ID in the news: The role of the physician to educate, advise

Infections are capable of spreading as quickly as the panic that often accompanies them. However, many diseases can be slowed or even prevented if the proper steps are taken, and raising awareness of these precautions is often among the most important duties of the infectious disease specialist.

To explore these challenges, Infectious Disease News spoke with several experts about the role of the media and how best to communicate important information to the general public about infectious diseases.

‘A core responsibility’

“The right message to the right person at the right time can save lives,” Barbara Reynolds, PhD, senior advisor of crisis and risk communication at the CDC, told Infectious Disease News. “It is a core responsibility in a crisis situation to work as hard as possible to share the information that people need, when they need it.”

Unfortunately, disseminating vital knowledge that could potentially save lives is not always an easy task. Intermediaries such as news organizations and social media can be useful tools for offering guidance during an outbreak, but accurate information often can be lost in the commotion of public discourse. Meanwhile, translating complex data into digestible public health messages continues to be an obstacle, even for the most knowledgeable experts.

“Especially in the infectious disease field, it is really important to have physicians who understand how the media work, how they approach their job and how to talk to them in a way that ensures that the message gets across and your meaning is understood,” Diana Olson, vice president of communications for the Infectious Diseases Society of America, said in an interview. “That’s not a skill that is intuitive for people — it really does require training and practice.”

Photo by Nathan Danskey

Flaws in previous coverage

The relationship between infectious diseases and the media is nothing new. Public health scares surrounding HIV, anthrax, influenza A(H1N1) and other outbreaks frequently receive national attention in mainstream news. According to Reynolds, discussion on the subject often begins with the recent Ebola outbreak.

“This Ebola event, frightening as it may have been for people as they were watching it unfold, was not in itself a public health emergency in the way we might plan for something that might spread widely among [the U.S.],” Reynolds said. “But, it’s a cautionary tale, and it certainly did challenge suppositions about how messaging would work.”

First identified in early 2014, growing case numbers and a high mortality rate quickly turned Ebola into an outbreak of international concern. By fall, the infection of two Dallas health care workers and debates concerning transmission risks had led to rampant misinformation about the Ebola virus, according to Infectious Disease News Editorial Board member Donald Kaye, MD, professor of medicine at Drexel University College of Medicine.

“[News media] had people commenting on Ebola who had absolutely no knowledge of the disease,” Kaye said. “They had people who might have an MD after their name, but certainly had no knowledge or expertise in either infectious diseases epidemiology or anything that would give them the background or knowledge to comment on something like Ebola. But they were commenting, and saying things that, frankly, were inappropriate.”

Although faulty coverage can lead to misinformation, evidence suggests it also can lead to panic. In a recent study, researchers examined and quantified daily U.S. Google and Twitter data alongside television news coverage of the Ebola outbreak. They found that each Ebola-related news video appearing on a major television network prompted tens of thousands of related tweets and Internet searches, suggesting that increased news coverage of the outbreak was responsible for increased panic among the public.

Kaye described this “hype” as symptomatic of the fast-paced, 24-hour news cycle. Reynolds added that public health’s inexperience with Ebola made it difficult to quickly provide consistent, evidence-based advice.

“When Ebola became a true public health concern in the United States, there weren’t as many voices who could talk authoritatively about it,” Reynolds said. “So, it increased the uncertainty, and there weren’t as many consistent voices out there responding to it, and that left room for scientific debate to become inflated.”

Epidemics of relatively unknown pathogens may be a hotbed of misinformation, but they are hardly its exclusive home. According to Infectious Disease News Editorial Board member Timothy F. Jones, MD, state epidemiologist for the Tennessee Department of Health, similar issues have plagued many well-known diseases for very different reasons.

“There’s a lot of familiarity with flu, so a lot of people think they’re experts,” Jones said during an interview. “Everyone’s willing to comment about it, and so there can be very mixed messages that come out. That’s the tender situation where things can get a little bit sticky.”

An irreplaceable tool for communication

Regardless of these criticisms, news media can be an invaluable public health tool. Reynolds said that time and again news media have been the CDC’s go-to resource during emergency situations.

