EPA/625/R-06/012 I August 2007 I www.epa.gov/ord United States Environmental Protection Agency Risk Communication in Action THE TOOLS OF MESSAGE MAPPING Office of Research and Development National Risk Management Research Laboratory ------- EPA/625/R-06/012 August 2007 in The of By Ivy Lin, M.S., ASPH/EPA Fellow and Dan D. Petersen, Ph.D., DABT, USEPA National Risk Management Research Laboratory Office of Research and Development United States Environmental Protection Agency Cincinnati, OH 45268 ------- Notice This document has been reviewed in accordance with the USEPA's peer and administrative review policies and approved for publication. Mention of trade names or commercial products does not constitute endorse- ment or recommendation for use. Contents of the message maps in this report are representative in nature and may not be appropriate guidance for actual message maps. ------- Foreword The U.S. Environmental Protection Agency (EPA) is charged by Congress with protecting the Nation's land, air, and water resources. Under a mandate of national environmental laws, the Agency strives to formulate and implement actions leading to a compatible balance between human activities and the ability of natural systems to support and nurture life. To meet this mandate, EPA's research program is providing data and tech- nical support for solving environmental problems today and building a science knowledge base necessary to manage our ecological resources wisely, understand how pollutants affect our health, and prevent or reduce environmental risks in the future. The National Risk Management Research Laboratory (NRMRL) is the Agency's center for investigation of technological and management approaches for preventing and reducing risks from pollution that threaten human health and the environment. The focus of the Laboratory's research program is on methods and their cost-effectiveness for prevention and control of pollution to air, land, water, and subsurface resources; protec- tion of water quality in public water systems; remediation of contaminated sites, sediments and ground water; prevention and control of indoor air pollution; and restoration of ecosystems. NRMRL collaborates with both, public and private sector partners to foster technologies that reduce the cost of compliance and to an- ticipate emerging problems. NRMRL's research provides solutions to environmental problems by: developing and promoting technologies that protect and improve the environment; advancing scientific and engineering information to support regulatory and policy decisions; and providing the technical support and information transfer to ensure implementation of environmental regulations and strategies at the national, state, and com- munity levels. This publication has been produced as part of the Laboratory's strategic long-term research plan. It is pub- lished and made available by EPA's Office of Research and Development to assist the user community and to link researchers with their clients. Sally Gutierrez, Director National Risk Management Research Laboratory ------- to Section 1.0 introduces the topics of risk communication and message mapping. Section 2.0 provides a background on risk communication. Since a message map is a tool used in risk com- munication, this chapter will discuss the history of risk communication and outline some general principles of effective risk communication. Section 3.0 provides information for preparing risk communication messages. Risk perception, risk com- munication theories and guidelines will be discussed. The role of the media in risk communication will also be discussed. Section 4.0 discusses the structure of a message map, and includes a blank message map template as well as an example of a working message map. Section 5.0 will provide step-by-step directions about how to create a message map. Section 6.0 provides examples of how to create a message map in the event of a public health crisis. Examples chosen are: the West Nile virus epidemic of 2002 in the United States, the anthrax scare of 2001 and the Cryptosporidiosis drinking water outbreak in Milwaukee, Wisconsin, 1993. Section 7.0 is a short conclusion. Section 8.0 is a glossary of important terms. Section 9.0 is a list of the most frequently asked questions during a crisis. Section 10.0 is a template for risk communication. Section 11.0 is a list of references that were cited throughout the paper. IV ------- of Notice[[[ii Foreword iii How to Use this Workbook iv Table of Contents v 1.0 Introduction [[[ 1 1.1 What Is a Message Map? 2 1.2 What Are the Benefits of Using a Message Map[[[ 2 2.0 Background of Risk Communication[[[ 3 2.1 Introduction to Risk Communication 3 2.2 Goals of Risk Communication 3 2.3 History of Risk Communication 4 2.4 Cardinal Rules of Risk Communication 4 3.0 Risk Perception and the Preparation of Messages 7 3.1 Risk Perception[[[ 7 3.2 Preparing Messages in Advance 9 3.3 Risk Communication Theories[[[ 9 3.4 Other Guidelines for Risk Communication[[[ 11 3.5 Risk Communication to the Media and General Public[[[ 12 4.0 Message Mapping - Design and Structure 15 4.1 Purpose and Structure of a Message Map 15 4.2 The Overarching Message Map 16 5.0 Creating a Message Map 17 ------- V! ------- 1. Introduction In 1976, a 19-year old U.S. Army private named David Lewis came down with flu-like symptoms, and died within 24 hours. Two weeks after the private's death, health officials disclosed to the American public that something called "swine flu" had killed Lewis and hospitalized four of his fellow soldiers at the Army base in Burlington County, New Jersey. Healthcare of- ficials feared a repeat of the 1918 flu epidemic, which killed 20 million people around the world. The Centers for Disease Con- trol and Prevention (CDC)'s recommendation was to vaccinate all Americans. The National Influenza Immunization Program (NIIP) officially started in October of 1976. The number of vac- cinations given each week increased rapidly from less than one million in early October to more than four million in the later weeks of the month, and reached a peak of more than six mil- lion doses a week by the middle of November 1976.' Overall 40 million people were vaccinated, although it was later discovered that the vaccines were technically flawed and contained only one of the antigens necessary for an effective inoculation. Moreover, on December 16, 1976 the NIIP was suspended fol- lowing reports from more than ten states of a rare degenerative disease, Guillain-Barre syndrome (GBS), in vaccinated people. By January of 1977, more than 500 cases of GBS had been reported, with 25 deaths. Based on the weekly numbers of vac- cinations, a comparison of observed cases with expected cases showed that the relative risk of acquiring GBS during the six weeks after vaccination was about ten times the endemic ex- pectation.2 Meanwhile, the expected mass epidemic of swine flu never occurred. However, the regular seasonal flu did break out, and the only flu vaccines available were mixed with swine flu vaccine.3 The swine flu incident illustrates the difficulties of risk com- munication. The fear of a swine flu epidemic was so great that a mass inoculation program was implemented without proper thought and planning. In this case, the vaccine caused more harm than good. Currently, there is much concern in the news about the avian flu, which to date has killed 70 people in Asian countries.4 But how can organizations prepare for a threat that is so unpredictable? Communicating risk is a task with unique difficulties. Law enforcement officials, public health officials, and government agencies all face the same challenge: in a high- stress, high-concern, or emotionally charged situation; how does the organization quantify and convey risk in an appropri- ate, effective and factual manner? What are the proper actions to recommend (or discourage)? How will the public react? Will the message change behavior? hi spite of the challenges, risk communicators have many re- sources that can help them create informative, balanced, and well-considered risk messages. Risk Communication is a fairly new science developed mainly by Vincent Covello and Peter Sandman. This workbook, Risk Communication in Action: The Tools of Message Mapping will describe one robust and effec- tive tool of risk communication, message mapping. Figure 1-1. The swine flu incident was an example of a risk communi- cation disaster. Massive stockpiles of swine flu vaccine were prepared and administered for an epidemic that never became widespread. The vaccine itself, however, did cause 500 cases of Guillain-Barre syndrome and 25 deaths. ------- 1.1 What Is a Message Map? A message map is a detailed description of hierarchically or- ganized answers to anticipated questions and concerns from stakeholders (e.g., the public, the media, and special interest groups) in the event of a disaster, crisis, or alarming situation. A well-constructed message map should bring focus and clarity to a potentially high-stress, high-concern, or emotionally charged situation. The three key goals of a message map are: to educate and inform the public (stakeholders) to build and maintain trust and credibility between the gen- eral public and decision makers during a crisis to create informed dialogue and decision making among the public and figures of authority. A message map is a template, containing three tiers of informa- tion. The first tier identifies the audience for the message map (called the stakeholder) as well as the questions or concerns that the message map is intended to address. The second tier of the message map contains three key messages pertaining to the situation. These key messages can serve as themes for a pub- lic presentation and sound-bites for the mass media. The third tier of the message map contains supporting information for the three key messages. The supporting information is blocked in groups of three under the key messages. Supporting informa- tion amplifies the key messages and provides additional facts and details. 1.2 What Are the Benefits of Using a Message Map? A message map is a useful organizational tool by providing guidance and clarity to both the authorities and the stakeholders in a high-stress situation. A well-designed message map helps multiple partners (e.g., the firemen, the police, the health-care workers and other authorities) speak with one voice, in a clear, concise manner. It minimizes the chances of speaker's regret at an inappropriate comment, omission of pertinent following information, or disinformation that can confuse stakeholders. The three key messages and hierarchically organized support- ing information provide talking points that a speaker can check off in order of importance. hi addition to providing guidance during a crisis, message maps are useful planning tools in anticipation of potential threats and crises. Organizations can develop these messages and test them through focus groups and surveys. A message map as a public health tool was developed by risk communication expert Vincent Covello in the early 1990s and was first widely adopted in the aftermath of the anthrax attacks of the fall of 2001. ------- 2. Background of Risk Communication 2.1 Introduction to Risk Communication The National Research Council of the United States gave the following definition of risk communication: "Risk communica- tion is an interactive process of exchange of information and opinions among individuals, groups, and institutions. It often involves multiple messages about the nature of the risk or ex- pressing concerns, opinions, or reactions to risk messages or to the legal and institutional arrangements for risk manage- ment."5 Thus, risk communication involves messages about the nature of the risk as well as messages that express concerns, opinions, and/or reactions to risk messages. An ideal risk communication tool would put a risk in context, make comparisons with other risks, and encourage a dialogue between the sender and the re- ceiver of the message. Complexities are inherent in any risk situation. Although it is tempting and sometimes advantageous to use basic, unspecific terms, risk communicators must also explain the complexity of the situation. There may be 20 appointed experts with many dif- ferent assessments whereby opinions and risk regulators must understand multiple conflicting objectives. For instance, even though data overwhelmingly prove that smoking is a carcino- gen, risk communicators must acknowledge the rights of the tobacco industry, as well as those of smokers. There are also degrees of risk. Risk communication expert Peter Sandman also makes the distinction between hazard and out- rage; hazard is the experts' assessment of risk and outrage is the public perception of risk.6 Some situations may have a very low hazard factor but a great outrage factor, while other situations will have very high hazard but very low outrage. One example is malaria and tuberculosis, two diseases that are still top kill- ers in the developing countries and are increasingly resistant to treatment but still receive little coverage in the press. It is also possible to have a situation with both great hazard and great outrage - i.e. the Chernobyl nuclear reactor incident. The swine flu incident was an example of a situation that aroused great outrage but had very little actual hazard. Instead, the real hazard became the treatment of the swine flu, which caused 500 Guil- lain-Barre cases and 25 deaths. 