public said they’d be fair.
So that’s a pretty substantial size of the public who says they’re not fair. It’s about a third who say they’re not fair or they don’t know.
And this is something they probably haven’t thought too much about before the poll. And there’s some pretty, you know, in past efforts where they have been Closed PODs for H1N1 vaccine for example. There was a lot of public uproar about that.
So I think this is certainly a reminder to be careful about the presentation of that and to think about how to design that effectively and ensure a public compliance and continuing trust in government efforts to support the public.
We also said, you know, the premise of this is that, you know, in order to deliver pills to everyone more quickly state and local government could give some antibiotic pills to large employers (etcetera).
So we kind of premised that there was a logic to it since people wouldn’t probably just except gosh we’re just going to give it to these people seemingly preferentially.
And we asked them whether or not they actually believed that it would be more efficient as well? And what we see is like, you know, is the premise of this argument actually compelling to the public is what we’re trying to get at?
And what’s interesting is that 70% did say everyone would actually get more get pills more quickly this way.
But again you have this sort of substantial minority of folks who say that actually true everyone would not get pills more quickly. So these are things to think about.
Now I’m going to take one last minute and this poll provided a little bit of an opportunity to tap into an important area that was actually the major focus for us in round two of the polling.
And I encourage you to actually to go to the publication of our study in Biosecurity and Bioterrorism to look at the - at the data on this in more detail.
But I’m going to focus on just a couple of key findings from this and then we’ll close up for a question and answers because this is kind of the new questions in this poll and where we have a chance to provide some complementary information.
Okay so the first thing is that in terms of knowledge and awareness we talked in the beginning about people being knowledgeable about the awareness of medicine aside from vaccine to prevent illness or death.
And we said we know if people think there explicitly isn’t a medicine there can be some resistance or some confusion when you introduce that idea and potentially skepticism.
And what we see here is that whites and African-Americans were more likely than Hispanics to believe there isn’t a medicine.
And so that’s kind of key information when we kind of reach out to all segments of the population and make sure everyone has the same information to make healthy decisions. We want to take into account sort of what people’s baseline understanding is.
We don’t see the same issue in terms of no there isn’t a vaccine interestingly enough.
Another key area that we were able to tap into is actually the issue of evacuation that is would people actually flee?
And what’s important I think to note here is that this last bucket “definitely leave” well here we see that African-Americans and Hispanics were substantially more likely than whites to say they would definitely leave.
So in terms of people who are at risk from flight this is really a particular issue for racial and ethnic minorities. And I think again we need to be thoughtful about this and reach out effectively to populations with this information in mind.
We also wanted to address straight on the issue about fairness of Closed PODs. And to note that in terms of the populations who believe it’s not fair to have Closed PODs we see that African- Americans and Hispanics are more likely than whites to believe it’s not fair.
And so again in terms of reaching out to people something important in terms of perception and continuing trust in the government. There’s a lot of research suggesting that racial and ethnic minorities are less likely to be trusting of government particularly in some of these emergencies.
And that they bear a disproportionate burden of the harm that comes from public health emergencies. And so be mindful of this. It’s quite important.
Finally one last issue that I’ll address -- and it’s a little tricky with the clinical audience -- here but again we’re talking about people’s perception of their ability to swallow the pills.
And what’s interesting is that we see in African-American and Hispanic populations that more adults are likely to say that they will need the liquid form.
Now whether there’s any clinical basis to this I have, you know, is not really the point here. The idea is that folks believe they’re going to need this tool.
And so this is something that we’ll have to make sure that we reach out in support PODs that serve racial and ethnic minority communities more directly.
We see the same thing for their children. So you now get to up almost a third of African- American or Hispanic parents who believe that their child certainly more than a quarter maybe not quite a third but somewhere in there saying at least one of their eligible children will need a liquid form.
We saw this actually in our previous round where we talked - we had larger samples of African-Americans and Hispanics and we were talking about the Postal Service’s ability to deliver pills.
