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Risk Communication Recommendations and Implementation During Emerging Infectious Diseases: A Case Study of the 2009 H1N1 Influenza Pandemic

  • Anat Gesser-Edelsburg (a1), Emilio Mordini (a2), James J. James (a3), Donato Greco (a4) and Manfred S. Green (a1)...



To examine their implementation, we analyzed World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) guidelines from 2005 to 2008 for risk communication during an emerging infectious disease outbreak, WHO and CDC reports on implementing the guidelines worldwide after the 2009 H1N1 pandemic; and a case study of a member state.


A qualitative study compared WHO and CDC guidelines from 2005 to 2008 with WHO and CDC reports from 2009 to 2011, documenting their implementation during the H1N1 outbreak and assessed how these guidelines were implemented, based on the reports and Israeli stakeholders (n=70).


Eight risk communication subthemes were identified: trust, empowerment, uncertainty, communicating the vaccine, inclusion, identification of subpopulations and at-risk groups, segmentation, and 2-way communication. The reports and case study disclosed a gap between international guidelines and their local-level implementation. The guidelines were mostly top-down communications, with little consideration for individual member-state implementation. The WHO and CDC recommendations were not always based on formative evaluation studies, which undermined their validity.


In formulating effective communication strategies, the first step is to define the goal of a vaccination program. We recommend implementing conceptual elements from the most current theoretical literature when planning communication strategies and increasing organizational involvement in implementing guidelines in future health crises. (Disaster Med Public Health Preparedness. 2014;0:1–12)


Corresponding author

Correspondence and reprint requests to Anat Gesser-Edelsburg, PhD, School of Public Health, University of Haifa, Mount Carmel, Haifa 31905, Israel (e-mail