2.2 Goals of Risk Communication Risk analysis experts Ralph Keeney and Detlof von Winter- feldt, of the Institute of Safety and Systems Management at the University of Southern California7, conducted extensive discus- sions with regulatory officials, after which they listed the objec- tives of risk communication7: To educate the public about risks, risk analysis, and risk management Risks should be put in perspective. The public should grasp the complexity of the problem and also understand the ra- tionale of risk assessment and risk management. The public should understand that there is no "zero risk" solution. In any risk situation, tradeoffs are necessary, and uncertainty cannot be avoided. To inform the public about specific risks and actions taken to alleviate them Risk managers should speak in user-friendly words as op- posed to technical jargon. Accessible graphics/visual aids are helpful in achieving this goal. To encourage personal risk reduction measures This is perhaps the most important goal. Ideally, risk com- munication should also change individual behavior. If the presentation is about the dangers of carbon monoxide poi- soning, one goal would be to persuade some of the audi- ence to indicate that they plan to install a carbon monoxide detector in their homes. To improve understanding of public values and con- cerns To do this, risk communicators must consider the differ- ence (if any) between hazard and outrage about a risk, and the factors that influence risk perception (see Section 3.0). This understanding will allow the risk communicators to address the issue in an appropriate manner. To increase mutual trust and credibility between the au- thorities and the public For organizations to exude credibility and engender public trust, the manner of communicating risk is critical. Some general guidelines: communication must be honest, must not evade or exaggerate, and must not second-guess the au- dience. This will engender the audience's trust and build up your credibility. ------- To resolve conflicts and controversies Many risk problems become a matter of heated debate and controversy because they affect people directly, because the authorities and decision makers disagree, and because of lost trust and credibility. Risk communicators should at- tempt to resolve these conflicts. Their tone should be caring and empathetic. 2.3 History of Risk Communication Risk communication is a relatively new science. Vincent Cov- ello and Peter Sandman have traced the evolution of risk com- munication from the 1980s to the present. They specify four distinct stages8: Stage 1: Ignore the public This was the pre-risk communication stage prevalent in the United States until about 1985. The assumption was that there was no point communicating risk to the general public, as they would not heed the warnings or understand the risks. It was thought that the public was largely content to let authorities shape environmental policy. Stage 2: Explain the risk data From the mid-to-late 1980s, the public reasserted its claim over environmental policy. Many organizations attempted to better explain risk data. Explaining risk data to the public is still a challenging task for many institutions, however. For instance, if an EPA spokesperson said, "The maximum allowable arsenic in drinking water is 10 parts per billion," only a small segment of the population would understand what that actually means, and how to follow those guidelines. This is exacerbated by the fact that many times there is no easy remedy for a risk. Stage 3: Dialogue with the community For some risk problems, such as radon, where the hazard is large but the controversy is minimal, doing a better job explain- ing risk data is important. However, when the hazard is not great but public outrage is very high, simply explaining data does little to ameliorate a tense situation. An example of this occurred in the late 1980s. Medical waste began showing up on the shore of the Atlantic coastline. In New Jersey, the Depart- ment of Environmental Protection reported that the waste was not dangerous, but this only increased public outrage. In Rhode Island, the Commissioner of Health agreed with the public that the waste was an outrage and unacceptable, and promised to use any means possible to clean the waste up. This in turn diffused public outrage and also forced the public to consider the costs of a thorough cleanup. Stage 4: Involve the public as a cooperating partner This is a very difficult stage to achieve, mostly because it is very difficult for individuals and organizations to adopt new decision-making approaches. There is also a mindset within organizations that they are the experts and that the public is in general not informed enough to be a fully cooperating partner. 2.4 Cardinal Rules of Risk Communication Before making a message map it is useful to consider Vincent Covello and Frederick Allen's Seven Cardinal Rules of Risk Communication9: Rule 1: Accept and involve the public as a legitimate part- ner Demonstrate respect by involving the community early, before important decisions are made. People and communities have a right to participate in decisions that affect their lives and liveli- hoods. The goal of risk communication is not to diffuse public concern, but to create an informed public. A scientific experi- ment that tested public support for space exploration policies showed that public participation during decision-making about risks can lead to more acceptance of risk policies.10 Another example of a successful public involvement effort was a public committee that debated and resolved several highly controversial water management issues involving a hydroelec- tric facility in British Columbia. The body of water of concern was the Alouette River, and the company, BC Hydro, was the sponsor of the project. The Alouette Stakeholder Committee was made up of 17 official members drawn from a wide array of organizations, from various interest groups and local citizens. The goal of the committee and BC Hydro was to select the best possible operating plan for the Alouette River. After 15 meet- ings, the group reached complete consensus on all major issues it was asked to address. This is an example of how the public can be a part of a successful decision-making team.11 Rule 2: Listen to the audience If people feel that they are not being heard, they cannot be ex- pected to listen. Effective risk communication is a two-way ac- tivity.9 Rule 3: Be honest, frank, and open Organizations should disclose risk information as soon as pos- sible without minimizing or exaggerating the level of risk, to create an atmosphere of trust and credibility. They should lean towards sharing more information, not less.9 Rule 4: Coordinate and collaborate with other credible sources University scientists, physicians, citizen advisory groups, trusted local officials, and national or local opinion leaders are among the credible sources available for collaboration.9 Rule 5: Meet the needs of the media Print and broadcast media are prime transmitters of informa- tion on risks. Communication should be accessible to reporters and should include digestible sound-bites. Sound-bites are brief statements, often made by organizations or reporters, intended to explain information or defend a position in simple, memo- rable, easily understandable terms. If organizations don't sim- plify, the press will simplify the message at the risk of adding misinformation.9 ------- Rule 6: Speak clearly and with compassion Rule 7: Plan carefully and evaluate performance Technical language and jargon are barriers to successful com- Risk communication will be successful only if carefully planned munication with the public. Clear, non-technical language and and evaluated. Organizations should identify important stake- sensitivity to cultural norms is essential. Personalizing risk data holders, pretest messages to focus groups, and train staff in along with graphics to clarify the message will enhance public communication skills.9 understanding.9 ------- ------- 3. Risk Perception and the Preparation of Messages 3.1 Risk Perception Risk perception is one of the most complex and challenging aspects of risk communication. Research on risk perception has shown that misunderstanding of probability, biased media cov- erage and misleading personal experiences often cause risks to be misjudged, underestimated or overestimated.12 Strong initial views are resistant to change. New evidence is considered "reli- able and informative" only if it is consistent with initial beliefs. Contrary evidence tends to be dismissed as unreliable, wrong, or unrepresentative.13 Risk communicators must make a distinction between objective risk (actual risk) and subjective risk (perceived risk). Whereas risk is objective, risk perception by nature is subjective. It is imperative for risk communicators to consider the factors that influence risk perception before creating any message or state- ment. Researchers have studied the characteristics of risk that influence risk perception/outrage. A comparison of character- istics of underestimated risks vs. overestimated risks is listed in Table 3-1. The most important perception factors are listed below14: Dread Certain risks invoke more dread than others. Cancer, for ex- ample, causes more dread than heart disease because cancer is seen as a terrible way to die. When asked to estimate the aver- age lifetime chance of developing breast cancer, the average woman in a 2005 survey guessed that the risk was three times higher than the actual risk.15 Control People are more afraid of events when they feel a lack of con- trol. An example: per mile traveled, the risk that one will die in a car accident is far greater than the chances of dying in a plane crash, yet fear of plane crashes is greater than fear of car crash- es, because in an airplane there is very little sense of control.14 Natural vs. man-made risk Man-made risks evoke more fear than natural risks. Nuclear energy sources are often a greater cause of concern than the radiation produced by the sun, even though the sun's radiation leads to many skin cancer deaths each year. Likewise, a toxic Superfund site causes more concern than radon, even though radon exposure kills more Americans each year than all the Su- perfund sites combined.6 (For a definition and explanation of radon, see the glossary.) Figure 3-1. Natural vs. man-made risks: Radon in homes increases risk of lung cancer, but since it is a natural threat there is less fear and outrage. Figure 3-2. Natural vs. man-made risks, and unknown risks: A man- made risk with unknown hazards such as the Superfund site shown above (Bunker Hill, Washington, at the Couer d'Alene River Basin) causes more fear and outrage. ------- Effects on children If children are exposed to, say, asbestos or lead paint in schools, this is perceived as a greater danger than when adults are ex- posed to the same substances.14 Figure 3-3. Since lead paint affects the cognitive development of chil- dren, there is great public concern about lead. Scientifically unknown/new risks Many risks, such as a toxic Superfund site, are unfamiliar, and therefore produce a lot of alarm. Another example would be the SARS epidemic of 2003, which caused great alarm, compared to the yearly influenza epidemic, even though the flu causes more deaths each year.14 Awareness Wide coverage by media and public health officials will often create more alarm in the public. An example is the West Nile Vi- rus, which has received a lot of coverage in the media in recent years. Meanwhile, air pollution is a risk that many Americans are exposed to every day. Health effects include an increased risk for cancer, respiratory ailments (including asthma), and developmental and reproductive problems. Yet, the press rarely reports about the dangers of air pollution, so most laypeople are not worried about it.16 Possibility of personal impact People who are close to a risk, and who have a clear knowledge of the consequences, will have a greater perception of risk.14 Trust Public perception of risk is greater if the lines of communica- tion are from sources that are perceived to be untrustworthy. For instance, studies or statistics about the relationship between smoking and lung cancer from a tobacco company may be mis- trusted by many.14 Table 3-1. A Summary of Risk Perception Factors14 Underestimate Risk Not dreaded (i.e. heart disease) Voluntary Natural Scientifically well understood Known Controllable by the individual In the hands of a reliable source Managed in a responsible way Reversible Immediate health effects Children not as victims Moral/ethical Not memorable Random/scattered Little media attention Victims statistical Risk to future generation Overestimate Risk Dreaded (cancer) Coercive (involuntary) Industrial Scientifically unknown Unknown Controllable by others Managed by an unreliable source Managed in an irresponsible way Irreversible Delayed health effects Children as victims Immoral/Unethical Memorable Catastrophic Much media attention Personal impact No risk to future generation For a hypothetical situation, if the risks are primarily in the "overestimate risk" column of Table 3-1, the public will overestimate the risk and overreact and/or panic. If the risks are primarily in the "underestimate" column, it will be difficult to persuade the public to adopt risk-decreasing behaviors. The role of the risk communicator is to overcome these risk perception factors so a balanced assessment of risk can be produced. ------- Cost-benefit ratio If there is a perceived benefit in a specific choice, the risk as- sociated with that behavior or choice will seem smaller than when no such benefit is perceived. In a study of residents living near a Tacoma, Washington, copper smelter (which emitted ar- senic), the respondents with more tolerance towards the smelter believed that its benefits outweighed its dangers.17 Choice A risk that humans choose to take seems less hazardous than one imposed by another person. This explains why many people skydive or bungee jump, but fear a visit to the dentist.14 Memory of risks A memorable incident makes a risk easier to evoke and imag- ine, and therefore seem greater. For example, the September 11 attacks instantly made "terrorism" a huge fear among the American public, although actual acts of terrorism on American soil are still exceedingly rare.14 Wrote by Nelson Figure 3-4. A memorable incident such as the September 11,2001 at- tacks caused terrorism to become a huge fear for the American public, although terrorist acts remain fairly rare, at least on American soil. Spread over space and time Unusual catastrophic events such as nuclear accidents (e.g., the Chernobyl nuclear accident in 1986) are perceived as riskier than commonplace events, such as a hurricane or blizzard. This is perhaps why many people refuse to evacuate during hurri- canes despite repeated warnings - they think it's "just another storm." Along the same lines, people often drive in blinding snowstorms that cause extremely icy roads and practically no visibility.14 Effects on personal safety and personal property An event is perceived as risky when it affects basic interests and values such as shelter, finances and human life. Examples are hurricanes and earthquakes.14 Reversibility Risks perceived to have potentially irreversible adverse effects are less readily accepted and perceived to be greater than risks posing no permanent, personal threat.14 Ethical or moral nature Risks perceived to be ethically or morally objectionable (e.g., rape, robbery) are less readily accepted and perceived to be greater than risks perceived not to be ethically objectionable or morally wrong, such as a skiing accident.14 Delayed effect People fear hazards that have a delayed effect (e.g., carcino- gens) more than hazards with immediate health effects.14 High risk to future generations Activities that pose a threat to future generations (e.g., radia- tion from a nuclear accident) are judged to be a more risky than those that threaten the current generations, such as influenza.14 3.2 Preparing Messages in Advance Preparing an appropriate, concise, effective message prior to an event actually occurring is probably the most crucial part of risk communication. When preparing messages, it is important to consider the several risk communication theories that are out- lined below. 