And we mentioned that they wouldn’t need a liquid - they wouldn’t be able to deliver a liquid form. And we saw some sort of sideline indicators that this would be a concern and maybe drive more racial and ethnic minorities to PODs rather than waiting at the - waiting for postal delivery.
So these perceptions can have real implications in terms of how we develop our strategic plans, how we operationalize these, how we reach out to people with communications, but also how we actually develop the infrastructure that’ll be needed to help families keep themselves safe.
So this is kind of the end of the data portion and hopefully just give you some keen insights into sort of what we collected, what the implications are, and hopefully made it relevant for you all.
And maybe now we can turn it to open some the lines for questions. And hopefully we’ll be able to provide some answers as well. Thank you so much everyone.
Okay. Thank you. We’ll now begin a question and answer session. To ask a question please press Star 1 on your touch-tone phone, un- mute your phone, and record your name clearly when prompted because your name will be required to introduce your question.
To withdraw your question please press Star 2. One moment please for any incoming questions. And our first question is from (Billy Adkins). Sir your line is open.
Thank you two questions. First of all great presentation. My questions are is there a conflict early in the presentation of the survey data. I thought there was a slide that said there was a high percentage of the population that thought anthrax was contagious. And that could prevent them from going to a POD to get medication yet the slide showed pretty significant number that said they would go to PODs?
And my second question is in the question relating to those who indicated they would be unlikely to go to a POD. I was wondering, were the respondents given reasons to choose from or did they supply their own answers that were later categorized such as they’re afraid crowds won’t be able to be controlled? Thank you.
Dr. Gillian SteelFisher:
Thank you so much those are great questions. I’ll try to reiterate them and make sure I’m answering the - sorry this is Gillian SteelFisher for the recording, try to make that I’ve addressed your question, if I haven’t please jump back on the line.
So I think the first question was whether or not there was a conflict because the data shows that people are fearful about they believe inhalation anthrax is contagious and this might make them fearful about going to PODs. And yet we see a large percentage of the population saying they’re likely to go to PODs.
So I think while not a conflict what we’re seeing here is kind of a tension. And that is that people are saying, you know, I’m very likely to go. You know, you have like more than half and close to 3/4 of people saying they’re very likely to actually go to the PODs.
But what they’re weighing in that consideration is all upsides of going and all the risks. And one of those risks is that they might be getting sick. They might get sick from anthrax by being close to someone else who has the illness that it’s contagious. They might get it passed from person to person.
So it’s not really a conflict in the sense that people, you know, there’s an underlying probability here like is risk of my not getting the prophylaxis worse than the risk of my getting sick from people that (are in line).
But what we’re suggesting is if we can reduce the number of people who believe that it’s infectious that weighs their - that puts more weight on the side of the decision to go because that means there’s one less risk that they have to worry about.
And so that’s kind of how we think about those pieces of the data.
The second question - and I’ll just go back to the specific slide that I think you’re referring to if I can find it quickly enough. We asked about reasons that people unlikely or only somewhat likely to go to dispensing sites within 48 hours to get antibiotics.
And it’s an interesting question here. Do we ask essentially what would be called open-ended, them to supply their own answers and then we would code it or whether we provide them answers and ask them to choose.
And we did the latter in this case. So we had worked up from previous qualitative research and from other inputs into the process about what kind of the likely reasons might be. And then we asked them in a randomized order to identify which of these factors are - for each factor whether it would be a major reason, a minor reason or not a reason at all.
And this allows people to kind of consider the issue. We think in some ways because this isn’t something that they think about every day. And they may be unlikely to think through all the possibilities on the phone with someone.
But this allows us to kind of tease out and move beyond some of the kind of initial challenges of asking people about these issues in a poll. Like it’s tricky to get kind of their quote, real answers here.
And so we try to supply them with things that they’re likely to be - tons of issues they’re likely to be exposed to through media so we can get a sense of their reaction to them as well. And we came with a list again from previous research.
