Zika Virus Infection- Step-by-Step Guide to Risk

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Pan American Health Organization / World Health Organization
November 2016
Zika Virus Infection
Step-by-Step Guide to Risk
Communication and
Community Engagement
www.paho.org/viruszika
Acknowledgments
This document was produced by PAHO/WHO under the
direction of Cristina Mañá Fernández, PAHO/WHO risk
communication manager for the Zika outbreak, with significant contributions from Bryna Brennan, Vilma Gutiérrez
(PAHO/WHO), Leticia Linn (PAHO/WHO), Haroldo Bezerra
(PAHO/WHO), Ramón Pillar (PAHO/WHO), and Sonia
López.
Pan American Health Organization / World Health Organization
Title of original Spanish edition:
Acciones de comunicación de riesgos y movilización comunitaria con respecto
a la infección por el virus del Zika
ISBN 978-92-75-31938-3
PAHO HQ Library Cataloguing-in-Publication Data
Pan American Health Organization
Zika Virus Infection. Step-by-Step Guide to Risk Communication and Community Engagement.
Washington, D.C. : PAHO; 2017.
1. Mosquito Control. 2. Insect Vectors. 3. Aedes. 4. Zika Virus. 5. Public Health Surveillance.
6. Health Communication. 7. Social Communication in Emergencies. Title.
ISBN 978-92-75-11938-9 (NLM Classification: QX 600)
© Pan American Health Organization 2017
All rights reserved. Publications of the Pan American Health Organization are available on the PAHO
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addressed to the Communications Department through the PAHO website (www.paho.org/permissions).
Publications of the Pan American Health Organization enjoy copyright protection in accordance with the
provisions of Protocol 2 of the Universal Copyright Convention. All rights are reserved.
The designations employed and the presentation of the material in this publication do not imply the
expression of any opinion whatsoever on the part of the Secretariat of the Pan American Health Organization concerning the status of any country, territory, city or area or of its authorities, or concerning the
delimitation of its frontiers or boundaries.
The mention of specific companies or of certain manufacturers’ products does not imply that they are
endorsed or recommended by the Pan American Health Organization in preference to others of a similar
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distinguished by initial capital letters.
All reasonable precautions have been taken by the Pan American Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material
lies with the reader. In no event shall the Pan American Health Organization be liable for damages arising
from its use.
Pan American Health Organization / World Health Organization
Contents
I. Introduction
II. Frequently asked questions about ZIKV and its potential
health consequences
9
ZIKV and modes of transmission
10
Complications of ZIKV
10
Vector control or elimination
11
Personal protection against ZIKV
12
Sexual transmission
13
Vertical transmission of ZIKV
14
Preventing ZIKV in pregnant women
15
III. Communication activities with respect to Zika
virus infection
8
18
Communication objectives for Public Health Communication Officials
18
Basic suppositions
19
Guiding principles for preparing risk communication plans
19
Evaluation of risk perception
21
Main communication channels
24
Audience segmentation
26
Appointment of official ZIKV spokespersons
28
Tasks for internal organization of the risk communication team
28
Tasks to address the needs of the most vulnerable populations
28
Liaison with stakeholders and partners
29
Preparatory stage
29
Pan American Health Organization / World Health Organization
Preparation of messages and distribution channels
29
Examples of immediate activities in your communication plan
30
Examples of the principal key messages
31
“Listen”: monitoring communications
32
Media relations
33
Community engagement
33
IV. References
36
Pan American Health Organization / World Health Organization
Acronyms
GBS
Guillain-Barré Syndrome
IEC
Information, education, and communication
IHR
International Health Regulations
PAHO
Pan American Health Organization
PHEIC
Public Health Emergency of International Concern
WHO
World Health Organization
ZIKV
Zika virus
Pan American Health Organization / World Health Organization
Introduction
On 1 February 2016, the World Health Organization (WHO) announced that the cluster of microcephaly cases and other neurological disorders
in newborns reported in Brazil since October
2015 and associated with the incidence of Zika
virus (ZIKV) cases constituted a public health
emergency of international concern (PHEIC).
This guide to activities and recommendations for
managing risk communication on ZIKV is
designed for spokespersons, health authorities
and health workers, other sectors, and partners
inside and outside the health sector to assist
them in tailoring communication initiatives to
the needs of each country and target audience.
Since then, information and communications
about ZIKV and its consequences have multiplied
exponentially, with information in many
instances contradictory appearing in the news
media, social networks, and other communication channels. This has led to considerable
anxiety and confusion among the general
public, mainly about issues related to the birth of
babies with microcephaly and other congenital
malformations born to mothers infected with
ZIKV during pregnancy and to the higher
incidence of Guillain-Barré Syndrome (GBS)
associated with ZIKV.
The elimination of mosquito breeding sites
remains the most important strategy for the
prevention and control of ZIKV (as well as dengue
and
chikungunya)
infection.
Therefore,
communication plans for the response to ZIKV
should include intersectoral action and
community engagement to modify behaviors
and encourage sustained practices to eliminate
breeding sites and control the mosquito, as well
as to inform and educate target audiences
about the steps they can take to prevent ZIKV
transmission.
This document provides
Technical content on ZIKV, its manifestations,
complications, modes of transmission, and
prevention measures to be used in answering
frequently asked questions and conveying
messages in information and communication
materials, community talks, press conferences,
etc.
Recommendations for the preparation of risk
communication and action plans to respond to
ZIKV.