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1. Jennings, LC, Monto, AS, Chan, PKS, Szucs, TD, Nicholson, KG. Stockpiling prepandemic influenza vaccines: a new cornerstone of pandemic preparedness plans. Lancet Infect Dis. 2008;8(10):650-658.
2. Allen Catellier, JR, Yang, ZJ. Trust and affect: how do they impact risk information seeking in a health context? J Risk Res. 2012;15:897-911.
3. Lee, NR, Kotler, P. Social Marketing Influencing Behaviors for Good, 4th ed. Thousand Oaks, California: SAGE Publications, Inc; 2011.
4. Sandman, P. Risk communication. In: Eblen RA, Eblen WR, eds. Encyclopedia of the Environment. Boston, Massachusetts: Houghton Mifflin; 1994:620-623.
5. Barry, JM. The Great Influenza: The Story of the Deadliest Pandemic in History. New York, New York: Penguin Books; 2005.
6. Covello, VT. Best practices in public health risk and crisis communication. J Health Commun. 2003;8:5-8.
7. Freimuth, V, Linnan, H, Potter, P. Communicating the threat of emerging infections to the public. Emerging Infectious Dis. 2000;6:337-347.
8. Holmes, BJ, Henrich, N, Hancock, S, Lestou, V. Communicating with the public during health crises: experts’ experiences and opinions. J Risk Res. 2009;12(6):793-807.
9. Cvetkovich, G, Lofstedt, RE. Social Trust and the Management of Risk. London, England: Earthscan Publications; 1999.
10. Earle, TC, Cvetkovich, G. Social Trust: Toward a Cosmopolitan Society. Westport, Connecticuut: Praeger; 1995.
11. Lofstedt, RE. Risk Management in Post-Trust Societies. London, England: Palgrave Macmillan; 2005.
12. Frewer, L, Hunt, S, Brennan, M, Kuznesof, S, Ness, M, Ritson, C. The views of scientific experts on how the public conceptualize uncertainty. J Risk Res. 2003;6:75.
13. Sandman, P. Understanding the risk: what frightens rarely kills. Nieman Rep. 2007, spring 59-66.
14. Frewer, L. The public and effective risk communication. Toxicol Lett. 2004;149:391-397.
15. Mebane, F, Temin, S, Parvanta, C. Communicating anthrax in 2001: a comparison of CDC information and print media accounts. J Health Commun. 2003;8:50-82.
16. Rudd, R, Comings, J, Hyde, J. Leave no one behind:improving health and risk communication through attention to literacy. J Health Commun. 2003;8:104-115.
17. Slovic, P, Finucane, M, Peters, E, MacGregor, D. Risk as analysis and risk as feelings: some thoughts about affect, reason, risk and rationality. Risk Anal. 2004;24(2):311-322.
18. Holmes, BJ. Communicating about emerging infectious disease: the importance of research. Health Risk Soc. 2008;10(4):349-360.
19. Centers for Disease Control and Prevention. Updated CDC estimates of 2009 H1N1 influenza cases, hospitalizations and deaths in the United States, April 2009-April 10, 2010. Accessed December 10, 2012.
20. Poland, GA. The 2009-2010 influenza pandemic: effects on pandemic and seasonal vaccine uptake and lessons learned for seasonal vaccination campaigns. Vaccine. 2010;28(suppl 4):D3-13.
21. Rubin, GJ, Amlot, R, Page, L, Wessely, S. Public perceptions, anxiety, and behaviour change in relation to the swine flu outbreak: cross sectional telephone survey. BMJ. 2009;339:b2651.
22. Hartl G, Kieny M-P. Strategic Advisory Group of Experts (SAGE) advise WHO on pandemic vaccine policies and strategies: pandemic (H1N1) 2009 briefing note 14 [virtual press conference]. October 30, 2009 (updated November 2, 2009). Accessed March 26, 2014.
23. World Health Organization. WHO Outbreak Communication Guidelines. Geneva, Switzerland: World Health Organization; 2005. Accessed October 20, 2012.
24. World Health Organization. WHO global influenza preparedness plan: the role of WHO and recommendations for national measures before and during pandemics. Geneva, Switzerland: World Health Organization; November 2005. Accessed October 20, 2012.
25. World Health Organization. World Health Organization Outbreak Communication Planning Guide, 2008 ed. Geneva, Switzerland: World Health Organization; 2008. Accessed October 20, 2012.
26. Reynolds B. Crisis and emergency risk communication: pandemic influenza. Atlanta, Georgia: Centers for Disease Control and Prevention; 2007. Accessed June 9, 2010.
27. World Health Organization. International Health Regulations (2005), 2nd ed. Geneva, Switzerland: World Health Organization; 2008. Accessed October 20, 2012.
28. Katz, R. Use of revised International Health Regulations during influenza A (H1N1) epidemic, 2009. Emerg Infect Dis. 2009;15(8):1165-1170.
29. World Health Organization. The international response to the influenza pandemic: WHO responds to the critics. pandemic (H1N1) 2009 briefing note 21; June 10, 2010. Accessed October 20, 2012.
30. Centers for Disease Control and Prevention. 2009 H1N1: overview of a pandemic April 2009-August 2010. Accessed October 20, 2010.
31. Lam PP, McGeer A. Communication strategies for the 2009 influenza A (H1N1) pandemic. Winnipeg, Manitoba: National Collaborating Centre for Infectious Diseases; December 2011. Accessed August 20, 2013.
32. Centers for Disease Control and Prevention. The 2009 H1N1 pandemic: summary highlights, April 2009-April 2010. 2010. Accessed October 20, 2012.
33. World Health Organization. Constitution of the World Health Organization. In: Basic Documents, 47th ed. Geneva, Switzerland: World Health Organization; 2009:1-18.
34. Pan American Health Organization; US Department of Health and Human Services. Putting planning into practice: the communications response to H1N1 [final report]. Washington, DC: US Department of Health and Human Services; July 22, 2009.
35. Brownstein, JS, Freifeld, CC, Madoff, LC. Digital disease detection: harnessing the Web for public health surveillance. N Engl J Med. 2009;360(21):2153-2155; 2157.



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