“I find the news media to be very responsible and responsive when there’s a true threat,” Reynolds said. “We know early on in a crisis situation, when lives are truly at risk, that the media are very critical to helping the response officials get the word out. There’s no question about it.”

Despite the growing number of outreach options that are now available, health experts would be unable to reach large portions of the population without the pre-established network of communications that news media can offer.

“If we don’t have that support, it makes it so much more difficult for us to work through the clutter of information and try to share what we know,” Reynolds said.

To best collaborate with news media, it is important to understand the pressures and limitations many outlets face. Chief among these is the need to release information as quickly as possible, which Olson said her organization takes into account whenever coordinating with reporters.

“We recognize that media outlets — especially when there’s a breaking news situation — are under the gun, they’re pressed for time,” Olson said. “We do try to develop resources, press releases, fact sheets ... those simple tools to help reporters relay the information to their audiences.”

While the speed of mainstream news reporting is often thought to hamper data accuracy, there also is evidence of its unexpected benefits. A recent study by Gerardo Chowell, PhD, associate professor of epidemiology and biostatistics at Georgia State University School of Public Health, and colleagues analyzed a sample of news reports on 286 suspected and confirmed Ebola cases. These articles came from a variety of sources, including mainstream print publications such as The New York Times and regularly released WHO situation reports.

When compared with records from epidemiological surveillance data, they found the two data sets to be in “close agreement” regarding the regional estimate of case fatality rates and other areas of surveillance, and concluded that news reports such as these could reliably predict outbreak patterns in real-time.

Still, first and foremost, the goal of many news organizations is to accurately convey information to its audience. Despite witnessing gaps in media coverage firsthand when asked to contribute during past outbreaks, Amesh A. Adalja, MD, FACP, senior associate at the Center for Health Security at the University of Pittsburgh Medical Center, believes this goal is evident now more than ever.

“We’ve seen since Ebola that there definitely is much more interest in the general media regarding infectious disease stories,” Adalja said. “There’s still some room for them to improve, but they’re actually paying attention to infectious diseases now ... is a testament to the fact that they realize it’s important to get these stories right, and to not be sensationalistic and drive the world into a panic.”

Speaking to an uninformed public

In the midst of an emergency, the layperson may not only lack direction, but could also be unable to contextualize vital information, according to Jones. This frequently can lead to panic, an outcome Jones said is crucial for ID specialists and public health to avoid.

“We view ourselves as scientists and epidemiologists of the health department ... but a lot of the time I feel like society’s psychiatrist,” Jones said. “Probably the most important part of our job is translating science and data into something that the public can understand correctly.”

There are important differences in speaking to individual patients and the general public, and Jones warned that practitioners may need to tailor their message in the right context before contributing. Research presented at this year’s American Psychiatric Association Annual Meeting by Daniel Witter, MD, PhD, of the University of Florida, highlighted this point by examining three Ebola news briefings held by CDC Director Thomas R. Frieden, MD, MPH. Transcripts from these events were analyzed to identify instances where Frieden’s presentation followed or violated risk communication guidelines published by WHO in 2004. Although Witter and colleagues determined Frieden to be “at his best in establishing humanity and acknowledging deficiencies about specific aspects of how the Ebola crisis was handled,” they identified several areas in which his message was unrefined and could potentially provoke anxiety in audiences.

Olson said the presentation of information is one of the leading challenges for medical experts addressing the public, and advised that all specialists seek out media training to avoid potential misunderstandings.

“Physicians and scientists are used to speaking to other physicians and other scientists,” Olson said, “and they’ll phrase things in a certain way that makes sense to their colleagues, but could easily be misconstrued by the general public.”

These concerns are not exclusive to the general public, but extend to several members of the media.

“There’s a huge difference when it becomes a general public story, and instead of just dealing with the science reporters, you’re dealing with the general reporters,” Adalja said. “It’s a very different tack you have to take. There’s a lot of context you can take for granted when you’re talking to a medical or science or global health reporter that you can’t when you’re talking to a general features reporter.”

This is not to say that experts or public health should withhold information. Jones said that above all, people want instruction from those in a position of authority. Even if the advice is simple, he said it is important to explain as much of the available data as possible and offer reassurance.

“It’s really important for the public that they’re reassured no one’s hiding anything,” Jones said. “If there’s the slightest hint of there being reservations ... this does a lot of damage.”