The fourth meeting of the Emergency Committee
under the International Health Regulations1
agreed that, “due to continuing geographic
expansion
and
considerable
gaps
in
understanding of the virus and its consequences,
Zika virus infection and its associated
congenital malformations and other related
neurological disorders, ZIKV continues to be a
Public Health Emergency of International
Concern.”
Fourth meeting of the Emergency Committee under the International
Health Regulations (2005) regarding microcephaly, other neurological disorders and Zika virus
http://www.who.int/mediacentre/news/statements/2016/zika-fourth-ec/es/
1
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Pan American Health Organization / World Health Organization
Frequently asked questions
about ZIKV and its potential
health consequences
The messages for different target audiences
should be timely, accurate, applicable, and
relevant and should therefore be tailored to the
specific audience for which they are intended,
be it the general public, pregnant women,
women of reproductive age, health workers,
partners and allies, or community leaders.
Below is a list of the most frequently asked
questions about ZIKV, its manifestations or
complications, and prevention measures.
The frequently asked questions about ZIKV that
follow can be used to disseminate information
through a range of channels, including communication materials, call centers, institutional
websites, social networks, community talks, and
public appearances.
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Pan American Health Organization / World Health Organization
ZIKV and modes of
transmission
at risk of getting this disease. It can strike women
and men of any age. There is still no vaccine to
prevent it.
What is ZIKV and how do people
become infected?
What are the symptoms?
ZIKV is a disease that people contract through
the bite of an infected mosquito. When a mosquito feeds on the blood of an infected person and
then bites others, it passes ZIKV to them. There is
documentation that the infection can also be
passed from mother to child, sexually, and
through blood transfusions.
Aedes aegypti is the mosquito that carries ZIKV,
as well as dengue, chikungunya and yellow fever.
This mosquito lives in and around dwellings and
reproduces in any receptacle that contains
water.
Mosquitoes are born 7 to 10 days after the eggs
are laid, emerging as larvae before taking the
adult form. They have a life span of 3 to 4 weeks.
Mosquitoes search for food close to their
breeding site, biting people living nearby or who
happen to be in the area. The mosquito’s flight
range is around 25 meters, though it may be as
far as 500 meters.
Aedes aegypti mosquitoes lay their eggs every
3 or 4 days. A single female can lay around 400
eggs in her lifetime. The eggs are also resistant to
drought and can survive for more than a year,
with larvae emerging when the eggs come into
contact with water.
The mosquito is most active, and therefore the
risk of getting bitten the highest, at dawn and
dusk.
Only one out of four people infected with ZIKV
will have symptoms, and if they do, they will be
very mild. Thus, many people will not realize they
have the disease, as they will be symptom-free.
The most common symptom is the sudden
appearance of a rash, possibly coupled with a
low-grade fever (more than 37.5°C), dry
conjunctivitis (reddened eyes without secretions), and joint pain or inflammation.
Complications of ZIKV
Does ZIKV cause microcephaly
and GBS2?
Microcephaly is a birth defect in which a
baby’s head is much smaller than that of other
children of same age and sex. This is due to
abnormal development of the baby’s brain in the
womb or during infancy. Infants and children
with microcephaly often have problems with
brain development as they grow.
Microcephaly can be caused by a number of
environmental and genetic factors, including
Down syndrome, exposure to drugs, alcohol, and
other toxins in the womb, and rubella during the
mother’s pregnancy.
WHO, Zika virus and complications: Questions and answers:
http://www.who.int/features/qa/zika/en/
Zika is a new virus, which means that we are all
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Pan American Health Organization / World Health Organization
Based on a growing number of preliminary
studies, there is a scientific consensus that Zika
virus causes microcephaly and GBS.
While intensive efforts are being made to learn
more about the relationship between the virus
and several neurological disorders, rigorous
research to date supports the conclusion that
there is an association between ZIKV and microcephaly and GBS.
What are the complications of ZIKV
in pregnant women and their
babies?
There have been documented cases of microcephaly and other birth defects in babies born to
mothers infected with ZIKV during pregnancy.
What is the relationship between
ZIKV and GBS cases?
The main prevention measure continues to be
the elimination of mosquito breeding sites and
the personal protection measures described
below.
How do I eliminate mosquito
breeding sites?
To eliminate the risk of mosquito-borne infection,
it is recommended that you:
Eliminate mosquito breeding sites in and
around your home, as well as in public areas (for
example, drains, cemeteries, uncultivated plots
of land, markets, etc.) and/or private areas.
Eliminating breeding sites should be everybody’s
responsibility—the authorities, the public sector,
the private sector, NGOs, families, and
individuals—and not just the public or health
sector.
GBS is a rare disorder in which the patient’s
immune system attacks the peripheral nerves.
People of all ages can be affected, but it is most
common in adults and men.
Prevention implies knowing about the mosquito’s behavior and breeding sites and understanding every individual’s environmental
responsibility in the ongoing elimination of
breeding sites. This should be a continuous practice in homes and communities.
The majority of people, even those with the
most serious cases, fully recover. In 20% to 25%
of cases, the chest muscles are affected, making
breathing difficult. Serious cases are rare but
can involve total paralysis.
Aedes mosquitoes prefer to lay their eggs in
water found in receptacles in the home, schools,
workplaces, and their surroundings, so it is
important that everyone do their part in identifying and eliminating these breeding sites.
Vector control or
elimination
Keeping the area surrounding the house clean
and removing any containers where water can
collect is key to eliminating the breeding sites for
new mosquitoes.
How can I protect myself and my
family from being infected with
ZIKV?
