Lessons Learned from the 2009-2010 H1N1 Outbreak for the Management of the 2013 Silent Polio Outbreak

"[A]spects such as trust, integrity and mutual communication (which were not considered during the H1N1 2009-2010 outbreak) characterized the relationships between the public and the Israeli health system during the 2013 silent polio outbreak."

The aim of this study was to identify factors that contributed to the improvement in the Israeli Ministry of Health (MoH) response to Israel's 2013 silent polio outbreak in light of the H1N1 influenza outbreak in 2009-2010. During the latter large-scale event, policymakers and public health leaders had to make decisions under conditions of uncertainty and to function without sufficient and efficient data and resources. The public response included low adherence to protective measures and to vaccination. This was suggested to be related to lack of planning and to the low value ascribed to the skills of policymakers.

The picture was quite different during the 2013 poliovirus outbreak (described in detail in the paper), which involved, in brief: setting a multidisciplinary response team early in June; launching an inactivated polio vaccine (IPV) catch-up vaccination campaign among the Southern Bedouin communities; carrying out a hygiene campaign for intensified sewage and hospital acute flaccid paralysis (AFP) surveillance; reaching a consensus within the local health community in Israel (policymakers along with primary physicians and hospital staff) prior to launching an oral polio vaccine (OPV) campaign; holding repeated consultations with experts from the World Health Organization (WHO) and the United States Centers for Disease Control and Prevention (CDC); and eventually launching a nationwide OPV campaign (aiming to prevent polio spreading) starting in August that year. In order to "market" to the public a live vaccine that was withdrawn from the Israeli immunisation schedule in 2004 without losing the public's trust, a special media response team was formed by the MoH. This team paid special attention to the social media, and acted in a two-way communication process with the public. These actions led by the MoH assisted in containing the outbreak.

This qualitative study consisted of interviews with 18 policymakers involved with the 2013 silent polio outbreak in Israel; most of the interviewees (15 out of 18) occupied the same position during the 2009-2010 influenza outbreak. The interviews were conducted between January 2016 and July 2016.

Most interviewees felt that the experience of the 2009-2010 outbreak, which was perceived as unsuccessful, fueled the MoH engagement and proactiveness in the later polio outbreak. Three main themes were found in the interview analysis: 1) clinical and epidemiological differences between the two disease courses (e.g., unlike polio, the public perceived influenza as a harmless condition), 2) differences in the functioning of the MoH during the outbreaks (e.g., a consensus reached within the Israeli medical community prior to the launch of the OPV campaign contrasted with the variety of misaligned voices that were raised during the H1N1 outbreak within the medical community, when some opposed the vaccination), and 3) differences in the risk communication strategies used to reach out to the local health community and the general public. On the latter, one participant believed that the effort to be as transparent as possible assisted the MoH to achieve the OPV campaign goals. Participants stated that unlike the 2009-10 outbreak, during the polio one, social media was approached as a legitimate source of information. It also served as a two-way communication channel with the public: to deliver MoH messages and to respond to the public's fears and opinions. Lastly, participants explained that in order to gain public trust, the MoH relied on paediatrician spokespersons in all media channels. They were perceived to create more empathy and identification with the audience compared to public health officials and infectious diseases specialists who had dominated the media during the H1N1 crisis.

One point to emerge in the paper's discussion section: "The positive perception of the Israeli MoH response during the polio outbreak constantly and spontaneously contrasted with the negative perception of the response to the H1N1 outbreak may be attributed to the MoH thorough organizational learning process....However, the reciprocity between the two outbreaks indicates the MoH not only improved its de-facto functioning during the later outbreak, but also switched from an authoritarian, maybe paternalistic style of management to a more participatory and holistic style which was more sensitive to the general public and local health community concerns."

As is noted here, "This research finding may guide policymakers when facing future outbreaks....During the early stage of the event, decisions should be made regarding the type, the scale and the relevant vulnerable population(s). These decisions, in turn, shape the extent of the response, the most suitable means for communication with the population at risk (e.g. using channels tailored to specific subgroups as possible to enhance response efficacy) and adequate methods to monitor public behavior with clear and measurable outcomes. A routine assessment should be carried out constantly to measure these outcomes. Constant reassessment during the crisis enables evaluation of the system's actions to contain the event, and assist in reaching selected subgroups which may need special attention."

In conclusion, this study identified specific factors that contributed to the improvement in the MoH response: consensus among the Israeli health community, transparency and two-way communication with the public, proactive activities within social media, and cooperation with internal and external partners. "It appeared that the relatively poor outcomes of the H1N1 outbreak fueled the response of the MoH in Israel towards the polio outbreak 4 years later. These findings highlight the importance of a learning process within the health care organization. Encouraging structural learning processes within health care organizations may facilitate the management of future outbreaks and contribute to higher immunization rates and improved outcomes."