Combating misinformation

Perhaps the most important way to avoid confusion in the public is to present a unified message, Olson said. Even if medical advice is presented well, too many competing ideas can confuse audiences and obfuscate important information.

“Close coordination with CDC and other public health authorities is essential,” Olson said. “If we have disparate messages coming from different institutions or different experts ... that really contributes to confusion among the public.”

More vexing are situations when even the best possible guidance is rejected by members of the public. Reynolds described encounters with those reluctant to accept the reassurances of sound medical science as an ongoing problem.

“That’s where the disconnect can sometimes happen,” she said. “When you have expert knowledge and confidence in the science and others don’t, how do you bridge that gap? What we shouldn’t do is to arrogantly believe, ‘Because we say it, it must be accepted as true.’ The onus is always on us to be as credible and empathetic as possible in our messaging so that people can receive it no matter where they are, no matter what their social pressures might be.”

Unfortunately, this problem is compounded when those whose opinions do not align with proven science are public figures. For example, during the Sept. 16 Republican presidential primary debate, candidates discussed the link between vaccines and autism — an association that has been disproven in numerous studies — as well as “alternative” immunization schedules and the potential benefit of delayed vaccination. Concerns of personal freedom to vaccinate and possible connections between vaccine manufacturers and the government superseded peer-reviewed evidence, prompting those in the medical community to speak out.

“Claims that vaccines are linked to autism, or are unsafe when administered according to the recommended schedule, have been disproven by a robust body of medical literature. It is dangerous to public health to suggest otherwise,” Karen Remley, MD, MBA, MPH, executive director and CEO of the American Academy of Pediatrics, said in a press release.

Instead of a single, centralized message, dissenting opinions can stir debate and confuse those searching for information. Adalja said this chain of events can happen at any time, and is even more frustrating when the challenging voices are offered an equal platform to medical science.

“The media is looking for good television, so they often will try to play the other side when the other side really doesn’t have any facts,” he said. “It happens with every infectious disease outbreak or any infectious disease topic.”

Citing his own on-air experiences with debating supporters of unnecessary Ebola quarantine programs and opponents of vaccination, Adalja warned any professionals who find themselves in this situation not to become flustered or upset when contesting a point of view that is not based on empirical evidence. Instead, the best advice is simply to repeat the facts and defend them with the available data in a way that is easy for viewers to understand.

“You have to remember, when you’re the medical expert, you have the facts on your side,” Adalja said. “You are the sober professional there to communicate public health information to the general public. The other people are there for entertainment value.”

An emerging resource

Among the most influential arenas for these debates is social media, with services like Facebook and Twitter now allowing for two-way conversations between experts and the general public. On the one hand, Kaye warned that the “totally uncontrolled” nature of the platform can point people in the wrong direction. However, it also provides an additional outlet for government and professional organizations to spread public health messages and gauge feedback.

“One of the aspects of social media that’s really important to us is that it gives us a way to interact with the public in terms of their true fears or concerns or misunderstandings,” Reynolds said. “It is, of course, a place where misinformation can move quickly — but correct information can move quickly, also.”

Reynolds explained that social media outreach is a growing area for the CDC, and was an especially useful tool to reduce panic during the height of the Ebola outbreak. Olson added that these services are a resource for organizations or individual practitioners to harmonize their recommendations with those of health agencies through retweets and shares, according to Reynolds.

Recent data also have demonstrated how social media can contribute to various areas of the infectious disease field. One study by Michael J. Paul, PhD candidate at Johns Hopkins University, and colleagues created an accurate influenza prediction model using a combination of Twitter and historical data. Another study, from Michelle Odlum, EdD, MPH, of the Columbia University School of Nursing, and colleagues found that millions of Twitter users were informed of the Ebola outbreak 3 days before announcements from the Nigerian Ministry of Health and 7 days before announcements from the CDC.

In an interview with Infectious Disease News, Odlum attributed this outcome to the speed and easily digestible messages characteristic of the service. While social media may not play a role in preventing the initial transmission of an outbreak, according to Odlum, events such as the Ebola crisis demonstrate its potential in reducing further harm.