Avoid keeping water in receptacles inside and
outside the home (vases, flower pots, bottles,
containers where water can collect, the gutters
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Pan American Health Organization / World Health Organization
of roofs) to ensure that they do not become mosquito breeding sites.
Hermetically seal water tanks or containers or
treat them with chemicals (such as bleach, larvicides) or biological agents (for example, fish
that feed on larvae) to destroy mosquito eggs
and larvae.
Do not allow trash to accumulate and put any
trash in plastic bags that are tied shut.
Unclog drains where water can stagnate.
Thoroughly scrub sinks and vats to destroy any
eggs that stick to their sides; this will prevent
larvae from emerging when water is present.
Keep the garden or property free of weeds,
check planter saucers, pet’s water bowls, etc.
Turn containers not in use, such as plastic
bottles, face down.
How can we eliminate populations
of adult mosquitoes?
Insecticide spraying operations to eliminate
adult mosquito populations are not enough,
since breeding sites must also be eliminated.
Given the hours when the mosquito is most
active, it is recommended that outdoor control
measures be conducted at dawn and dusk. Thus,
it is essential that individuals/families be notified about the fumigation schedules in their
neighborhood or vicinity a day or two in
advance, so that people will keep their doors and
windows open to facilitate the insecticide’s
entry.
When insecticide is applied indoors by health
professionals or others, care should be taken to
ensure that kitchen utensils and food and water
for human and animal consumption are properly
covered or kept in enclosed spaces.
When insecticide is applied indoors by health
professionals or others, residents should leave
the house during the treatment and keep it shut
for 20 minutes after fumigation to guarantee that
the mosquitoes die.
Personal protection
against ZIKV
What can be done to prevent
mosquito bites and the risk of
sexual transmission3?
Cover exposed skin with long-sleeved shirts,
trousers, and hats.
World Health Organization. Prevention of sexual transmission of ZIKV
virus. Interim guidance update. 7 June 2016. WHO/ZIJV/MOC/16.1
Rev.2
3
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Pan American Health Organization / World Health Organization
Hang screens in doors and windows to keep
mosquitoes out.
Sleep in areas protected by mosquito nets.
Use repellents containing DEET, IR3535, or
Icaridin that are recommended by the health
authorities and follow the instructions on the
label.
Use repellents and regularly apply them to
exposed skin or clothing. Pregnant women can
also use repellents, as long as they follow the
instructions on the product label.
To minimize the mosquito’s contact with
dengue, chikungunya, or ZIKA patients, people
suspected of having any of these diseases
should always sleep or rest under mosquito nets.
Although ZIKV is transmitted mainly by infected
mosquitoes, sexually transmitted cases have
also been confirmed; this is troubling, given the
association between ZIKV infection and complications such as microcephaly, GBS, and other
neurological disorders. In some case studies,
ZIKV has been detected in saliva and urine.
Sexual transmission
What steps can be taken to protect
against sexual transmission?4
All people with ZIKV infection and their sexual
partners should receive information about the
risk of the sexual transmission of ZIKV, contraceptive measures, and safe sex, and, whenever
possible, be provided with condoms.
Women who have unprotected sex and do not
wish to become pregnant for fear of ZIKV
infection should have access to and counseling
on emergency contraception services.
To prevent negative consequences for the
pregnancy and baby, men and women of childbearing age residing in areas where the virus is
known to be circulating should receive accurate
information and guidance, so that they will
consider postponing pregnancy and follow the
recommendations for prevention, particularly
the use of condoms.
The decision to have children and when should
be considered a strictly personal matter and be
based on complete information and access to
affordable quality health services.
Pregnant women’s sexual partners living in or
returning from areas where the virus is
circulating should practice safe sex or abstain
from sex for at least the duration of the
pregnancy.
Women who plan to become pregnant and
return from areas with known circulation of ZIKV
should wait at least eight weeks before
attempting to conceive to give a potential ZIKV
infection time to clear. This period will be six
months if their male partner has symptoms of the
disease.
Men and women who return from areas with
known ZIKV circulation should practice and
continue safe sex or abstain from sex for at least
eight weeks following their return.
a. If ZIKV symptoms appear before or during that time, men
should practice safe sex or abstain from sex for at least 6
World Health Organization. Prevention of sexual transmission of ZIKV
virus. Interim guidance update. 7 June 2016. WHO/ZIJV/MOC/16.1
Rev.2
4
months.
b. WHO does not recommend systematic semen analysis for
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Pan American Health Organization / World Health Organization
ZIKV detection; however, men with symptoms of the disease
scientifically demonstrated.
can be offered these tests 8 weeks after their return,
depending on the country’s policy.
WHO always recommends safe sex, especially
the systematic and proper use of condoms to
prevent HIV, other sexually transmitted
infections, and unwanted pregnancies.
Vertical transmission of
ZIKV
Can a pregnant woman pass ZIKV
to her unborn baby during
pregnancy or childbirth?
Pregnant women in general and those with
symptoms of ZIKV infection in particular should
see a health professional who will monitor the
pregnancy.
Can women infected with ZIKV
breastfeed?
ZIKV has been detected in breast milk, but there
is no proof that it is transmitted to a baby
through breastfeeding.
WHO recommends exclusive breastfeeding
during the first six months of life.
It has been verified that some pregnant women
pass ZIKV to their unborn baby.
