Command and control structure

The literature highlights the significance of having a command and control structure in place before the pandemic. Organizations at all administrative levels including the ministry of health, national and local public health authorities and primary and secondary healthcare facilities are part of this structure (Krumkamp, 2009). This underscores the need for preparing administrative structures that ensure smooth and effortless information flow and exchange among these institutions during a pandemic. Communication within a countryÕs healthcare system has to be improved. The command structure with predetermined roles and responsibilities of different stakeholders is necessary to maintain a smooth flow of information among authorities (Krumkamp, 2009).

Avian influenza outbreak experience in Turkey in 2006 revealed that organizational structure and command system was not quite ready to respond to public health emergencies. Authorities reported on the poor connection and coordination between the MOH and Ministry of Agriculture (Sarikaya and Erbaydar, 2007). In the evaluation of Sweden response, stakeholders felt that they were not sufficiently informed about the allocation of roles between them and what their expectations of each other should be and with regard to the demarcation of which issues fall under which department (National Board of Health and Welfare and the Swedish Civil Contingencies Agency, 2011).

8.3.6 Communication with the public

Communication with the public is a crucial element during planning and response to a public health emergency. Communication with the public aims at preventing further morbidity and mortality, reduce panic among the community and to stimulate confidence in operational response (Gupta et al., 2006). Risk communication is an essential element during emergency response as it can be used to educate the public and raise their awareness on pandemic influenza and provide people with relevant health information and advice about what to do at different stages of pandemic (Hine, 2010). This type of communication can engage people to protect the wider community by following for example hand hygiene and disposing of used tissues in the right way (Reynolds and Quinn, 2008).

Stakeholders across countries interviewed highlighted the importance of communication with the public to ensure an effective and smooth response by engaging the public in prevention and control strategies. A variety of communication channels were implemented before and during the pandemic to educate the public about influenza disease and prevention. These communication channels include the use of official pandemic influenza websites, leaflets and posters, hot lines and media spokespersons. In addition, countries with advanced pandemic plans mentioned having communication specialists to interact with media and public as part of press office or a public relation team. This team is responsible to ensure consistency and transparency of messages and public education material so they can be easily understood and perceived by the public (Reynolds, 2006).

Findings suggest that communication planning for pandemic influenza is an essential pandemic preparedness activity because it determines the set of messages to be shared with the public during the response and the communication channels that will be used and spokespersons. It is considered good practice to integrate the communication plan with the pandemic plan. The national and the regional level, and also any other actors felt to have a role to play, should be involved. It is best to have a flexible plan to be adaptable to the actual situation.

Planning for communication tools and infrastructure before the pandemic will enhance countriesÕ ability to cope with the rapid and intense demand for information during pandemic. These include pandemic websites and information hotlines for the public and healthcare workers. CDC reports on the importance of establishing information hotlines to respond to outbreaks of smallpox (Centres for Disease Control and Prevention, 2002). This is applicable to other public health emergencies including pandemic influenza. Hotlines are necessary to be established before the pandemic in order to be able to deal with the immediate and sustained demand for information from the public and healthcare workers. The plan highlights the importance of providing the hotline staff with the most up-to-date and accurate information to be able to respond to the publicÕs demand for information (Centres for Disease Control and Prevention, 2002).

Communication training is an essential activity to be implemented beforehand to ensure that spokesperson is confident and comfortable to speak in press

conferences or broadcast. Exercising the communication plan on a regular basis is highly recommended and this can be done using exercise scenarios and getting stakeholders feedback on how to revise the plan in line with new developments.

During the response it is crucial ensure consistency of messages that target the public (Reynolds and Quinn, 2008). The source of information and the content of messages need to be consistent throughout all stages so that general public do not get confused and know which advice and information to follow. Uncertainty and the unpredictable course of influenza pandemics play an important role in delivering inconsistent and controversial messages to the public. Consequently, this will make the response to the novel virus challenging and complex. The World Health Organization communication guidelines focus on building trust between the public and the lead organization, announcing updates at early stage, provide information whether good or bad as soon as possible, sharing precise and full information transparently, listening to public fears and concerns, and planning for communication.

Stakeholders from sub-national authorities mentioned that communication at the local level was different from those at higher levels. This is mainly due to pandemic can affect different areas at different times with different severity. For example, schools in one region can be closed before the rest of the country because the rates of influenza infection are higher. This mandates a direct communication with the public in that region to update them about this

localized situation and to answer their concerns. Local websites and media can be utilized to deliver such information to the target populations but this will be challenging in low-income countries such as category C countries with limited access to computers and the Internet.