The list that I’m showing you here is actually people who said it was a major reason. So of course if I included major reason or minor reason it would have been larger.
But we try to focus on major reason because this is really helps us discern what are the key messages that we have to get out to people because we want to address sort of the top critical issues for people given our limited ability to talk to them all day and reach out in which will be sort of - surely a sea of media and the communications.
So if I haven’t answered that question please jump back on the line. But I hope that does it and thank you so much for you question.
It does. Thank you very much.
Dr. Gillian SteelFisher:
Thank you. Our next question is from (Gordon Greene). Sir your line is open.
Thank you. Excellent presentation. You recently just a minute ago you mentioned media. And one of the things that is very much going to affect the results that you’ve gotten are communications locally.
If there is any reason to believe there’s been some kind of biological attack my guess is the media will be jumping on it very quickly. And there will be a good deal of information out there, some of it true, some of it not so true.
So the data that you’ve gathered is going to be very sensitive to concurrent media initiatives that are going on.
If they’re getting information from C. Everett Koop that’s one thing. And if they’re getting it from Justin Beaver or Kate Kardashian it’s something else.
Are you planning to do anything that looks at how to reach with certain information?
Dr. Gillian SteelFisher:
Well thank you so much for that question and I think you’re exactly on track. I mean certainly the media, it’s going to be a sea of information and media coverage both credible and not credible sources. And then we’re going to have to try to kind of navigate through that to try to reach people effectively.
There are two pieces that we try to do that with. So one is we do look at people’s views and credibility and their assessments of credibility of various organizations.
We did not include the Kardashians in our list. However we did include a number of other kinds of resources, federal and state. We included both political and non-political agencies and individuals. It’s not in this round of data but it’s in some previous.
And we had done similar things in other areas. And we do find that the CDC and state and local public health departments are viewed as credible.
In general we find that scientific and medical people are seen as more credible than politically appointed ones.
And this is very important for those of you in public health departments or working with public health departments because very often like the mayor or whoever else wants to get out in front and explaining that there is really a critical role in terms of credibility when you have someone with a scientific or medical background can be important in getting your message out there more directly.
And also that people some may search more broadly due to trust physicians and nurses and actually pharmacists. And getting spokespeople to serve in those roles who have that background can help enhance their credibility.
So we have some data that kind of support the strategy around this is actually - exactly as you suggest.
And hopefully what - the data that I have here it’s not an exact prediction of people’s reactions because as you say this may vary substantially when people hear from media.
But this gets at kind of the baseline so that we know what we’re working with so if we hear there are really rumors about the infectiousness of inhalation anthrax we know we’re already addressing it.
Or if we hear rumors about the safety of the pills we’re - we can come out proactively with information and maybe can kind of contain that media and information kind of direct it more strategically at the time.
Sounds like you’re on top of it. Thanks.
Dr. Gillian SteelFisher:
We try to be. Thank you so much for your question - appreciate it.
Thank you. Our next question is from (John Hernandez). Sir your line is open.
Yes, good afternoon. Thank you for the presentation. It was very good, very informative.
I work in Texas. I’m an SNS (Coordinator) for (far) West Texas region. We are a border state. One of my questions in regards to this was the high responses of the Hispanic population being fearful or being hesitant to reporting to these PODs.
Did you guys take into consideration the immigration status of those individuals? And if so do you think there’s a fear of deportation or mistrust of the government once information gets put out?
Dr. Gillian SteelFisher:
So this is a really critical issue. And I thank you so much for your question and your work in this area.
So the questions that we asked in this poll did not ask about immigration status explicitly. Part of the challenge and just be upfront about the limitations about this kind of research is that - well there’s two challenges.
So one is it would actually be difficult to get people to disclose their immigration status in a poll because people who are undocumented may not be as likely to answer a poll. And so they may not be as well reflected in this.
But also even if they answer the poll they may not want to tell you their status.
Second I would not want to have that fear as part of it so I do not ask people about their immigration status in this particular context. We have in another context.