“The impact of just being able to disseminate on such a level — could you imagine what that could do to potentially halt the spread of an outbreak, or potentially stop an outbreak in its tracks?” Odlum said. “The opportunities to use social media in such ways are tremendous.”

Role of the local ID specialist

Public health agencies and organizations may play a large role in spreading information, but Jones stressed that a cohesive message is nearly impossible without the support of local specialists. He recommended that infectious disease practitioners actively seek out opportunities to educate the public, whether it is through local media programs or simple dialogue among peers. He stipulated, however, that such prospects should only be pursued after self-educating.

“Before any of us go out in the media and start giving opinions ... call your local health department to find out what the local context is,” Jones said. “Sometimes what seem like very reasonable textbook decisions — when you’re looking at it from a more societal perspective — are a little bit more nuanced, and hence some communication between medical folks and public health is nice before we’re standing in front of the camera.”

Reynolds agreed, emphasizing the importance of practitioners as a source of authority for those seeking guidance.

“It’s important that infectious disease specialists who are eager to explore a new topic in the threat environment should also understand that their words carry a great deal of weight,” Reynolds said. “You are a part of the message, and have a responsibility for how people will behave if you’re going to talk about it.” – by Dave Muoio

• References:
• Odlum M, et al. Am J Infect Control. 2015; doi:10.1016/j.ajic.2015.02.023.
• Paul MJ, et al. PLoS Curr. 2014;doi:10.1371/currents.outbreaks.90b9ed0f59bae4ccaa683a39865d9117.
• Towers S, et al. PLoS One. 2015;doi:10.1371/journal.pone.0129179.
• Witter D, et al. P1-208. Presented at: American Psychiatric Association annual meeting; May 16-20, 2015; Toronto.

• For more information:
• Amesh A. Adalja, MD, FACP, can be reached at ameshaa@aol.com.
• Timothy F. Jones, MD, can be reached at tim.f.jones@tn.gov.
• Donald Kaye, MD, can be reached at donjank@aol.com.
• Michelle Odlum, EdD, MPH, can be reached at mlo12@cumc.columbia.edu.
• Diana Olson can be reached at dolson@idsociety.org.
• Barbara Reynolds, PhD, can be reached at bsr0@cdc.gov.

Disclosures: Paul reports receiving support from a Microsoft Research PhD fellowship and currently serving on the advisory board for Sickweather. Adalja, Chowell, Jones, Kaye, Odlum, Olson, Reynolds and Witter report no relevant financial disclosures. Infectious Disease News was unable to confirm Remley’s disclosures at the time of publication.

Is social media helping or harming the dissemination of information about infectious diseases?

Social media is helping to disseminate ID information.

I strongly believe social media is helping to spread information on infectious diseases. This is based on my personal experience with Twitter and published studies. To the doubters saying, “Show me the evidence!” look no further than the Ebola outbreak.

As the world watched in fear, the front-line health care providers, WHO and the CDC turned to Twitter to disseminate information in real-time. The Nigerian Minister of Health and CDC announcement of the first Ebola case was tweeted on July 24, 2014 and reached 1,196,793 people. Publications on emerging resistance and antimicrobial stewardship in ID journals do not reach a large percentage of physicians who prescribe antibiotics, so I turned to Twitter to educate, engage, advocate, collaborate and network with others globally.

My own tweets are focused on antimicrobial stewardship and resistance. After 1 year of active tweeting, I have over 1,400 “followers” from over 34 countries. That’s more than any article I have published. I have learned more from the people and organizations I follow on Twitter than any other method. Most importantly, surgeons have embraced Twitter. As frequent users of antibiotics, surgeons are important stakeholders in stewardship. I used Twitter to educate surgeons during the recent outbreak of carbapenem-resistant Enterobacteriaceae during endoscopic procedures. Tweets with links to articles provided surgeons with real-time information. A study I presented at IDWeek 2015 titled “Using Twitter to Engage Surgeons in Antimicrobial Stewardship” showed that 31 ID tweets retweeted by surgeons reached over 15,000 surgeons.

The power of Twitter should not be underestimated. National organizations and patient advocacy groups have learned how to effectively use Twitter to provide education on various ID topics. The Peggy Lillis Foundation has an effective Twitter feed providing education and patient stories on Clostridium difficile. The National Foundation for Infectious Diseases regularly tweets on vaccinations. The CDC posts tweets daily on various ID topics. IDWeek 2015 had over 4,000 tweets sent during the conference.