For more information, see Breastfeeding in the
context of ZIKA virus, at:
Infection in late pregnancy can be passed to
the baby during pregnancy and childbirth,
although this hypothesis has not yet been
http://www.who.int/csr/resources/publications/zika/breastfeeding/en/
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Pan American Health Organization / World Health Organization
Preventing ZIKV in
pregnant women
What are the recommendations for
preventing ZIKV infection in
pregnant women?5
It has been shown that ZIKV infection during
pregnancy results in babies with microcephaly
and other birth defects; it is therefore
recommended that women living in or traveling
to areas where ZIKV is circulating postpone
pregnancy.
Pregnant women should adopt the same
general personal protection measures to avoid
mosquito bites.
Pregnancy is a decision for individuals or
couples; when deciding in favor of pregnancy, it
is recommended that people adopt all the
self-protection measures indicated to prevent
this disease.
The use of repellents containing DEET, IR3535,
or Icaridin for personal protection are not
contraindicated during pregnancy, provided
they are used according to the instructions on
the product label.
If pregnancy is suspected, visit the health
center and follow the health workers’ recommendations.
Even if they have no symptoms, pregnant
women should always go for prenatal check-ups
and follow medical advice.
If pregnant women develop a fever,
conjunctivitis (redness of the eyes), a rash, pain,
or malaise, they should immediately go to the
nearest health center.
Pregnant women, as well as the general public,
should avoid using drugs without a doctor’s
recommendation.
What are the recommendations for
women of childbearing age or
those who plan to become
pregnant?
World Health Organization. Prevention of sexual transmission of ZIKV
virus. Interim guidance update. 7 June 2016. WHO/ZIJV/MOC/16.1 Rev.2
World Health Organization. Psychosocial support for pregnant women
and for families affected by microcephaly and other neurological
complications in the context of Zika virus. Interim guidance for
health-care providers. 2016
5
If you wish to postpone pregnancy, it is
important that you visit a health facility to
obtain information on available family planning
methods.
If your partner has been in an area where
mosquitoes infected with ZIKV are circulating, it
is recommended that condoms be used when
you have sex, given the possibility of becoming
infected with the virus through semen.
For more information, see the publication:
Ensuring human rights in the provision of
conceptive information and services, at:
http://www.who.int/reproductivehealth/
publications/family_planning/
human-rights-contraception/en/
What should I do if I have
symptoms of the disease?
Visit a health facility, especially if you are
pregnant or suspect you are. People with chronic
diseases should, too.
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How concerned about ZIKV should
the public and pregnant women
be?
Pregnant women have the same risk of being
infected with ZIKV through the bite of an infected
Aedes mosquito as the rest of the population.
Many women may not learn that they have ZIKV
because they will not develop symptoms.
Everyone, including pregnant women and
women of childbearing age, should avoid
exposure to mosquito bites—for example, by
wearing clothes that cover their skin (long
sleeves), sleeping under treated mosquito nets,
and using the repellents indicated by the health
authorities, following the instructions on the
label. It is very important to find and eliminate
potential mosquito breeding sites in every home
and its surroundings.
Are there antiviral or other
treatments? Is there a vaccine?
There is currently no vaccine to prevent ZIKV
infection. Normal treatment for the infection is
limited to treating the symptoms as they appear
and providing supportive care. Thus, mosquito
control and the elimination of breeding sites are
essential for protecting everyone’s health.
Other potential questions:
What are the recommendations for pregnant
women living in or traveling to areas where ZIKV
is circulating?
Can people travel to a country where ZIKV is
circulating?
Concerning future pregnancies, what are the
recommendations for women of childbearing
age in areas where the virus is circulating?
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Pan American Health Organization / World Health Organization
How do health workers confirm that a baby has
microcephaly? What is microcephaly and what
other types birth defects can occur? What are
the consequences for the development of babies
born with some of these birth defects?
For more information on how to respond to these
and other questions, visit the frequently asked
question section of the PAHO website:
www.paho.org/viruszika
What are the consequences of this disease?
What are its symptoms? What should be done if
symptoms appear? Is there a treatment for this
disease? Is it curable? What complications can
occur?
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Pan American Health Organization / World Health Organization
Communication activities
with respect to Zika virus
infection
Communication
Objectives for Public
Health Communication
Officials
Communicate information about ZIKV in a
timely manner, addressing the population’s
public health concerns and need for information
about the potential complications of this
disease.
Segment audiences to emphasize the risks of
ZIKV to the more vulnerable groups at higher
risk--in this case, women of reproductive age,
pregnant women, and health workers.
Continue promoting individual behavioral
changes, social mobilization, and community
engagement to control the vector and eliminate
breeding sites in dwellings.
Keep the public fully informed about the risk of
ZIKV infection, state what is known, and describe
the efforts of health institutions and the
international community to respond to this
health emergency, as well as the research and
other action being taken to learn more about this
new disease.
Maintain the credibility of health institutions
and public confidence in them by disseminating
accurate, evidence-based information.
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Set up a system for monitoring public speculation and conjecture to dispel rumors and refute
inaccurate information and misconceptions as
quickly as possible.
Quickly respond to the concerns and specific
information needs of the public, partners and
allies, health care providers, and the public
health community in general.
Adopt a consistent and uniform government
(national) approach to strategic and operational
communications. Include partners and allies
from the nongovernmental sector (NGOs, private
enterprise, the community).
Set up a system for ensuring the consistency of
the messages conveyed by personnel from the
national government, hospitals, and the rest of
the local health authorities. A content guide for
standardized messages is one alternative for
promoting consistency in messaging, as is a
protocol or policy to regulate the release of
public information about this issue.
Basic suppositions
Without mosquitoes there is no disease.