3.3 Risk Communication Theories Risk Denial Risk denial is a common reaction to a specified risk. Studies have shown that individuals may acknowledge the existence of a risk, yet assume that they personally are not vulnerable to it and are more knowledgeable about hazards relative to others. hi the Tacoma survey, those who lived the closest to the cop- per smelter tended also to be employees at the smelter. These residents were most likely to deny any risk from the smelter's arsenic emissions, even though they were most vulnerable to the emissions. When a risk is counterbalanced with a perceived benefit, very often the risk is simply denied.17 Stigmatization, fear, withdrawal, hopelessness and helplessness can also con- tribute to risk denial.18 In the case of an infectious disease (such as AIDS), Stigmatization or fear of Stigmatization may be so ------- great that ignorance is preferable to seeking help. Fear is also a psychological consideration in a crisis - it is often debilitating and prevents quick, decisive action. In other cases people may feel that the threat is real, but that there is nothing they can do about it. Thus they withdraw into hopelessness and helpless- ness. Very often people will recognize a risk but consider themselves less personally in danger than other people. A survey that asked participants about their personal vulnerability to eight risks (contaminants in drinking water, smoking, radon, chemical residues on food, AIDS, low-level radioactive waste, and high blood cholesterol) found that respondents recognized potential harm to others, but rated their own personal vulnerability to the eight risks as lower.19 Trust Determination Theory The trust determination theory proposes that when people are upset they often doubt that others are listening, caring, empa- thetic, competent, and/or committed. Thus the first and most important goal of preparing a risk communication message is building trust with the audience or stakeholders. According to a survey conducted by the Center for Risk Com- munication, factors that build trust and credibility are: caring and empathy; competence and expertise; honesty and openness; and dedication and commitment.20'21 Caring and empathy are the most important factors in building trust and credibility. Studies also show that people make their initial judgments about caring and empathy within the first 30 seconds.22 It is also important to build trust and credibility by using support from credible third party sources. According to surveys, health professionals, sci- entists, educators and advisory groups have high credibility and promote trust on health, safety, and environmental issues. Me- dia and activist groups have medium credibility, while industry and paid consultants have low credibility. An example of an industry that regained public trust was John- son & Johnson Co. during the Tylenol tampering incident of 1982. The company aggressively removed all Tylenol from re- tail shelves. The recall cost the company $100 million, but the public perception was that Johnson & Johnson was concerned about public health and safety.20 Mental Noise Theory The mental noise theory hypothesizes that when people are stressed or upset, they have difficulty hearing, understanding, and remembering information.22 Providing messages to the public that are brief, concise, and clear, while still providing all necessary information is a way to overcome this challenge. Ways to ameliorate mental noise include: Provide a limited number of clear messages: 3 key mes- sages Keep messages brief: 9 seconds or 27 words Repeat messages Use simple language (6-8 grade level) Use visual aids: graphics, slides, charts, diagrams, video, photographs Use personal stories, rather than impersonal statistics Negative Dominance Theory The negative dominance theory hypothesizes that people tend to focus more on the negative than on the positive in emotion- ally charged situations.21 Solutions to the negative dominance theory include:23-24 Balancing negative key messages with positive, construc- tive or solution-oriented key messages Employing a ratio of at least 3:1 positive to negative words Avoiding unnecessary, indefensible, or nonproductive use of absolutes and the words "no," "not," "never," "nothing," "none." Body Language Body language, the language of gestures and postures, is an important - and often decisive - factor in risk communication.22 Experts believe that it provides up to 75% of message impact, is noticed intensely, and overrides verbal communication. There are some general rules for appropriate body language in risk communication. The speaker should make eye contact; not do- ing so makes the audience feel that you are dishonest, uncon- cerned, or nervous. Sit up straight; not doing so can convey lack of interest or concern. Do not cross arms; this can be seen as defiant, defensive or uninterested. Frequent hand to face contact can seem dishonest or nervous. Drumming or tapping hands or feet conveys nervousness, hostility or impatience. Resting a hand on the head can give the impression of boredom or fatigue. A raised voice can send a message of hostility, nervousness or deceit. In other words, risk communicators should be trained about proper body language when speaking to stakeholders. Figure 3-5. Body language can affect viewer perception, irrespective of the actual words spoken. 10 ------- Presentation Format When people lack strong prior opinions or understanding, they can be easily manipulated by the way risk information is pre- sented. In one study, participants were asked to imagine they had lung cancer and had to choose between two therapies, sur- gery and radiation. Some subjects were then presented with the cumulative probabilities for surviving after the treatment. Other subjects received the same probabilities, except framed in terms of dying rather than surviving. Framing the statistics in terms of dying rather than surviving dropped the percentage of subjects choosing radiation over surgery from 44% to 18%.25 In another study, a hypothetical situation about the risk of side effects of an influenza vaccine was presented in either a probability for- mat (i.e. 5%) or a frequency format (i.e. 1 out of 20). The 42 subjects given the probability format of 5% were more likely to describe the risk as "uncommon" or "rare," as opposed to the 43 people given the frequency format (1 out of 20).26 Pitfalls in Risk Communication22 The Association of State and Territorial Health Officials lists common pitfalls made by organizations when communicating risks. These include over-reliance on jargon, losing one's tem- per, speaking in overly abstract terms, resorting to personal at- tacks, giving unrealistic promises and guarantees, referring to financial concerns, blaming other people/organizations, talking "off the record," using improper risk comparisons, and talking for too long. 3.4 Other Guidelines for Risk Communication 1. The primacy/recency principle. This principle states that the most important messages should occupy the first and last position in a list26, since information that is mentioned first or last on a list is the most likely to be remembered. The primacy/recency effect has been confirmed in various psychological tests. In one experiment, college students viewed lists of 15 commercials in a laboratory simulation and recalled the product brand names. In an immediate test, the first commercials in the list were well recalled (a primacy effect), as were the last items (a recency effect), in comparison with the recall of middle items.27 The primacy/ recency effect has also been replicated with recall of non- words28 and affective word lists.29 Non-words in this case are letters of the alphabet jumbled together; affective word lists are words that are related in some way. For instance, an affective word list would be: sadness, grief and heart- break. 2. Speak with compassion, conviction, and optimism. This guideline is modeled after the behavior and persona of Prime Minister Winston Churchill. In a time of great stress and turmoil, Churchill was an anchor who embod- ied Britain's indomitable spirit during World War II. There are many quotations which reflect Churchill's compassion, conviction, and optimism, such as: "Success is not final, failure is not fatal: it is the cour- age to continue that counts." "The pessimist sees difficulty in every opportunity. The optimist sees the opportunity in every difficulty." "We shall not fail or falter; we shall not weaken or tire...Give us the tools and we will finish the job."30 Figure 3-6. British Prime Minister Winston Churchill's oratory style serves as a model for effective risk communication. 3. Average Grade Level Minus Four: During stressful situ- ations people do not comprehend information at their nor- mal grade level. If a person's normal reading level is eighth grade, during a crisis his reading/comprehension might drop to fourth-grade level. In a study that compared chil- dren who attended a school with high aircraft noise (from London Heathrow airport) versus schoolchildren who at- tended a school with no aircraft noise, the children chroni- cally exposed to aircraft noise were associated with high levels of stress, as well as poorer reading comprehension and sustained attention.31 4. Stick to three main points. According to information the- ory, both short-term memory and attention span are limited by the number of items the mind can consider simultane- ously.32 This is one of the oldest rules of risk communica- tion - Aristotle wrote about it in Art of Rhetoric. Famous examples of the "Rule of Three" are Julius Caesar's "I came, I saw, I conquered," or the Declaration of Indepen- dence's "Life, liberty, and the pursuit of happiness." Infor- mation theory also states that generally, people organize their thinking in terms of only three or four items.33 11 ------- 5. Use visual aids, such as pictures or graphs, analogies, ex- amples, and photographs that can enhance audience com- prehension. Experiments have shown that effective work- ing memory may be increased by presenting material in a mixed (auditory and visual) rather than a single mode.33 6. For every negative statement, include three positive state- ments. This is the 1N=3P rule. This rule is derived from the Negative Dominance Theory, which has also been rep- licated in psychological studies. In an experiment where subjects were asked to rate pleasant and unpleasant noun pairs, the unpleasant noun of a pair made a stronger im- pression in recall tests than the pleasant noun.34 If forced to make a negative statement, here is the template to follow: 1. Positive news 2. Acknowledge negative 3. Positive statement 1 4. Positive statement 2 5. Positive statement 3 6. Follow up 7. In the event that the speaker cannot answer a question that is asked, follow this template: Repeat the question Admit to not knowing the answers Give the reasons why Indicate follow-up with a deadline for getting the information Bridge to a positive statement: "While I don't have that specific information at the moment I want to remind everyone ..." Below is a table that summarizes general rules for risk commu- nication, taking into account risk perception, risk communica- tion theories, and common pitfalls of risk communication. 