So in terms of the limitation of the poll this may not fully reflect people who are sort of - who are marginalized for various reasons who are less likely to answer a poll who are fearful about doing so.
That said I think we can apply some real intuition and logic from some of that data. And it really shows in other contexts that people are fearful of these things and that certainly this may play a role.
And so I think it’s well advised to try to account for that upfront and to make clear that people will be safe in this context. They won’t be, you know, asked to provide documentation of their immigration status to be protected.
I think maybe Laura can speak to this about the - more directly about the specifics but people’s ability to get (prophylaxis) pills is going to be a sort of ride as possible to make sure we have as much coverage.
Because the real goal is just to get as many pills into people as possible. So I think you’re right on track with considering that and suggesting that may be a risk and a concern for people and addressing that. Maybe Laura can tell us briefly if there’s any other considerations from the technical guidelines perspective.
Dr. Laura Ross:
Yes so this is Laura and did just want to add on to that. You know, it has been a recommendation in the past not to require any type of ID for people going to the points of dispensing.
So you might want to consider having that as one of your key messages going out if you’re really - if you have a high population that might be fearful of going to the POD because of that.
So things like that. There might be some other messaging. There might be some strategizing with community organizations that serve that group to ensure that those are actually trusted messages as they come out.
But yes I think it’s definitely a valid point and it’s one of those operational considerations that we take as well.
Thank you very much. I appreciate it, great job.
Operator we do have a question that has come through the Webinar system.
The question is do you advise stockpiling Cipro or other antibiotic to distribute to employees and their family members in the event of a mass anthrax exposure?
Dr. Laura Ross:
This is Laura and I’ll go ahead and try and take that one.
So what we would advise if there are corporations or larger organizations that are interested in doing such a thing is that they work with their local public health jurisdiction. Many local public health jurisdictions as I was mentioned earlier when I was talking about closed PODs and that as a concept.
I would say work with the jurisdiction and see if that’s an option for the company or the corporation cause then that could be accounted for when they’re - with their planning and, you know, there would be a lot of assistance to be able to provide both ways both from the corporation to the health jurisdiction and from the health jurisdiction to the company in designing and laying out and thinking through many of those considerations. So I would advise that type of connection get made.
Okay we do have four more questions on the phone. The next question is from (Kerry) with the Department of Health.
Hi. Actually it’s (Sherry). It’s no problem. But thank you for the presentation. We really enjoyed it. There’s a couple of us in the room. And just a question regarding your sample size. Noticed that your sample size was somewhat small. And I was just curious the method used to choose your sample size and why such a small group. Thank you.
Dr. Gillian SteelFisher:
Hi there. So this is Gillian answering. So our sample’s about 1,500 people. And actually in terms of national representation it’s actually a pretty big sample. Most polls are about 1,100 people and so we have a booster sample here.
And at the national level you get a confidence interval or the ability to specify really around like the two points eight-ish sort of level here. So actually it’s pretty precise.
And so we followed polling guidelines which really suggest that you need a specific representative sample in order to provide this kind of level of guidance.
And here we wanted to have the additional sample to be able to look more closely at parents and then where possible at racial and ethnic minority parents.
Now once you get down to these smaller samples your confidence intervals or your ability to say things with precision, you know, does go down a bit.
And ideally if there were a bigger budget I’d love to have bigger samples of Hispanic parents and African American parents. And that was one of our focuses for round two where we have much bigger samples.
I apologize, I don’t know them off the top of my head but there are bigger samples of Hispanics and African Americans there. So we can look at that a little more closely and provide a little more in-depth response to some of the key questions here.
Thank you so much for your question.
Thank you. Our next question is from (David Dietch). Your line is open sir.
Good afternoon and thank you. This has been very informative. I wanted to know if there has been any research on techniques or approaches to reducing suspicion in a population or if any such research is planned for the future?
Dr. Gillian SteelFisher:
That’s a great question and it’s actually something I think that public health agencies struggle with a lot but not only public health agencies do is across the board there’s a growing suspicion of government agencies and of other institutions. And we see this in polling data going back at least the 1970s and before that were really kind of at a low point.