Reducing Aedes mosquito populations, eliminating breeding sites, avoiding bites, and cleaning
up the environment remain the basic tools for
lowering the risk of ZIKV infection.
The more that new cases of microcephaly
and/or other birth defects and GBS are reported
in the Americas, the more sensationalism there is
likely to be in the media: the media and social
networks may be the first to announce these
events unofficially.
There will be a gap between reports of the first
probable suspected cases and their confirma
tion; the longer this period, the greater the
speculation by the media and the public. Thus,
the period between confirmation of these cases
and public announcements should be as brief as
possible.
The demand for information by the health
authorities, partners, the media, government
agencies, the general public, and other
audiences will be enormous, immediate, and
persistent. This will put considerable pressure on
the government to rapidly divulge the facts.
Social networks will exponentially increase the
pressure and demand for information. They will
also increase the potential for inaccurate
information and rumors, which will spread like
wildfire.
There will be incomplete and inaccurate
information, and rumors and misconceptions will
circulate. People may take action based on this
information.
Health guidelines and recommendations may
change as more is known about the health
impact of ZIKV—for example, the complications
of congenital malformation syndrome, GBS, and
modes of transmission. As a result, the information must be updated as it changes.
Guiding principles for
preparing risk
communication plans
When there is uncertainty about health risks
(for example, not knowing for certain how many
children will be born with congenital malformations and/or the association between ZIKV and
GBS), people need information not only about
what is known and unknown about this infection,
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but about what action the authorities are taking
to find answers to the questions still pending. It is
important to publicize this action to guarantee
the population’s confidence that the authorities
are working to identify evidence-based reasons
for decision-making, determining the actual level
of risk to the public, and issuing preliminary
guidance for making decisions that will help
people protect their own health and that of
others. Insofar as possible, this information
should be disseminated before related cases are
diagnosed, as this will help allay initial concerns.
Timely, transparent dissemination of accurate
and accessible evidence-based information
about ZIKV infection gives the public confidence
in the action taken by the health authorities,
especially when the real effects of a new disease
in the Region still are unknown. It is important to
use all available channels (social networks, institutional websites, community leaders, mass
media, target audiences of partners and allies,
etc.) to reach the population with consistent
messages.
Coordinating messages and disseminating the
information to all health organizations and
health officials are essential to avoid confusion
that can undermine public trust, spark fear and
anxiety, and hinder response measures.
To prioritize messages, there must be a hierarchy, considering those that will have a greater
impact (in containing the infection) and produce
faster behavioral changes in the population.
Information targeting the public should be
accessible, technically accurate but tailored to
the various audiences, and complete enough to
promote support for official policies and
measures such as the control and elimination of
mosquitoes and breeding sites. It is important to
translate the messages into other languages or
dialects, as necessary, adopting an intercultural
approach.
The community should be at the center of the
response. Thus, it is important to design activities that encourage social mobilization and
effective community engagement for mosquito
control and the elimination of breeding sites.
The information provided should reduce
speculation to a minimum and avoid the the
exaggerated interpretation of data, as well as
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assessments of public health research and zcontrol measures that are too sanguine.
It will be important to ensure that our guidance
and recommendations can change as we learn
more about this disease.
Prepare contingency plans; that is, create
mechanisms and activities for potential public
awareness campaigns and social mobilization.
The foundation for behavior modification will
be education, whose results will be manifested in
changes in environmental practices and the
maintenance
of
dwellings
and
their
surroundings. Schools and community leaders
are key to effecting these changes.
It is important to keep journalists constantly
updated about the evolving situation. Thus,
trained spokespersons should make regular
appearances and provide consistent information.
Evaluation of risk
perception
With any health event, it is necessary to analyze
the individual perceptions of different audiences
about the event—in this case, ZIKV infection and
its potential complications and the mosquito’s
association with the transmission of this disease,
as well as sexual transmission. This is essential
for implementing prevention and control activities with the active engagement of individuals
and communities.
The population’s risk perception is based on
what people think or perceive about their possibility of contracting this disease, its severity, the
benefits of modifying their behavior versus the
personal costs, and their willingness to make
these changes.
Analyzing risk perception is important for the
design and implementation of successful
communication activities:
The accuracy of the data must be ensured to
avoid contradictory information.
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The table below is a practical aid for people to
rate the following problems to better define their
risk
VERY
HIGH RISK
HIGH
RISK
MODERATE
RISK
LOW
RISK
Dengue
Why?
Chikungunya
Why?
ZIKV
Why?
Microcephaly
Why?
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The table below provides sample
questions for use in public surveys
DIMENSION
ZIKV
AEDES MOSQUITO
Are you aware of this risk?
Are you aware of this risk?
Do you understand what form
complications of ZIKV take?
Do you understand what form
the complications take?
Uncertainty
Can you predict whether you will
be infected with ZIKV in the next
five years? (It doesn’t matter
whether or not the respondent
believes he will; only whether he
can predict what will happen)
Can you predict whether you will
develop a disease resulting from
a mosquito bite in the next five
years? (It doesn’t matter whether
or not the respondent believes he
will; only whether he can predict
what will happen)
Control
Can I personally take steps to
reduce my risk of ZIKV infection?
Can I personally take steps to
reduce mosquito populations?
Equity
Are there people whose living
conditions put them at greater
risk of ZIKV infection?
Are there people whose living
conditions put them at greater
risk of ZIKV infection?
Benefits
Is there any benefit to
contracting ZIKV infection?
Is there any benefit to controlling
mosquitoes and their breeding
sites?