3.5 Risk Communication to the Media and General Public The mass media exerts an influence on people's perception of risk, so it is important for risk communicators to understand the media's strengths and limitations as a tool for risk communica- tion. Some risk communicators have charged the media with exaggerating some risks and ignoring others, and focusing on rare, headline-grabbing hazards (terrorism, for example) while ignoring more commonplace risks (heart attacks). However, evidence suggests that it is not so much media bias that affects risk perception, but the media's availability and the medium with which the information is transmitted. Television news may convey greater danger, resulting in increased levels of fear among audience members than print media conveys. It is one thing to read about hurricanes, but seeing destroyed homes and downed trees on television makes the risk much more vivid. hi addition, television often conveys information in less depth than written media.19 However, it is unclear how much impact the media actually has on an audience's risk perception. Studies indicate that while the media can amplify general societal risk perception, personal risk perceptions are much harder to change. Personal risk judg- ment is based more on personal experiences and direct informa- tion. 19,35 Table 3-2. General Guidelines for Good Risk Communication Good Communication Clearly state and estimate the risk Ex: "We have a serious and immediate problem requiring attention ..." Use clear, non-technical language - write in an eighth-grade reading level if talking to the general public Use credible sources - government agencies, scientific experts, reliable news sources (AP, Reuters, etc.) Listen to the audience - assume that if one communicates in a clear, appropriate manner, the audience will understand Remain calm - do not get agitated or defensive Keep messages brief - main message about 25-30 words (and 10 sec- onds) Balance a negative statement with 3 positive statements Place most important messages first and last Use visual aids and graphics - charts, videos, pictures, graphs Repeat messages - three times, to make sure the most important points are remembered Speak with a serious tone - it will give the impression of taking the audience seriously Poor Communication Exaggerate or minimize the risk Ex: "No one has anything to worry about"; "It's time to panic" Use technical language/jargon - for example, filling the speech with acronyms ("For the RfD, go to EPA's IRIS") Use non-credible sources - lobbying groups, industries Ignore the audience's concerns - a "they won't understand anyway" mentality Get angry - "That's a stupid question ..." Make messages long-winded - droning on and on with long lists Use an overload of negative statements, and words like "no," "never," "nothing" Hide most important message in the middle of the speech Use impersonal statistics - "the chances of one having an exposure of more than 50 ppb is about 1 in 1 00" Mention an important message in passing - "Oh, by the way, the hur- ricane warning is effective immediately ..." Add humor - can often come off as flippant or be misunderstood as a lack of concern 12 ------- There is, however, evidence that the media's focus is related to public attitudes. Thus, situations with "high outrage" factors receive greater coverage. A study of seven British newspapers found that threats with high definition (infectious diseases, rabies, and food poisoning) were disproportionately reported relative to their frequency of occurrence.36 Another issue between the media and risk communicators is the fact that few journalists have the scientific background to sort through and understand the complex and often contradictory opinions of risk "experts."37 Therefore it is important for risk communicators to be well prepared and well organized before any interview with a journalist. There are many ways of getting emergency information to the media: press releases, press con- ference, satellite media tours, telephone news conference/web casts, commercial press releases, email list-servs, web sites, and video streaming. There are plusses and minuses to every method of communication with the media.18 The method ulti- mately chosen will be based on the urgency of the situation, the risk communicator's time constraints, need for consistency, the media's time constraints, and financial considerations. As a rule, the media are more interested in the following20: Human interest stories (as opposed to statistics) Bad news (as opposed to good news) Personal perspectives (i.e. "An eyewitness account of...") Yes or no (safe or unsafe) answers (as opposed to nuanced, ambiguous answers) Front-page headline news stories Quick, digestible sound-bites During a press conference or another form of communica- tion with the media, it is important to remember some dos and don'ts: Do: Present a short, concise, and focused message Make the most important points immediately Give action steps in positives, not negatives Repeat the message Create action steps in threes Use personal pronouns for the organization Don't Use: Technical jargon Filler information that is not pertinent to the main mes- sage Condescending or judgmental phrases (i.e. "Anyone with a bit of sense would realize ...") Attacks or judgmental language Promises/guarantees ("Read my lips, no new taxes" is a well-known example.) Speculation; stick to the facts Discussion of money or financial considerations; these are deemed to be less important in a tense situation than hu- man and safety issues Humor, as it gives an impression of flippancy Also, remember to break up information into more digestible pieces for the media. Many experts resent doing this, but if they don't simplify the news for journalists, they will do it them- selves, and much confusion and misinformation may result. Table 3-2 lists some of the Do's and Don'ts of communicating with the media. ATO CDRL C.F.R. CLIN CO CSO FAIR FAR FICA FTE FWS GAO GFP GS HRA MEO OMB OPM PWS SCA SCF SLCF SSA SSEB U.S.C. VERA VSIP Agency Tender Official Contract Data Requirements List Code of Federal Regulations Contract Line Item Number Contracting Officer Competitive Sourcing Official Federal Activities Inventory Reform Federal Acquisition Regulation Federal Insurance Contribution Act Full-time Equivalent Federal Wage System General Accounting Office Government-Furnished Property General Schedule Human Resource Advisor Most Efficient Organization Office of Management and Budget Office of Personnel Management Performance Work Statement Service Contract Act Standard Competition Form Streamlined Competition Form Source Selection Authority Source Selection Evaluation Board United States Code Voluntary Early Retirement Authority Voluntary Separation Incentive Pay Figure 3-7. Filling a speech with acronyms like the ones listed above often just confuses listeners. 13 ------- 14 ------- 4. Message Mapping - Design and Structure 4.1 Purpose and Structure of a Message Map The principles of risk communication can be applied when cre- ating a message map. The message map is an organized means for displaying layers of information. It contains detailed, hier- archically organized responses to anticipated questions or con- cerns. It helps organizations meet several risk communication goals38: Identify stakeholders early on in the communication pro- cess. Anticipate the questions and concerns of the stakeholders before they appear. Organize our thoughts and ideas and prepare messages in response to the concerns and questions of the stakehold- ers. Develop key messages and supporting information in the context of a clear, concise, transparent, and accessible framework. Promote an open dialogue about the messages both inside and outside the organization. Provide the spokesperson with a user-friendly guide. Make sure that the organization has consistent information and messages. Make sure that the organization speaks with a single voice. A message map template is a three-tiered grid containing mul- tiple boxes (see Figure 4-1 below). The top tier of the template identifies the audience for the message map as well as the question or concern that the message map is intended to address. The second tier of the message map contains three key messages that answer the question or concern. The third tier contains supporting information, which is blocked in groups of 3's under each key message. Support- ing messages amplify the key messages, and provide ad- ditional facts or details. They can take the form of visuals, analogies, personal stories, hotline numbers, and/or cita- tions of credible sources of information. Stakeholder: Question or Concern: Key Message 1 Supporting Information 1-1 Supporting Information 1-2 Supporting Information 1-3 Key Message 2 Supporting Information 2-1 Supporting Information 2-2 Supporting Information 2-3 Key Message 3 Supporting Information 3-1 Supporting Information 3-2 Supporting Information 3-3 Figure 4-1. Template of a message map. 15 ------- 4.2 The Overarching Message Map The Overarching Message Map (see Figure 4-2 below) is the most important message map. If a message map were a news- paper article, the Overarching Message Map would be the headline and the first paragraph. It contains and displays the organization's key messages. At an EPA sponsored workshop for Water Utilities and Water Security and Message Mapping in March 2005, an Overarching Message Map38 was described as: What the speaker/organization most wants people to know about the issue or topic What the speaker/organization would put in the opening statement at a presentation or press conference relating to the issue and topic. Suppose the situation is an ongoing influenza epidemic. The Overarching Message Map would look something like what is shown on Figure 4-3. How you can PREVENT rf* FLU Vaccination 1$ not the only way to combat the flu. Use these simple lips lo prevent the flu before it happen*. Avoid close contact. Avoid close contact with people who are sick. When you are sick, keep your distance from others to protect them from getting sick too. Clean your hands. Washing your hands often will help protect you from germs. Stay home when you are sick. iftf.f. If possible, stay home from work, school, and errands when you arc sick. You will help prevent others from catching your illness. Cover your mouth and nose. Cover your mouth and nose with a tissue when coughing or sneezing. It may prevent those around you from getting sick. Avoid touching your eyes, nose, or mouth. ^ Germs art often spread when a person (ouches something that is contaminated with germ and then touches his or her eyes, nose, or mouth. Figure 4-3. A message map can serve as a guideline for a health awareness poster like the one above. Stakeholder: Public, health care workers Question or Concern: What does the public most need to know about the influenza epidemic? Key Message 1 Vaccination a top priority for: Supporting Information 1-1 Elderly Supporting Information 1-2 Health care workers Supporting Information 1-3 Immuno-compromised individuals Key Message 2 Symptoms Supporting Information 2-1 Fever Supporting Information 2-2 Congestion (cough, sore throat) Supporting Information 2-3 Muscle aches and pain Key Message 3 Highly contagious Supporting Information 3-1 Avoid direct contact with others Supporting Information 3-2 Avoid sharing food, drinks Supporting Information 3-3 Keep bedding (sheets, linens) clean Figure 4-2. Example of an overarching message map. 16 ------- 5. Creating a Message Map ,38 A message map can be one of the most useful of risk com- munication tools. It is important, however, to create well-con- structed message maps in order to effectively communicate with the public by clearly explaining the situation, the risks, and the remedies. Before getting started, remember these important guidelines: Be prepared. Know the subject and the audience. Prepare your key messages. Remember, limit to three key messages and a maximum of three supporting statements for each key message. Keep answers short and focused. Speak and act with integrity. Tell the truth. 5.1 The Creation of a Message Map Can Be Separated into Eight Steps Step 1: Identify stakeholders The first step is to identify stakeholders. Stakeholders include the public at large as well as all interested, affected, or influen- tial parties in a situation. Supposing the risk alert concerned influenza, stakeholders would include the public at large, health care workers, public health officials, as well as those most at risk for influenza (the elderly, for example). Identifying stakeholders is also a crucial step of the message mapping process because risk communicators must adjust their messages to fit the needs and capabilities of an audience. A situ- ation where the stakeholders are children/laypeople would yield a very different message map than a message map where the stakeholders are doctors or health workers. Step 2: Identify anticipated stakeholder questions and con- cerns Prepare a complete list of specific questions and concerns for each major group of stakeholders. A list of the Most Commonly Asked Questions by a Journalist is contained in Section 9.0. The questions that are generated or anticipated are the first tier of the message map grid. Questions and concerns typically fall into three categories, overarching questions, informational ques- tions, and challenging questions. Overarching questions are broad in topic and are developed by the organization to analyze the general status of a situation. Informational questions ask about a specific aspect of the situation. Challenging questions are often hostile/tense in tone. Examples are: 1) 2) 3) Overarching questions: "What do people need to know?" Informational questions: "What is the budget for your re- sponse?" Challenging questions: "Why should we trust what you are telling us? How many people have to die before you take more aggressive action? Can you guarantee that people are safe? What are you not telling us?" Lists of specific stakeholder questions and concerns can be gen- erated through34: Focus groups Surveys Media content analysis Reviews of complaint logs, hot line logs, toll free number logs, and media logs Focused interviews with subject matter experts Public meeting records, public hearing records, and legisla- tive transcripts Step 3: Identify frequent concerns Make an analysis of the list of specific concerns, and identify common groups of underlying general concerns. Case studies indicate that most high-concern issues are associated with no more than 15-25 categories of concern. As part of this step, it is useful to create a matrix or table matching the stakeholders (in order of priority) with their concerns. Here is a list of common sets of concerns:39 human health, trust, safety, environment, information, ethics, economics, responsibility, legal, process, pets/livestock, religion, fairness. Step 4: Develop key messages When preparing the messages, it is important to consider the risk communication theories outlined in Section 3.3 (mental noise, negative dominance theory, etc.). During staff brain- storming sessions, key words should emerge for each message. Each issue should have no more than three key messages. These key messages fill in the second tier of the message map. Step 5: Develop supporting information The fifth step of constructing a message map is to develop sup- porting facts, information, or proofs for each key message. Sup- pose for a message map about influenza one key message was, "All high-risk groups must be vaccinated." The supporting mes- sages in this instance would be directed to the high risk groups: the elderly, the immuno-compromised, or health care workers. 