And so these challenges we all face it, you know, the research about improving the trust is not as good as the research suggesting that it’s low. I think is a huge challenge.
Some of the strategies that people have talked about includes sort of ongoing messaging and relationship building, finding key informants who can partner with an organization to help build bridges into parts of the population that might be more distrustful and to having credible spokespeople that the public is connected with.
So as I mentioned, you know, building spokespeople who have technical training who reflect particular ethnic or religious backgrounds and who are sort of stayed members and stable, trusted members of the community are kind of the key strategies that people work on.
And I think maintaining, there’s a lot about kind of crisis communication talking about how when you reach out you need to provide people with the information that you have in a timely manner that you’re not reactive but proactive with information, that you’re empathetic to the people who are suffering under the circumstances that you provide people with information as it changes and you’re honest about what you don’t know and at the same time you provide them with action steps or things that they can do to help protect themselves.
So there’s a larger literature on this area that I would, you know, I’ve summarized in the briefest of ways here but these are some of the key elements.
And I would recommend that this is something you’re interested in kind of pursuing that a little bit because there are some guidance about that that can be helpful. But what you say is just a challenge regardless so thank you for raising that issue.
Thank you very much.
Dr. Gillian SteelFisher:
Operator we have time for one more question.
Okay very good. And our next question is from (Marcus Castle). Sir your line is open.
Hi there. How’s it going? Thank you for taking my call. Texas kind of mirrored our same question for what we had being a border state in Arizona in regards to the trust of the local government with the minority groups specifically law enforcement.
But we were curious just to know if in your surveys you had any questions that dealt with if the messaging or public messaging was in their native language if that would help them feel more comfortable with coming to the POD and not feeling as though they wanted to leave the state.
Dr. Gillian SteelFisher:
That’s an important question and I thank you so much for raising it and for the work you’re >doing as I said to your colleagues in Texas as well. So thank you.
So I don’t have any data in these as part of these polls explicitly. But the broader literature around making connections to minority and at risk communities would suggest that native language certainly helps.
It’s not sufficient but it certainly does help in terms of connecting people. And certainly if you want people to actually file the information it has to be in a language they can understand.
So if suddenly, you know, at baseline people who don’t speak English will need to have the information in alternative languages. And I think that that’s - maybe Laura can speak to some of the technical requirements or recommendations on that front.
And so, you know, by building that I think secondarily the research suggests that when you have it in someone’s native language that they are - they perceive a court element of trust which is that you care about them, you know, that the literature will break trust down to a lot of different components.
But caring about people is one component of that. Competence is another. But having it in a language can make people think that you care about them which you do. In fact the link can actually provide them, you know, with information that would help improve perceptions of confidence as well, maybe more to it but I think in some yes.
And maybe Laura I don’t know if you want to say anything about recommendations on that front from a technical perspective?
Dr. Laura Ross:
Thanks Gillian. And I would completely echo what Gillian just said. I do think it’s important probably to have (definitely) language of your audience.
For me the reasons that Gillian just stated I again don’t have the research at my fingertips to answer that question.
But a couple things that I do want to point out is, you know, there are usually many ethnic media stations that might be able to assist you as getting a lot of this information out as well as these pre-established community based networks and other organizations that might be able to help with translating some of these key bits of information that you expect to be using during an emergency. You know, these might definitely come in handy.
Additionally we’ve done a lot of work with the FDA, the Food and Drug Administration on translating the fact sheets, the approved fact sheets for use with the drugs for this type of an emergency.
So we’ve got those, I think it’s up to 57 languages right now. So hopefully that should be good enough to take care of a lot of the languages that we’re going to have issues with.
So and I’m sorry you don’t have the research available but I do think that translating into your language is a good idea.
Thank you. On behalf of COCA I would like to thank everyone for joining us today with a special thank you to our presenters, Dr. Ross and Dr. SteelFisher.
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