Are you afraid of falling ill with
ZIKV infection?
Are you afraid of falling ill from a
mosquito bite?
Familiarity
Understanding
Comprensión
Fear
Mistrust
Reversibility
Are there institutions responsible
for preventing the risk of ZIKV
that are taking steps to do so?
Can people recover from ZIKV
infection?
Are there institutions responsible
for reducing mosquito populations and eliminating breeding
sites that are taking steps to do
so?
Can people recover from mosquito-borne diseases?
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DIMENSION
ZIKV
AEDES MOSQUITO
Personal
Interest
Have you felt that you or your
immediate family are at risk of
getting dengue?
Ethics and
Moral
Do you believe that people who
become infected with ZIKV have
risk behaviors?
Known
Victims
Did you have ZIKV? Do you know
anyone who has had ZIKV or
dengue?
Catastrophemagnitude
Do you think your country is at
risk of a ZIKV epidemic?
Have you felt that you or your
immediate family is at risk of
getting chikungunya?
Do you think your country is at
risk of an epidemic of
mosquito-borne diseases?
Other
Other questions on attitudes and practices can
be included in this survey, since the table above
primarily explores knowledge.
Main communication
channels
A useful tool for conducting Knowledge,
Attitudes, and Practices (KAP) studies is the
WHO methodology developed specifically for
ZIKV, which is available at:
The Ministry of Health may use a variety of channels to disseminate information and messages to
the media and the public on the general
response to ZIKV, be it on the action taken by
public health institutions, prevention measures
(non-pharmaceutical interventions), recommendations for more vulnerable groups, what to do,
where to go, etc.
http://www.who.int/csr/resources/publications/zika/kap-surveys/en/
The key information channels include, but are
not limited to:
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Briefings for the media, including televised
press conferences and information for
journalists over the phone.
Grant interviews with public health officials
who are well-versed in the matter and prepared
to respond to questions from the media.
Social networking channels (for example,
Twitter, Facebook, YouTube, Instagram, podcasts, text messages, etc.).
Issue a fact sheet containing key data and
information on the preparations made by the
government and health authorities for a
response.
Micro-websites with detailed information on
ZIKV (frequently asked questions, etc.).
Radio broadcasts of public service announcements.
Update the website with basic public information.
Distribution of print materials (informational,
educational, etc.).
Update the list of frequently asked questions
for the telephone hotline (if any); ensure that the
telephone hotline number is included in all materials distributed and provided to the media.
Other social and community engagement
activities.
Update the information for international
partners that provide technical cooperation.
Channels used by other partners and allies
(churches and parishes, town hall meetings,
sporting events, celebrities, etc.).
Provide information on cases that arise,
protecting the patients’ identity and/or preventing stigmatization and discrimination against
patients and their families.
If ZIKV-associated cases of congenital malformation syndrome in newborns or GBS are detected,
the Ministry of Health can:
Collaborate closely with other public health
and local authorities (for example, hospital staff
and the members of medical, academic, and
research associations) to assess the situation
and prepare for public announcements.
Prepare a statement and send it to the entire
media list.
Issue an official announcement for the media.
Simultaneously send text messages and live
tweets to inform the population (if possible).
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Audience segmentation
Health authorities will widely disseminate information to the general public, health workers, and the
public health community to inform them about ZIKV infection and address their concerns.
Some of the specific audiences are identified below. All of these groups have concerns and information needs, both mutual and differentiated, which requires a special communication effort tailored
to each segment. This will help to build and maintain the trust of these audiences and better manage
their expectations.
GENERAL
PUBLIC
People living in areas where there is a risk of infection
Pregnant women and women of reproductive age
Patients and individuals with symptoms
HEALTH
WORKERS
Physicians and other health workers
Hospital workers
Workers from medical associations
Laboratory staff
Travelers to areas where there is a risk of infection
Airline workers
Cruise workers
TRAVELERS AND
TOURIST INDUSTRY
Schools
Faith-based organizations
Businesses
Civic organizations
COMMUNITY
ORGANIZATIONS
Examples of channels, by target audience
CHANNEL
SOCIAL NETWORKS
WEBSITES
INDICATE AUDIENCE TYPES TO BE
REACHED THROUGH THIS CHANNEL
General public
Health workers
Partners and allies
Journalists
Travelers
General public
Health workers
Journalists
Travelers
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CHANNEL
THE MEDIA
PHYSICIANS’ AND NURSES’
ORGANIZATIONS AND NETWORKS
INDICATE AUDIENCE TYPES TO BE
REACHED THROUGH THIS CHANNEL
Journalists
General public
Health workers
Public health community
NATIONAL TELEPHONE HOTLINE
(CALL CENTERS)
General public
Pregnant women and their partners
Women of reproductive age
MEDICAL CONSULTATIONS–HEALTH CENTERS
Pregnant women and their partners
Women of reproductive age
General population
PARTNERS AND ALLIES: Partners
that can participate in communication
initiatives and should receive up-to-date
information and key messages, so that
they are prepared to answer questions
from the public and/or share answers
with their target audiences.
COMMUNITY CENTERS
OTHER: Points of entry, workplaces
(factories, assembly plants, unions,
schools, health centers, prisons, etc.)