17 ------- These supporting messages fill in the third tier of the message map for this key message. Step 6: Conduct testing The sixth step of message mapping is to conduct systematic pre-testing. The message testing should start by asking experts on the topic at hand, who were not involved in the original mes- sage-mapping process, to validate the accuracy of the informa- tion. Subsequently, the message map should be tested on fo- cus groups that are representative of target stakeholders. (For instance, supposing the message map was about influenza, a focus group could be elderly citizens planning to get the flu vaccine.) Step 7: Overarching Message Map39 An Overarching Message Map contains the organization's core messages. The Overarching Message Map addresses: What people most need to know about the issue or topic What to put in the opening statement at a presentation or press conference relating to the issue or topic One method for assuring that the message of the Overarching Message Map is delivered to the audience is bridging. Bridg- ing is a tool used by risk communicators to connect statements and responses in a smooth, straightforward manner. During an influenza epidemic, an example of a bridging statement might be: "I want to remind you again that the influenza vaccine is easily available at all local hospitals and clinics ...." Step 8: Delivery The key to successful delivery is anticipation, preparation, and practice. Once the message map has been pre-tested, it should be delivered through a trained spokesperson through suitable media (i.e. a news conference or a recorded reply in emergency telephone lines, etc.). The stakeholders must feel that their con- cerns are treated seriously. Audiovisual aids are often very help- ful in a presentation. The presentation sequence should follow these guidelines:22 1. Introduction Perceived empathy is a vital factor in establishing trust and building credibility, and it is assessed by your audience in the first 9-30 seconds. Include a statement of concern, a statement of organizational intent, and a statement of pur- pose and plan for the meeting. 2. Key messages and supporting data Stress the three key messages you want the public to have in mind after the meeting. Then mention the supporting data, which amplifies, clarifies, or bolsters the key messages. 3. After the presentation After the speaker has given all the information contained in the message map, he must answer questions from the me- dia and stakeholders. The speaker should prepare before- hand answers to some common, anticipated questions and concerns from the press and stakeholders. 18 ------- 6. Message Mapping in Action: Three Examples The next three sections will provide examples of message maps relating to real-life crises. These message maps provide a guideline for commonly asked questions during a crisis. In each case, real-life events provide some context and familiarity. They include West Nile Virus of 2002, the anthrax bioterrorism event of 2001, and the 1993 Cryptosporidium drinking water contamination episode in Milwaukee. 6.1 The West Nile Virus: Crisis Summary and Message Maps Time and location of crisis: The West Nile Virus started to attract much attention in the United States during the summer of 2002. Thirty-nine states and the District of Columbia reported a total of 4,156 cases of human West Nile Virus illness.40 West Nile Virus - a background: West Nile Virus is indigenous in Africa, Asia, Europe, and Aus- tralia. West Nile Virus was first isolated in 1937 from the blood of a febrile (feverish) female patient in the West Nile district of Uganda.41 The virus can cause severe human meningitis and encephalitis, both of which are characterized by inflammation of the spinal cord and brain. The main route of human infection from West Nile Virus is through the bite of an infected mosquito belonging to the Culex genus. Mosquitoes become infected when they feed on infected birds. The virus eventually gets into the salivary glands of the mosquito. During later blood meals (when mosquitoes bite), the virus may be injected into humans and animals, where it can multiply and possibly cause illness. Although mosquito bites are the most common method of infection, blood transfusions and organ donations are also possible methods of infection. The majority (80%) of West Nile viral infections are asymptomatic - without any signs of disease. The most common (20%) clini- cal symptom is uncomplicated West Nile fever, which is not life-threatening. The virus, however, can cause severe or fatal neuroinvasive illness. First indication of event: The West Nile Virus's first introduction to North America was in 1999, when an unusual cluster of cases of meningoencepha- litis was documented in New York City. The initial symptom was severe muscle weakness. At the same time, an epizootic disease (i.e. affecting a large number of animals) was causing the deaths of substantial numbers of birds in the New York City area. The West Nile Virus was isolated from tissue specimens obtained from American crows in Westchester County and a Chilean flamingo in a nearby zoo. West Nile Virus was deter- mined to be the common cause of the encephalitis outbreaks among both birds and humans.42 The ArboNET surveillance system was established by the Cen- ters for Disease Control in 2000 to monitor the spread of West Nile Virus in the United States. In 2002, 4,156 human West Nile virus illnesses were reported to ArboNET from 39 states and the District of Columbia. Of the 4,156 reported cases, 71% were neuroinvasive, 28% were uncomplicated West Nile fever, 1% was unspecified. There were 284 fatalities (6.8%) out of the 4,156 reported cases. Figure 6-1. An electron micrograph of the West Nile Virus, which can infect mosquitoes, birds, humans, and other mammals. 19 ------- Clinical features of West Nile Virus: The symptoms of West Nile Virus closely resemble the symp- toms of the St. Louis Virus, a flavivirus also transmitted by mosquitoes of the Culex genus, and other worldwide outbreaks of arboviral encephalitis.43 Arboviruses are any of a large group of viruses transmitted by arthropods, such as mosquitoes and ticks, that include the causative agents of encephalitis, yellow fever, and dengue. A flavivirus is one form of arbovirus. The majority (80%) of West Nile viral infections are asymptomatic - without any signs of disease. For those infected who do get sick, the incubation period is approximately 2-14 days.44 For those who do show clinical symptoms of infection, the most common (20%) clinical symptom is uncomplicated West Nile fever. Uncomplicated West Nile fever typically begins with an onset of fever, headache, and myalgia (muscle pain) often ac- companied by gastrointestinal symptoms. The acute illness usu- ally lasts less than one week, but prolonged fatigue is common. It is not life-threatening. About one out of 150 people that are infected will develop neuroinvasive illnesses such as encephalitis (inflammation of the brain), meningoencephalitis (inflammation of the brain and surrounding membranes), and meningitis (inflammation of the membranes surrounding the brain). Encephalitis, meningitis, and meningoencephalitis, can be fatal, especially in older vic- tims. Most West Nile case fatalities are due to encephalitis and meningoencephalitis. What can the public do to avoid West Nile Virus? Since the primary method of West Nile Virus infection is through mosquito bites, preventing bites is the best way to avoid WNV There are simple steps the public can take to avoid being bitten by mosquitoes: Remove standing water, including old tires that serve as breeding grounds for mosquitoes. Wear long-sleeved shirts and pants and avoid going out during "bite hours" - dusk till dawn. Use bug repellant that contains DEBT What is being done to prevent future outbreaks? The methods of prevention of future West Nile Virus outbreaks fall into three categories: surveillance, source reduction, and chemical control.45'46 Surveillance identifies mosquito species, location, ecologic locations, seasons, and breeding cycles. Ar- boNET is a nation-wide electronic database for states sharing information about WNV Source reduction attempts to reduce mosquito opportunities by altering the habitat to make condi- tions unfavorable for larval breeding. In the case of West Nile Virus the Culex pipiens mosquitoes tend to breed in standing water. Chemical control involves the use of pesticides to reduce mosquito populations. WEST NILE VIRUS TRANSMISSION CYCLE MOSQUITOES Some species of mosquitoes carry & amplify the virus. They Ir.msmil ihe virus when they bile to gel a protein bUxid me»l before laying eggs MAMMALS M0tl »p«tn are nrtuuwjrtlDktti BIRDS Infected mosquitoes bite birds tc. infer I them. Some infected birds lr.m-.mil llu- virus to other mosquitoes when Hlten 4g4in. Birds of some species get ill; others do not show disease symptoms, although infected. Infected migrating birds carry the virus to new places. MAMMALS ARE DEAD END HOSTS IlK Irvrl at vimnu in mAmnult it K«*TK rj|l> Sow low ID transmit Ito infection Figure 6-2. The West Nile transmission cycle, in which infected mosquitoes infect birds, humans, and other animals. 20 ------- 6,1.1 Message Maps about the West Nile Virus Message Map 1: Overarching Message Map This is an overarching message map, and it contains information the public most needs to know about the West Nile Virus: how one gets infected with the virus, the health effects of West Nile Virus, and the simple methods one can employ to avoid infection. Stakeholder. Public/Media Question or Concern: What does the public most need to know? Key Message 1 West Nile Virus transmitted by infected mos- quitoes Supporting Information 1-1 Mosquitoes become infected from biting in- fected birds Supporting Information 1-2 Blood-blood transmission also possible Supporting Information 1-3 Human-to-human contact not believed to be a mode of transmission Key Message 2 Health effects of West Nile Virus are: Supporting Information 2-1 80% of all infections are asymptomatic Supporting Information 2-2 Uncomplicated West Nile Virus fever: 20% Supporting Information 2-3 Encephalitis, Meningitis, Meningoencephalitis: 1 out of 150 cases, usually in elderly (<1 %) Key Message 3 There are simple steps people can take to avoid infection Supporting Information 3-1 Spray with DEBT Supporting Information 3-2 Wear long-sleeved clothing Supporting Information 3-3 Remove any standing water Message Map 2: What happened? What should the public know? This message map answers the "who, what, when, where, why?" questions. In this case, the message map documents the epidemic in the United States during the summer of 2002, and how the West Nile Virus became a health risk via mosquitoes. The last key messages are about avoiding infection. Stakeholder: Public/Media Question or Concern: What happened (Who, what, when, where, why?) What should the public know? Key Message 1 A West Nile Virus epidemic in the U.S. in the summer of 2002 Supporting Information 1-1 4,1 56 cases of West Nile Virus in 39 states and the District of Columbia Supporting Information 1-2 Of the cases, 71 % neuroinvasive, 28% uncom- plicated, 1 % unspecified, 284 (< 7%) fatal Supporting Information 1-3 First U.S. cases discovered in New York City, 1999 Key Message 2 West Nile Virus transmitted by infected mos- quitoes Supporting Information 2-1 Mosquitoes become infected from biting in- fected birds Supporting Information 2-2 A flavivirus - a virus transmitted by mosqui- toes Supporting Information 2-3 Virus originally from Eastern hemisphere Key Message 3 There are simple steps people can take to avoid infection Supporting Information 3-1 Spray with DEET Supporting Information 3-2 Wear long-sleeved clothing Supporting Information 3-3 Avoid exposure during "biting hours" - dusk to dawn 21 ------- Message Map 3: How did you find out about the West Nile virus? This message map explains the discovery of West Nile Virus in the United States, and how the first human cases were diagnosed. Stakeholder: Public/Media Question or Concern; How did you find out about the West Nile Virus? Key Message 1 First cases of meningoencephalitis in NYC, 1999 Supporting Information 1-1 719 patients with reports of meningitis and en- cephalitis Supporting Information 1-2 62 of these 71 9 patients were confirmed West Nile Virus cases Supporting Information 1-3 Illness resembled St. Louis encephalitis, as well as other outbreaks of encephalitis in Eu- rope and Israel Key Message 2 Deaths of birds occurring in NYC area Supporting Information 2-1 West Nile infection among birds more geo- graphically widespread than among humans Supporting Information 2-2 Flavivirus isolated from birds Supporting Information 2-3 Virus determined to be the common cause of the bird/human illnesses Key Message 3 Virus determined to be West Nile Virus Supporting Information 3-1 Mosquito with WNV bite birds Supporting Information 3-2 Mosquitoes with WNV also bite humans Supporting Information 3-3 Although most cases of WNV are asymptom- atic, some cases can be fatal; prevention from mosquito bites is crucial Message Map 4: What are the health effects associated with West Nile Virus? There are three major health effects of West Nile Virus. The majority (80%) experience no health effects. About 20% have uncom- plicated West Nile fever. One in 150 cases will develop potentially fatal neuroinvasive illnesses such as meningitis, encephalitis, and meningoencephalitis. Stakeholder: Public/Media Question or Concern: What are the health effects associated with West Nile Virus? Key Message 1 Older people are more at risk for serious ill- ness Supporting Information 1-1 Incubation period is 2-14 days Supporting Information 1-2 Eventual clinical symptom is a neuroinvasive illness Supporting Information 1-3 About 20% or one-fifth of people over 70 died. Deaths occurred in people averaging 77 years old Key Message 2 Mosf infections are not life-threatening Supporting Information 2-1 80% of all infections are asymptomatic Supporting Information 2-2 20% have mild illness, called West Nile Fever, often accompanied by gastrointestinal symp- toms Supporting Information 2-3 Acute illness typically lasts one week, but pa- tients report prolonged fatigue Key Message 3 About 1 in 150 infections develop meningitis, encephalitis, or meningoencephalitis Supporting Information 3-1 Muscle weakness often the first symptom Supporting Information 3-2 Encephalitis and meningoencephalitis most fatal Supporting Information 3-3 In 2002 epidemic, of the 2,942 neuroinvasive illnesses, 