Another form of social media helping to spread ID information is Instagram. Posts on Instagram are shared as an image, which may be paired with a text of up to 2,200 characters. One ID physician and ID pharmacist together have over 15,000 followers. Both of them provide a unique way of educating others with valuable, accurate ID information.

Social media does have risks. Whatever you say on social media stays on social media, forever. Health care professionals are held to a higher standard and must use social media responsibly. We must find ways to engage all health care providers who use antimicrobials. Antimicrobial resistance is a global health care problem, and social media can help spread ID information globally. United together on Twitter or Instagram, we can make a difference.

Debra A. Goff, PharmD, FCCP, is a clinical associate professor of pharmacy and infectious disease at The Ohio State University Wexner Medical Center. She can be reached at Debbie.Goff@osumc.edu. Disclosure: Goff reports no relevant financial disclosures.

• References:
• Gauthier TP, et al. Clin Infect Dis. 2015;doi:10.1093/cid/civ248.
• Goff DA, et al. Clin Infect Dis. 2015;doi:10.1093/cid/civ071.
• Odlum M, et al. Am J Infect Control. 2015;doi:10.1016/j.ajic.2015.02.023.

Online networking tools show early promise, but additional assessment is vital for public health.

Any global pronouncement about the good or ill of social media is likely to be wrong. The online networking tools/applications emergent in the early 21st century both create and address problems in contemporary society, and we must exercise restraint in our assessments of such a complex phenomenon. That said, in reflecting on the question at hand, it is instructive to think about the ways social media, in its relative infancy, have already begun contributing to public health.

Tools such as Twitter and other geo-tagging applications have been used — quite impressively — to coordinate responses to emergency situations such as natural disasters (eg, earthquakes, hurricanes, tsunamis, etc.), terrorist events (eg, the Boston Marathon bombing), and state violence against citizens (eg, Arab Spring, Iranian Green Revolution, etc.). And although much-maligned for its abuses of user privacy, the social network Facebook helped generate a 23-fold surge in donor pledges in 2013 after rolling out a feature to allow users to pledge as donors on their timelines. Research has also established that Facebook groups and pages can be useful tools in achieving salutary outcomes on such public health issues as smoking cessation, weight loss and HIV prevention. Moreover, organizations such as the CDC, American Red Cross, WHO and others have used popular social media tools like Facebook, Twitter and Instagram to amass enormous networks for dissemination of credible information. Creation of this infrastructure has built a global audience for public health messaging that is utterly unprecedented in human history.

Therefore, if it were to be argued that social networking tools are not yet helping in the infectious disease world, the question we must ask is — why not? From an epidemiological standpoint, are we using the right methods to aggregate data relevant to the spread of infectious diseases and outbreak? Are we using proper techniques to draw actionable “intelligence” from the data? If not, how might the emerging era of “big data” inform improvements in the infectious disease domain? And from a leadership standpoint, are we employing sound strategies to disseminate useful information? Are we engineering this information in ways that promotes its viral effects and countervails against the misinformation that we know can travel around the world before the truth gets out of bed (see the anti-vaxer movement)? Are we devoting enough resources and manpower to our efforts in the social media space, or are we still reticent because of fears or biases we might harbor toward the technology?

Ultimately, epidemics have the potential to unite us around our common frailty and capacity to experience pain and loss, and social media are already showing themselves to be a means through which we may respond to crises with greater empathy and powerfully mitigate human suffering. Learning how to best leverage these evolving tools/applications in the service of public health is a commitment worthy of the best minds of our generation.

Daniel R. George, PhD, is an assistant professor in medical humanities at Penn State College of Medicine. He can be reached at dgeorge1@hmc.psu.edu. Disclosure: George reports no relevant financial disclosures.

• References:
• Rovniak LS, et al. BMC Public Health. 2013; doi:10.1186/1471-2458-13-753.
• Young SD, et al. Sex Transm Dis. 2013;doi:10.1097/OLQ.0b013e318278bd12.
• Phua J. J Commun. 2013;doi;10.1111/jcom.12054.