Health workers
Public health community
General public
Travelers
NGOs and organizations that provide social
protection for vulnerable populations
Target audiences of these partners and allies
Community leaders
The public
Community dispensaries
Schools
Other
Workers
Travelers
People in confinement
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Appointment of official
ZIKV spokespersons
It is important to identify and appoint skilled
spokespersons to interface with the media about
ZIKV. The main spokespersons that interface with
the media should be identified as in the example
below:
Dr. XXXX
Mr./Ms. XXX
Tasks for internal
organization of the risk
communication team
1. Draft a transparency policy containing the
criteria (protocol) for disseminating public
information, including a process for quickly
approving announcements and warnings for
public distribution in the event of a real or
potential public health risk, as well as protocols
for issuing announcements or warnings outside
office hours.
2. Determine which members of your
communications team will serve as contacts for
the Ministry in coordinating communications
with other institutions involved in the response to
the ZIKV outbreak.
3. Activate the team responsible for monitoring
the media, social networks, and other information channels to monitor risk perception in the
target audiences.
4. Designate and train official spokespersons.
5. Determine what steps should be taken with
respect to the at-risk population and make the
necessary preparations to tailor/disseminate
the prepared messages to the target audience
through previously identified channels.
6. Issue the first announcement of the event and
subsequent announcements as the situation
evolves. Clearly and quickly answer the initial
questions from the media, partners, and allies,
and the public.
The information should be disseminated before
rumors with inaccurate information begin to
circulate.
In the first announcement, the spokesperson
should include information on measures to
prevent the disease, the situation surrounding
the first case(s), and the action that the health
authorities are taking to protect the public and
health workers.
7. Inform the media when and where updates will
be provided and where to find them online or
through other channels.
8. Use a variety of channels to keep in constant
communication with the public.
Tasks to address the
needs of the most
vulnerable populations
Identify mechanisms to communicate with
hard-to-reach vulnerable groups to ensure that
they have access to information on how to
prevent the infection and where to go for medical
care or counseling.
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Pan American Health Organization / World Health Organization
Obtain the support of primary care physicians,
nurses, midwives, and health promoters so that
they receive the information and transmit it to
users.
Work with celebrities and other spokespersons
to disseminate information on measures to
prevent the disease.
Preparatory stage
Prepare the mechanisms for transmitting the
information and decide who will be responsible
for doing so (including partners and allies).
Prepare the public for the possibility of microcephaly cases. During the preparatory phase, it
is important to disseminate messages describing
what steps the government is taking to protect
the public and health workers, inform the population about measures for the protection of individuals and families, reduce stigma, and strengthen
early interventions.
Select the communication channels that will be
used to distribute the messages, tailoring the
information to the target audiences.
Continually update the information in other
channels (such as websites, social networks,
print materials, and radio announcements).
Collaborate with health workers in drafting and
communicating disease prevention messages at
the first level of care through the comprehensive
health care models.
Engage the community in the response, working with community leaders and providing them
with support to carry out interventions with community engagement and social mobilization.
Preparation of
messages and
distribution channels
Prepare and test the key messages, including
basic information on the threat that ZIKV poses
to health, measures to eliminate breeding sites,
and personal protection measures.
Draft preliminary versions of press releases,
public service announcements, and documents
with frequently asked questions that include
information on protecting health and on the
potential complications of ZIKV in babies born to
mothers who contracted the disease during
pregnancy.
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Examples of immediate activities in your
communication plan
The following are suggested activities that can be implemented in the event of a ZIKV outbreak in your
country, region, or specific cities. These activities are not listed in order of importance, nor should
they be implemented in a particular sequence. Some of the activities can be implemented simultaneously or before or after the point in which they appear on the list, as the situation warrants.
ACTIVITIES
Adapt and distribute the key messages to the public.
Prepare and issue messages for a press release.
Report to partners and allies.
Hold a briefing for journalists (educational briefing about the event).
Upload information to the Ministry of Health website and keep this information updated.
Post messages in social networks.
Respond to media requests.
Monitor the information appearing in the media and social networks, as well as the questions asked by the public.
Inform and offer guidance to health workers, the public and private health community, and
laboratories.
Update the list of frequently asked questions and their responses for call centers.
Activate the call centers.
Hold press conferences to make public announcements with updated information on the
course of the event.
Prepare and provide supplementary information, education, and communication materials
for the various target audiences.
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Pan American Health Organization / World Health Organization
ACTIVITIES
Monitor and evaluate the news media, social networks, and the questions asked by the
public.
Activate communication channels with communities, partners, and allies, and other
previously identified groups.
Examples of the
principal key
messages
The Ministry of Health knows that the public is
concerned about this situation. We understand
these concerns and are taking them very seriously. When we know more about the event and its
consequences, we will update the information
and issue public announcements.
This situation is still evolving. The Ministry of
Health is investigating the following:
How many people had symptoms and the
health status of those individuals and their
children.
There is currently no vaccine that protects
against ZIKV infection. Treatment is limited to
treating the symptoms as they appear and
providing supportive care. Therefore, eliminating
breeding sites is essential for protecting everyone’s health.
Pregnant women have the same risk as the rest
of the population of acquiring ZIKV infection,
which is transmitted through the bite of an
infected Aedes mosquito and can also be transmitted.
Everyone, including pregnant women and
women of childbearing age, should avoid mosquito bites—for example, by wearing clothing
that covers their skin (long sleeves), using treated
mosquito nets, and applying the repellents
indicated by the health authorities, following the
instructions on the label. In each home and its
surroundings, it is very important to look for
potential mosquito breeding sites and eliminate
them.
The government has been preparing the
response to an event like this by:
Improving surveillance to monitor the geographic spread of the virus and obtaining the laboratory tests needed to detect cases.
Training health workers and health centers in the
use of appropriate response protocols.