276 (9%) were fatal 22 ------- Message Map 5: What can people do to prevent West Nile Virus? The simple steps people can take to prevent West Nile Virus fall under three categories: remove standing water, wear protective clothing, and use insect repellent. Stakeholder; Public/Media Question or Concern: What can people do to prevent West Nile Virus? Key Message 1 Remove standing water Supporting Information 1-1 Remove old tires which collect water and serve as breeding grounds for mosquitoes Supporting Information 1-2 Empty or clean flower pots and bird baths daily Supporting Information 1-3 Empty and clean cat/dog water bowls daily Key Message 2 Wear protective clothing Supporting Information 2-1 Wear long sleeved shirts Supporting Information 2-2 Wear long pants Supporting Information 2-3 Especially at dawn and dusk Key Message 3 Use insect repellent Supporting Information 3-1 Repellents containing DEET are recommend- ed Supporting Information 3-2 Use 23% DEET Supporting Information 3-3 Do not use repellents that do not contain DEET Message Map 6: What is being done to prevent this in the future? The large-scale prevention measures against West Nile Virus fall into three categories: surveillance (monitoring outbreaks), source reduction (reduce breeding grounds), and chemical control (pesticides). Stakeholder; Public/Media Question or Concern: What is being done to prevent this in the future? Key Message 1 Surveillance - monitor possible outbreaks (ArboNET) Supporting Information 1-1 Larval mosquito surveillance Supporting Information 1-2 Adult mosquito surveillance Supporting Information 1-3 Virus surveillance Key Message 2 Source reduction - reduce opportunity Supporting Information 2-1 Reduce breeding ground Supporting Information 2-2 Water management Supporting Information 2-3 Personal prevention measures Key Message 3 Chemical control - use pesticides Supporting Information 3-1 Larvaciding - killing larvae Supporting Information 3-2 Adulticiding - killing adult mosquitoes Supporting Information 3-3 These efforts are usually far from complete 23 ------- Message Map 7: How did this happen? This message map outlines the history of West Nile Virus, from the very first isolated patient (in 1937) to its introduction into the United States. Stakeholder: Public/Media Question or Concern: How did this happen? Key Message 1 Virus indigenous in Europe, Africa, Asia, and Australia Supporting Information 1-1 West Nile Virus first isolated in 1937 Supporting Information 1-2 Epidemics in Israel and South Africa Supporting Information 1-3 Key Message 2 Detected in NYC in 1999 Supporting Information 2-1 Also detected in birds in North America Supporting Information 2-2 Extended its range to much of the East Coast of the United States Supporting Information 2-3 Horses also infected Key Message 3 Mode of introduction into United States un- known Supporting Information 3-1 Mosquito-borne transmission Supporting Information 3-2 Blood-blood transmission also possible Supporting Information 3-3 Human-to-human contact not believed to be a mode of transmission 6.2 Bioterrorism (Anthrax): Crisis Summary and Message Maps Time and location of event: The anthrax scare occurred during the fall of 2001 in the United States. Anthrax was deliberately spread through the postal sys- tem by sending letters with powder containing anthrax. These letters were all sent from Trenton, NJ, and mailed to Florida, Washington D.C., and New York City. The letters seemed to target government or media figures - one letter was sent to an- chorman Tom Brokaw's office, another to Senator Tom Dasch- le's office. This caused 22 cases of anthrax infection.47 To date the culprits behind the anthrax attacks have not been found. Ot-11-01 CAN NOT STOP us. we HAW THIS Dig Now. ^*t Vou APA Dear* TO AUAH 15 Figure 6-3. A photo of the letter sent to Senator Tom Daschle's office that contained anthrax spores. Anthrax - a background: Anthrax is an acute infectious disease caused by the spore- forming bacterium Bacillus anthracis. It has a long reputation as deadly bacteria - the fifth and sixth plagues of the Exodus might have been outbreaks of anthrax in cattle and humans, respectively.46 Anthrax most commonly occurs in wild and do- mestic animals, but it can also occur in humans when they are exposed to infected animals or when anthrax spores are used as a bioterrorism weapon. In the mid-1800s, it became known as the wool sorters' disease in England and the rag pickers' disease in Germany and Austria because of the frequency of infection in mill workers exposed to imported, contaminated animal fi- bers. In the early 1900s, human cases of inhalational anthrax also occurred in the United States in conjunction with the tex- tile and tanning industries.49 Research on anthrax as a biological weapon began more than 80 years ago.50 First indicator of anthrax bioterrorism: In September 2001, Bacillus anthracis spores were sent to sev- eral locations via the U.S. Postal Service. It wasn't until October 2, 2001, that a physician recognized a possible case of inhala- tion anthrax in a patient hospitalized in Palm Beach County, Florida. The diagnosis of B. anthracis was confirmed by the Florida Department of Health and the CDC on October 4. Ev- idence of B. anthracis was found at American Media Inc. in Boca Raton, Florida, where this first victim worked as a photo editor. This was the first known case of anthrax in the United States.52 Eventually there were 22 confirmed or suspected cases of anthrax infection, all believed to be from contaminated letters delivered via the postal system. Eleven patients were inhalation cases, of these, five died; the other 11 were non-fatal cutaneous (under the skin) cases.52 Clinical features of anthrax: Anthrax infection can occur in three forms: cutaneous, inhala- tion, or gastrointestinal. Most (95%) cases occur cutaneously 24 ------- when the bacterium enters the skin. This can occur during han- dling of contaminated wool or leather, or touching of infected animals. The first symptom is an infected area of the skin: a raised itchy bump that resembles a bite, but within 1-2 days develops into a vesicle and then a painless ulcer. About 20% of untreated cases will result in death, so it is important to seek antimicrobial therapy quickly after infection. Figure 6-4. A microscopic photograph of Bacillum anthracis that has had a long historical reputation as a deadly bacteria. Inhalation anthrax is a biphasic illness - there are two distinct phases. In the first phase, the symptoms are not alarming; they may resemble a cold. After several days the symptoms may progress to severe breathing problems and shock. Unless treat- ed, inhalational anthrax can be fatal. The incubation period is 1-6 days. Gastrointestinal infection is the rarest form of anthrax infection. The intestinal disease form of anthrax may follow the consump- tion of contaminated meat and is characterized by an acute in- flammation of the intestinal tract. Initial signs of nausea, loss of appetite, vomiting and fever are followed by abdominal pain, vomiting of blood, and severe diarrhea. Intestinal anthrax re- sults in death in 25% to 60% of cases. The most common treatment for anthrax is antibiotics, usu- ally ciprofloxacin, doxycycline, and penicillin. The regimen is usually a grueling 60 days of antibiotic treatment. A vaccine is available, but it is usually given only to military personnel and "high risk" people such as those who work in laboratories that handle anthrax. Anthrax has little potential for person-to-person transmission.53 What can the public do to prevent anthrax exposure? Do not open any suspicious mail Keep mail away from the face Do not sniff/blow into mail Wash hands after opening mail Discard envelopes after opening mail Persons who think they might have been exposed should contact a health provider immediately What has been done to prevent future attacks? The CDC has developed plans and procedures to respond to an attack using anthrax. The plans fall into three categories: sur- veillance, education, and equipping. Surveillance The CDC has trained emergency response teams to help state and local governments control infection, gather samples, and perform laboratory tests in the national Laboratory Response Network (LRN). The LRN is a collaborative system linking state and local public health laboratories with advanced ca- pacity laboratoriesincluding clinical, military, veterinary, agricultural, water, and food-testing laboratoriesto rapidly identify threat agents, including anthrax. The CDC is working closely with health departments, veterinarians, and laboratories to watch for suspected cases of anthrax. It has developed a na- tional electronic database to track potential cases. Education The CDC has educated health-care providers, the media, and the general public about what to do in the event of an attack. Equipping To ensure that there are enough laboratories for quick testing of suspected anthrax cases, the CDC is working with hospitals, laboratories, emergency response teams, and health-care pro- viders to make sure they have the supplies they need (antibiot- ics, assays) in case of an attack. In 2004, President Bush signed into law the Project Bioshield Act, which establishes a permanent funding source through which the federal government can buy medical countermea- sures (vaccines, diagnostic tests, human and animal drugs) from private companies. Project BioShield gives the FDA authority to make promising drugs, vaccines, or diagnostic tests quickly available in emergencies.54 The question might arise: if there is a vaccine for anthrax, why not distribute it widely, in the same way as yearly flu vaccines? The reason is efficiency. Since anthrax is still a rare infection, the percentage of people that need to be pre-vaccinated would be extremely high (63-95%) in order to prevent 90% of anthrax cases. Post-exposure vaccination, however, can shorten the du- ration of an antibiotic regimen. An article published in Nature written by Ron Brookmeyer, Elizabeth Johnson, and Robert Bellinger, concludes that treating patients with antibiotics and post-exposure vaccination is more practical and that the most efficient way of preventing anthrax is heightened awareness of clinical symptoms, surveillance, and mass antibiotic distribu- tion.55 25 ------- Figure 6-5. Cutaneous anthrax infection: when infection occurs after entering the skin, symptoms are a raised itchy bump that develops into a vesicle and then a painless ulcer. 6.2.1 Message Maps about the Anthrax Bioterrorism Event Message Map 1: Overarching Message Map This is an overarching message map, and it contains information the public most needs to know about the anthrax: how it was used as a bioterrorist tool, the symptoms of anthrax infection, and the three methods of infection (inhalation, cutaneous, gastrointestinal). Stakeholder: Public/Media Question or Concern: Overarching Message Map - What does the public most need to know? Key Message 1 Anthrax bioterrorism event in fall 2001 Supporting Information 1-1 Anthrax spores transmitted through postal ser- vice letters Supporting Information 1-2 22 cases, 5 deaths (all from inhalation) Supporting Information 1-3 Treatable with antibiotics if diagnosed early enough Key Message 2 Symptoms of anthrax infection Supporting Information 2-1 Inhalation: initial cold-like symptoms, progress- ing to severe breathing problems, death Supporting Information 2-2 Cutaneous: raised itchy bump that resembles a bite or skin infection Supporting Information 2-3 Gastrointestinal: nausea, loss of appetite, fe- ver, severe diarrhea Key Message 3 Three methods of transmission Supporting Information 3-1 Inhalation (lungs) Supporting Information 3-2 Cutaneous (skin) Supporting Information 3-3 Gastrointestinal (digestive) Message Map 2: What happened? What should the public know? In this case, the message map describes the anthrax event of 2001: how many people were infected, how the anthrax spores were transmitted, and three methods of clinical infection. Stakeholder: Public/Media Question or Concern: What happened (Who, what, when, where, why?) What should the public know? Key Message 1 Anthrax bioterrorism event in fall 2001 Supporting Information 1-1 22 people were infected Supporting Information 1-2 1 1 inhalation cases, 1 1 cutaneous cases Supporting Information 1-3 5 deaths, all from inhalation of anthrax Key Message 2 Anthrax spores transmitted through postal service letters Supporting Information 2-1 Letters sent to Florida, NYC, and D.C. Supporting Information 2-2 All of the identified letters mailed from Trenton, NJ Supporting Information 2-3 Sender of letters is still unknown Key Message 3 Letters sent to media and political figures Supporting Information 3-1 American Media Inc. Supporting Information 3-2 Tom Brokaw Supporting Information 3-3 Senator Tom Daschle 26 ------- Message Map 3: How did you find out about the anthrax bioterrorism? This message map's key words are three key dates in the anthrax event of 2001: the first diagnosis, the date when anthrax spores were discovered at American Media Inc., and October 9, when the first cutaneous case of anthrax was recognized. Stakeholder: Public/Media Question or Concern: How did you find out about anthrax? Key Message 1 October 2, 2001 - first diagnosis Supporting Information 1-1 Patient awoke October 2 with nausea, vomit- ing, and confusion Supporting Information 1-2 Patient worked at American Media Inc. Supporting Information 1-3 Patient died October 4 Key Message 2 October 4, 2004 - Evidence of B. anthracis at American Media Inc. Supporting Information 2-1 Second AMI employee diagnosed on October 5 Supporting Information 2-2 Second employee worked in the mailroom Supporting Information 2-3 Key Message 3 October 9, 2004 - First cutaneous case of an- thrax recognized Supporting Information 3-1 Patient worked in mail-room for anchorman Tom Brokaw Supporting Information 3-2 Marked by skin lesions Supporting Information 3-3 NJ postal workers diagnosed with cutaneous and inhalation anthrax on October 13 Message Map 4: What are the health effects associated with anthrax? Anthrax has three modes of transmission, with different symptoms. This message map's key words are the three modes of transmis- sion: cutaneous, inhalation, and gastrointestinal. The supporting information describes the symptoms and prognosis of the cutane- ous anthrax, inhalation anthrax, and gastrointestinal anthrax. Stakeholder: Public/Media Question or Coneern: What are the health effects associated with anthrax? Key Message 1 Cutaneous Supporting Information 1-1 Small sore that develops into a blister, then a skin ulcer Supporting Information 1-2 Treated with antibiotics Supporting Information 1-3 Usually not fatal Key Message 2 Inhalation Supporting Information 2-1 1-6 day incubation period; biphasic illness - having two distinct phases Supporting Information 2-2 First phase: flu-like symptoms, then rapid de- terioration Supporting Information 2-3 Second phase: rapid deterioration, and death. Can be fatal Key Message 3 Gastrointestinal Supporting Information 3-1 Consumption of contaminated meat Supporting Information 3-2 Nausea, loss of appetite, bloody diarrhea, fe- ver, stomach pain Supporting Information 3-3 Death in 25%-60% of cases 27 ------- Message Map 5: What can people do to prevent an anthrax infection? Since anthrax was sent by mail, this message map is a guideline of how to handle mail, both for the public at large and postal work- ers. The third key message is steps to take if you think you have been exposed. Stakeholder: Public/Media Question or Concern: What can people do to prevent anthrax infection? Key Message 1 Mail Supporting Information 1-1 Do not open suspicious mail Supporting Information 1-2 Keep mail away from face when opening it; do not sniff Supporting Information 1-3 Wash hands afterwards Key Message 2 Postal workers56 Supporting Information 2-1 Wear protective, impermeable gloves Supporting Information 2-2 Avoid touching eyes, skin, or other mucous membranes Supporting Information 2-3 Wear long-sleeved clothing and pants to pre- vent skin exposure Key Message 3 If you have been exposed ... Supporting Information 3-1 Call the doctor right away Supporting Information 3-2 Antibiotic treatment Supporting Information 3-3 Post-exposure vaccination Message Map 6: What is being done to prevent anthrax outbreaks in the future? The methods of preventing anthrax attacks in the future fall into three categories which serve as the three key messages for this mes- sage map: surveillance, education, and equipping. Stakeholder: Public/Media Question or Concern: What is being done to prevent anthrax outbreaks in the future? Key Message 1 Surve///ance Supporting Information 1-1 State and local governments Supporting Information 1-2 Health departments, hospitals Supporting Information 1-3 National electronic tracking database Key Message 2 Education Supporting Information 2-1 General public awareness Supporting Information 2-2 Postal workers Supporting Information 2-3 Physicians so they can better recognize the clinical symptoms Key Message 3 Equipping (Bioshield Act) Supporting Information 3-1 Safe laboratories for testing Supporting Information 3-2 Antibiotics Supporting Information 3-3 Post-exposure vaccine 28 ------- 6.3 Water Contamination (Cryptosporidium): Crisis Summary and Message Maps Time and location of event: April 1993, in Milwaukee, Wisconsin. Outbreak sickened 403,000 people and 111 people died. Elderly and immuno-com- promised individuals were most at risk. Cryptosporidiosis - a background: Cryptosporidiosis is a disease caused by the protozoan Cryp- tosporidium parvum. Its mode of transmission is fecal-oral (infection-laden stool from one person gets into the mouth of another). This can happen from improper sanitation, as well as drinking contaminated water. An oocyst is a dormant form of the protozoa. An oocyst is 2 to 6 microns in diameter. Once an animal or person is infected, the parasite lives in the intestine and passes into the stool. Millions of Cryptosporidium oocysts can be released in a bowel movement from an infected animal or human. Feces from an infected animal or human can contam- inate water sources, which is the suspected cause in the Milwau- kee outbreak. Cryptosporidium is often found in rivers, lakes, and streams contaminated with animal feces or which receive wastewater from a sewage plant. Prevalence of Cryptosporidi- osis among calves and other livestock is particularly high. Overall there are three pathways of fecal/oral transmission/in- fection: 1) Transmission via water and food 2) Animal-to-person transmission 3) Person-to-person transmission Cryptosporidium has many features that make it a very chal- lenging contaminant to control. The parasite is protected by an outer shell that makes it resistant to chlorine-based disin- fectants. The shell also allows the oocysts to live outside the body for a long time.57 The ingestion of as few as 10 oocysts is enough to produce an infection.58 Even more troublesome is the fact that to date there is no safe and effective treatment for Cryptosporidiosis.59 Cryptosporidium parvum oocysts have been recognized as a human pathogen since 1976.60 In 1982, the number of report- ed cases began to increase dramatically as part of the AIDS epidemic, as immuno-compromised individuals are less able to ward off Cryptosporidiosis. The Milwaukee outbreak is the largest in the United States, but there have also been outbreaks associated with swimming or amusement parks. In 1997 there was an outbreak of Cryptosporidiosis associated with a water sprinkler fountain in Minnesota.61 First indicators of epidemic: Milwaukee has two main water treatment plants: one located in the northern part of the city, the other in the southern part of the city. The water supply is from Lake Michigan. The southern plant predominantly serves the southern part of the city. These plants collectively are known as the Milwaukee Water Works (MWW). Starting on March 21, 1993, plant records revealed an increase of turbidity on the southern plant. Turbidity refers to how clear the water is. The greater the amount of total suspended solids (TSS) in the water, the murkier it appears and the higher the measured turbidity. From January 1983 through January 1993, the turbidity of treated water did not exceed 0.4 nephelometric Figure 6-6. The protozoan Cryptosporidium parvum. Figure 6-7. The life cycle of Cryptosporidium and how the oocysts enter the human body. 29 ------- turbidity unit (NTU). An NTU is used to measure turbidity of water, as turbidity is often an indicator of contamination (in this case, from Cryptosporidium oocysts). From March 23 to April 1, 1993, the maximal daily turbidity of treated water was con- sistently 0.45 NTU or higher, with a peak of 1.7 NTU on March 28and30.62 Meanwhile, on Thursday, April 1, 1993, a pharmacist in Mil- waukee noted a dramatic increase in sales of over-the-counter anti-diarrheal and anti-cramping medications. Normally, his drugstore sold $30 a day of these medications. Starting April 1, the pharmacy drug sales increased to approximately $500 to $600 a day. The pharmacist contacted the health department to inquire about unusually frequent reports of gastrointestinal problems.63 On April 5, the Wisconsin Division of Health was contacted by the Milwaukee Department of Health after widespread cases of gastrointestinal illness, absenteeism among teachers, students, and hospital workers. On April 7, the laboratories identified Cryptosporidium oocysts in stool samples from seven adults in the Milwaukee area. By April 7, there was an advisory to Mil- waukee residents to boil their water, and the southern plant was closed on April 9. Overall an estimated 403,000 people were in- fected, 4,400 people were hospitalized, and 111 people died.62 Clinical features of cryptosporidiosis: Cryptosporidiosis is transmitted by ingestion of oocysts ex- creted in the feces of humans or animals. Cryptosporidiosis has three methods of transmission: 1) via water and food; 2) ani- mal to person; and 3) person-to-person.64 The incubation period is approximately 2 to 10 days. Children under two years old, immuno-compromised individuals65'66 and the elderly67 have a greatly increased chance of serious sickness from Cryptospo- ridium. The most common symptom of cryptosporidiosis is watery diarrhea. Other symptoms include: dehydration, weight loss, stomach cramps or pain, fever, nausea and vomiting. Some people with cryptosporidiosis will be asymptomatic (without noticeable clinical symptoms). In healthy individuals the symp- toms will typically last for about 1 to 2 weeks. However, in per- sons whose immune system is weakened, cryptosporidiosis can be serious, long-lasting, and even fatal.68 Cryptosporidiosis is often misdiagnosed as "stomach flu." What can you do to prevent cryptosporidiosis68? Wash hands frequently Practice safer sex Avoid touching farm animals Avoid touching the stool of pets Avoid swallowing water while swimming in the ocean, lakes, rivers, or pools, and when using hot tubs Wash or cook food thoroughly Drink safe water. Boiling and filtering water tends to get rid of the Cryptosporidium oocysts, but not all filters are ef- fective - look for the words "reverse osmosis," or absolute pore size of one micron or less, or one that has been NSF rated for "cyst approval" Dally age-ad)UBCed rate (+ standard deviation) of GIB per 100,000 elderly during the Hilvaufcee cryptospormiosis outbreak Horth plwtt 1.03 4- 2.7 Central, «re« 1.3-* * l.t Sooth plant 2,33 _ 2.6 Figure 6-8. The Southern plant of Milwaukee Water Works predomi- nantly serves the southern part of the city. In 1993 water from the southern plant became contaminated with Cryptosporidium oocysts, causing many hospitalizations, especially in the elderly and immuno- compromised. As the picture above shows, there were less gastrointes- tinal hospitalizations in the northern and central areas of the city. What can be done to prevent future outbreaks? The main method of preventing future outbreaks is improved water-treatment technologies. Cryptosporidium oocysts have a tough wall that makes them resistant to traditional methods of disinfection, such as chlorination. The most effective methods of removal are filtration and ozone treatment.69 However, many cities (Boston, Seattle, Portland, and San Francisco) do not filter municipal drinking water. In New York City, the Croton res- ervoir is filtered, but the Delaware and Catskill reservoirs are not.70 Since the Milwaukee incident, the practice of recycling filter backwash water was eliminated. The Milwaukee plants have also installed continuous turbidity monitors on each bed, with an alarm sounding and the system shut down if the turbid- ity of filtered water exceeds 0.3 NTU.62 Watershed protection is another method of preventing contami- nation. Septic system regulations and control of runoff into sur- face water reservoirs such as lakes or streams can help keep human and animal waste out of water supplies. 30 ------- 6-3,1 Message Maps for Cryptosporidium Infection Message Map 1: Overarching Message Map: What does the public most need to know? This message map touches upon three key messages: that there is an outbreak of cryptosporidiosis in Milwaukee, people most at risk of becoming seriously ill from cryptosporidiosis, and the symptoms of the disease. Stakeholder: Public/Media Question or Concern: Overarching Message Map - What does the public most need to know? Key Message 1 Outbreak of cryptosporidiosis in Milwaukee Supporting Information 1-1 From contaminated water supply Supporting Information 1-2 Two water treatment plants: southern and northern Supporting Information 1-3 Southern plant reported increased turbidity on March 21 Key Message 2 High risk groups are: Supporting Information 2-1 Immuno-compromised (HIV+, diabetes) Supporting Information 2-2 Elderly Supporting Information 2-3 Young children Key Message 3 Symptoms and precautions Supporting Information 3-1 Watery diarrhea most common symptom. Can also have nausea, fever, vomiting Supporting Information 3-2 Incubation period: 2-10 days Supporting Information 3-3 Symptoms last 1 -2 weeks Message Map 2: What happened? What should the public know? This message map answers the "What happened?" questions. In this case, the Milwaukee Water Works' Southern plant was contami- nated with Cryptosporidium oocysts, and an estimated 403,000 Milwaukee residents were infected. Stakeholder: Public/Media Question or Concern: What happened? (Who, what, when, where, and why?). What should the public know? Key Message 1 Outbreak of cryptosporidiosis in Milwaukee Supporting Information 1-1 Cryptosporidium is a protozoan (oocyst) Supporting Information 1-2 Released from feces into water supply Supporting Information 1-3 Oocyst resistant to chlorine treatment, can live outside the body for long periods of time Key Message 2 From contaminated water supply Supporting Information 2-1 Southern plant reported increased turbidity on March 21 Supporting Information 2-2 Two treatment plants: southern and northern Supporting Information 2-3 Notice on April 7 to boil water Key Message 3 403,000 people infected Supporting Information 3-1 April 7 - stool samples from seven adults con- firmed cryptosporidiosis Supporting Information 3-2 Watery diarrhea main symptom Supporting Information 3-3 1 1 1 deaths 31 ------- Message Map 3: How did you find out about the Cryptosporidium outbreak? Three main events led to the discovery of the Cryptosporidium contamination: water plants reported increased turbidity, there was a spike in pharmaceutical sales of over-the-counter anti-diarrheal medicine, and there was widespread absenteeism in schools and offices, which led to the Milwaukee Department of Health being contacted. On April 7 stool samples confirmed cryptosporidiosis. Stakeholder: Public/Media Question or Concern: How did you find out about the Cryptosporidium outbreak? Key Message 1 Pharmaceutical sales Supporting Information 1-1 Milwaukee pharmacist noticed a rise in OTC anti-diarrheal medicine Supporting Information 1-2 Normal sales: $30/day Supporting Information 1-3 After April 1 sales: $500-$600 a day Key Message 2 Water-treatment plant (MWW) Supporting Information 2-1 Increased turbidity noted March 21, 1993 at southern plant Supporting Information 2-2 Normal turbidity: 0.45 NTU Supporting Information 2-3 Outbreak period turbidity peaked at 1 .7 NTU (March 28 and 30, 1993) Key Message 3 Absenteeism Supporting Information 3-1 Among teachers, students, and hospital work- ers Supporting Information 3-2 Absentees all had gastrointestinal illness Supporting Information 3-3 Message Map 4: What are the health effects of cryptosporidiosis? This message map is straightforward: its key messages are the main symptom of cryptosporidiosis, the modes of transmission, and the groups of people who are most at risk of serious illness from Cryptosporidium. Stakeholder: Public/Media Question or Concern: What are the health effects associated with exposure to Cryptosporidium? Key Message 1 Watery diarrhea Supporting Information 1-1 Incubation period: 2-10 days Supporting Information 1-2 Symptoms last 1 -2 weeks Supporting Information 1-3 Can have dehydration, nausea, fever, stomach pain, vomiting. Some people show no symp- toms Key Message 2 Three modes of fecal-oral transmission Supporting Information 2-1 Eating/drinking contaminated food or water Supporting Information 2-2 Animal-to-person (fecesfrom animal somehow gets into food/water) Supporting Information 2-3 Person-to-person Key Message 3 High risk groups Supporting Information 3-1 Immuno-compromised, elderly, children under the age of 2 Supporting Information 3-2 Illness can be very serious and prolonged, with no known treatment Supporting Information 3-3 Death may result 32 ------- Message Map 5: What can people do to prevent Cryptosporidium infection? The ways to prevent infection fall under three categories: safe-drinking water habits, good hygiene/sanitation, and avoiding touching farm animals. Stakeholder: Public/Media Question or Concern: What can people do to prevent Cryptosporidium infection? Key Message 1 Safe-drinking water habits Supporting Information 1-1 Pay attention to public announcements about contamination Supporting Information 1-2 Filter water (NSF rated for "cyst approval" or pore size of one micron or less) Supporting Information 1-3 Boil water for persons that are immunocom- promised Key Message 2 Good hygiene/sanitation Supporting Information 2-1 Wash hands, especially after bowel movement or changing diapers Supporting Information 2-2 Practice safer sex Supporting Information 2-3 Wash/cook food Key Message 3 Animals Supporting Information 3-1 Avoid touching farm animals Supporting Information 3-2 Avoid touching the stool of pets Supporting Information 3-3 Wash hands after picking up stool of pets Message Map 6: What can be done to prevent this in the future? The three ways to prevent future outbreaks of Cryptosporidium are: more vigorous water treatment (filtering, ozone treatment), watershed protection (as fecal matter can easily wash into surface water reservoirs), and public awareness and surveillance. Stakeholder: Public/Media Question or Concern: What can be done to prevent this in the future? Key Message 1 Water treatment Supporting Information 1-1 Filter municipal water supplies Supporting Information 1-2 Ozone treatment is effective Supporting Information 1-3 Milwaukee plant automatically shuts down if turbidity exceeds 0.3 NTU Key Message 2 Watershed protection Supporting Information 2-1 Septic system regulations (septic tanks not al- lowed to run into lakes) Supporting Information 2-2 Runoff control Supporting Information 2-3 Difficult to do, especially around rural areas with a lot of cattle and other livestock Key Message 3 Public awareness and surveillance Supporting Information 3-1 Monitor turbidity levels Supporting Information 3-2 Boil water for high risk groups Supporting Information 3-3 Filter water for high risk groups 33 ------- Message Map 7: How did this happen? Unmet water quality standards, inadequate diagnosis, and the existence of populations vulnerable to infection all contributed to the 1993 outbreak. Cryptosporidium oocysts passed through the city's filtration system, cryptosporidiosis was often misdiagnosed by doctors, and immuno-compromised individuals became seriously ill. Stakeholder: Public/Media Question or Concern: How did this happen? Key Message 1 Inadequate water treatment Supporting Information 1-1 Cryptosporidium oocysts passed through city's filtration system Supporting Information 1-2 Marked turbidity in southern water treatment plant Supporting Information 1-3 Northern plant not affected Key Message 2 Inadequate diagnosis Supporting Information 2-1 Diagnosed often as viral gastroenteritis or "in- testinal flu" Supporting Information 2-2 Many patients do not seek treatment for diar- rhea Supporting Information 2-3 No known treatment Key Message 3 Three main vulnerable populations Supporting Information 3-1 Elderly (often in nursing homes) Supporting Information 3-2 Immuno-compromised (HIV+, etc.) Supporting Information 3-3 Very young children 34 ------- 7. Conclusions Risk communication is a relatively new concept of communi- cating environmental and health hazards to the public. Much of it was developed by Vincent Covello. The National Research Council of the United States gave the following definition of risk communication: "Risk communication is an interactive process of exchange of information and opinions among in- dividuals, groups, and institutions. It often involves multiple messages about the nature of the risk or expressing concerns, opinions, or reactions to risk messages or to the legal and insti- tutional arrangements for risk management? Different situations require different methods. Some situations will have very high public outrage but little actual hazard, which is a measure of the actual risk. Other situations will have the re- verse situation. An important factor to consider in all risk com- munication situations is risk perception. As a general rule, the public tends to underestimate risks that are: not dreaded, vol- untary, natural, scientifically well-known and well-understood, controllable by the individual, in the hands of a reliable source, reversible with immediate health effects, with adults as health victims, unmemorable and without significant media attention, and that pose no risk to the future population. The general pub- lic tends to overestimate risks that are: dreaded, involuntary, in- dustrial, scientifically unknown, controlled by others, managed by an unreliable, irresponsible source, with irreversible, delayed health effects, children as victims, catastrophic, that receive media attention, and have a risk to future generations. hi addition to applying risk perception information, risk com- munication has "Seven Cardinal Rules," according to Covello: Rule 1: Accept and involve the public as a legitimate partner Rule 2: Listen to the audience Rule 3: Be honest, frank, and open Rule 4: Coordinate and collaborate with other credible sources Rule 5: Meet the needs of the media Rule 6: Speak clearly and with compassion Rule 7: Plan carefully and evaluate performance Message mapping is simply one of the useful tools used by risk communicators to warn of hazards to the public. It consolidates many of the rules of risk communication (speaking briefly, lim- iting oneself to three key messages) and can be applied to many situations, as shown in the examples in this paper. It helps orga- nizations meet several risk communication goals: Identify stakeholders early on in the communication pro- cess. Anticipate the questions and concerns of the stakeholders before they appear. Organize our thoughts and ideas and prepare messages in response to the concerns and questions of the stakehold- ers. Develop key messages and supporting information in a context of clear, concise, transparent, and accessible frame- work. Promote an open dialogue about the messages both inside and outside the organization. Provide the spokesperson with a user-friendly guide. Make sure that the organization has consistent information and messages. Make sure that the organization speaks with a single voice. A message map is designed as a three tier grid, with emphasis on the three key messages. The top tier of the template identifies the audience for the message map as well as the question or concern that the message map is intended to address. The second tier of the message map contains three key messages that answer the question or concern. The third tier contains supporting information, which is blocked in groups of 3 's under each key message. They can take the form of visuals, analogies, personal stories, hotline numbers, and/or citations of credible sources of informa- tion. This template can be used during news conferences, presenta- tions, or any area where the risk of a hazard needs to be com- municated. 35 ------- 36 ------- 8. Glossary Arbovirus - Any of a large group of viruses transmitted by arthropods, such as mosquitoes and ticks, that include the caus- ative agents of encephalitis, yellow fever, and dengue. Biphasic - Having two distinct stages (as in an illness). Bridging - A method used in risk communication to reiter- ate and clarify key points. For example, "/ want to remind the public that the probability of death is very small if discovered early..." Cutaneous - Of, relating to, or affecting the skin. A cutaneous transmission (such as for anthrax) means transmission through skin. Epizootic - Affecting a large number of animals at the same time within a particular region or geographic area. Used of a disease. Fecal-oral - A method of transmission of disease in which the infection-laden feces from one person finds its way into the mouth of another person. Flavivirus - A family of viruses transmitted by mosquitoes and ticks that cause some important diseases, including dengue, yel- low fever, tick-borne encephalitis virus, and West Nile fever. Hazard - Experts' assessment of risk. Immuno-compromised - Having an immune system that has been impaired by disease or treatment. Most often used in con- nection with infections such as AIDS or HIV+ status. Incubation Period - The amount of time between infection to the onset of clinical symptoms. Key Message - Information that the target audience most needs or wants to know. Message Map - A detailed, hierarchically organized response to anticipated questions or concerns during a crisis/event. Myalgia - Muscle pain or tenderness. Oocyst - A thick-walled structure in which sporozoan zygotes develop and that serves to transfer them to new hosts. An ex- ample of an oocyst would be the Cryptosporidium oocysts. Outbreak - A sudden increase in the prevalence of a disease. In 1993 Milwaukee had an outbreak of cryptosporidiosis. Outrage - Public perception of how substantial or alarming a risk is. Overarching Message Map - The message map that contains the organization's core message. The focus is on what people most need to know about the situation or topics, and provides an opening statement at a press conference, presentation, or news alert. Protozoa - Any of a large group of single-celled, usually mi- croscopic, eukaryotic organisms, such as amoebas, ciliates, flagellates, and sporozoans. Radon -A toxic, colorless gas that comes from the decay of ra- dium and uranium found in the soil/earth/rock. This toxic, col- orless gas can seep into residences. Different geographic areas will have different levels of radon. Radon is a carcinogen and can cause lung cancer.71 Risk - Judgment concerning the likelihood, severity, or impor- tance of a threatening event or condition; the probability of loss of which people value. Risk Perception - The subjective perception of risk/danger. Not necessarily correlated with actual risk. Risk Communication - An interactive process in which infor- mation and opinions are exchanged among individuals, groups, and institutions in response to an event or a risk. Sound Bite - A short phrase or sentence that deftly captures the essence of the speaker's main message. Stakeholder - All interested, affected, or influential parties in an event, usually including the public at large. Turbidity - The cloudiness of the water. The greater the amount of total suspended solids (TSS) in the water, the murkier it ap- pears and the higher the measured turbidity. 37 ------- 38 ------- 9. Most Frequently Asked Questions by Journalists During a Crisis 22 1. What is your name, title, job responsibilities and qualifica- tions? 2. Can you tell us what happened, and when and where it hap- pened? 3. How many people were harmed? 4. Are those that were harmed getting help? 5. How certain are you about this information? 6. Is the situation under control? 7. Is there any immediate danger? 8. What is being done in response to what happened? 9. What are you advising people to do? 10. How long will it be before the situation returns to normal? 11. Can the situation worsen? What is the worst case scenar- io? 12. What help has been requested or offered from others? 13. What responses have you received? 14. How much damage occurred and what additional damage do you expect? 15. Who else is involved in the response? 16. Why did this happen? 17. What was the cause? 18. Did you have any forewarning that this might happen? 19. Can the situation worsen? 20. If you are not sure of the cause, what is your best guess? 21. Who is to blame? 22. Could this have been avoided? 23. Do you think those involved handled the situation well enough? 24. Who is conducting the investigation? 25. What have you found out so far? 26. Why was more not done to prevent this from happening? 27. What is your personal opinion? 28. Are people overreacting? 29. Has anyone broken the law? 30. What are you not telling us? 31. What effects will this have on the people involved? 32. What precautionary measures were taken? 33. Do you accept responsibility for what happened? 34. Has this ever happened before? 35. Can this happen elsewhere? 36. What lessons were learned and were they implemented? 37. What can be done to prevent this from happening again? 3 8. What would you like to say to those that have been harmed and their families? 39. Are people out of danger? Are people safe? 40. Will there be inconvenience to employees or to the public? 41. How much will all this cost? 42. Are you able and willing to pay the costs? 43. Who else will pay the costs? 44. What does this all mean? Figure 9-1. In crisis situations, journalists and reporters always want answers, NOW! 39 ------- 40 ------- 10. References 1 Marks, IS. and Halpin, TJ. Guillain-Barre syndrome in recipients of a New Jersey influenza vaccine. JAMA 1980; 243(24):2490-94. 2 Langmuir, A.D., et al. 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