Disseminating updated information to the
general public, travelers, and domestic and international partners and allies.
Actively working to control and eliminate the
mosquito and its breeding sites.
The Ministry of Health will provide new information about ZIKV infection online at:
www.example.com
Pan American Health Organization / World Health Organization
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Messages for service
providers
Keep up-to-date on the latest scientific information about ZIKV and its potential
consequences.
Follow the latest guidelines on the diagnosis
and treatment of ZIKV infection and its potential
consequences.
Familiarize yourself with the available support
or referral services and systems for women and
families affected by ZIKV infection during
pregnancy and/or by grade IV microcephaly.
Remember that pregnant women with ZIKV may
be upset, sad, or anxious; you should therefore
be very careful in communicating with these
patients.
Ask your pregnant patients what they know
about ZIKV and its potential consequences.
Take the time to listen to your patients’
reactions.
Throughout the consultation, encourage your
pregnant patient and her family to take notes
and return to the health center if they have
additional questions.
Explain to pregnant women with ZIKV the need
for regular check-ups to monitor their baby’s
neurological development and assess potential
complications.
Encourage women to invite a trusted person
(her husband, a friend, or a family member) to
be present at the consultation or any follow-up.
Guarantee the confidentiality of every visit.
Use simple words and avoid technical jargon
so that patients understand the information you
are giving them.
“Listen”: monitoring
communications
Establish mechanisms to monitor the
effectiveness of communication and methods for
understanding the public’s attitudes and motivations.
Create a team to monitor the media and set up
a telephone helpline.
Identify and communicate often with community leaders in at-risk populations and other target
groups to learn about their information needs
and concerns.
Engage the community and its leaders in an
ongoing dialogue about their concerns and the
response activities.
Activate the call centers and monitor calls from
the public.
Hold meetings with the community and
influential personalities.
Monitor the news and social networks.
Regularly share the results from the monitoring
of information channels with the authorities,
spokespersons, experts, risk managers, partners,
and the communications team, ensuring that
they are analyzed and used in the development
of new communications activities and materials.
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Pan American Health Organization / World Health Organization
that address misconceptions or inaccurate
information and the public’s concerns and in the
modification of ZIKV response interventions.
Media relations
Create or update the databases of news media
Determine the logistics for collaborating with
the media and provide continuous updates
Organize educational briefings for journalists
about ZIKV and its complications
What terminology and ideas about the disease,
mosquitoes, and hygiene should be used?
What resources does the community have that
would permit more effective control of the mosquito?
2. Establish lines of action, prepare materials, and test them with the target audience.
3. Reorient activities in line with the research
conducted about the community, such as
KAP studies, opinion polls, etc.
Community
engagement
1. Rapidly determine the community’s
attitude toward vector control and the
behavioral objectives we want to meet.
What behavior needs to be modified to control
mosquitoes and their breeding sites? Why is this
not being done? How can we influence those
behaviors and better support them? What barriers exist? Why have some people modified their
behavior and others have not? How are changes
achieved?
What do health workers and residents think
about the effectiveness of the control measures
instituted to date and what are their expectations?
Who are currently or potentially the most
important actors in the sphere of domestic
hygiene? Who influences those actors?
What are the best media for transmitting that
information?
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Pan American Health Organization / World Health Organization
Glossary
Zika virus:
Zika virus (ZIKV) is an arbovirus of the genus flavivirus (family Flaviviridae), and very similar to
other viruses such as dengue, yellow fever, Japanese encephalitis, and West Nile virus. Zika virus is
transmitted by infected mosquitoes, mainly of the genus Aedes. It was first isolated in 1947 from a
rhesus monkey during a study on jungle yellow fever transmission in Uganda’s Zika Forest. In 1968, it
was isolated in humans for the first time in Uganda and the United Republic of Tanzania. Outbreaks
have subsequently been recorded in Africa, Asia, the Western Pacific, and, more recently, the
Americas.
Guillain-Barré Syndrome:
In its typical form, Guillain-Barré syndrome (GBS) occurs as progressive, symmetrical, subacute,
ascending paralysis that reaches its peak at four weeks and is accompanied by the absence of
reflexes. In many cases, it is preceded by a history of infection.
Microcephaly:
Microcephaly is defined as an occipitofrontal circumference below -2 standard deviations from the
average for the reference population by age and sex.
Congenital ZIKV syndrome:
The syndrome currently described includes the presence of microcephaly, with other signs such as
craniofacial disproportion, as well as other anthropometric disproportions, redundant scalp with
visible folds, hypertonia or spasticity, irritability, and epileptic seizures.
Entomological surveillance:
Entomological surveillance is the continuous, orderly, systematic, and planned process of collecting
data on disease vectors and their environment in order to describe, analyze, assess, interpret, and
make decisions about vector control. Entomological surveillance, combined with disease surveillance, makes it possible to adopt appropriate control measures. As a result, hard reference data are
needed for the adoption of rational control measures. Entomological surveillance is a component of
epidemiological surveillance. It is also an essential vector control activity, must be conducted in
both the rainy and dry seasons, and should cover both the immature and adult phases of the vector.
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Health Organization
World Health Organization
Organización
Panamericana
de la Salud //Organización
Mundial de la Salud
References
World Health Organization. Prevention of sexual transmission of Zika virus. Interim guidance
update. 7 June 2016. WHO/ZIJV/MOC/16.1 Rev.2
World Health Organization. Outbreak communication guidelines. 2005. Available online at
http://www.who.int/csr/resources/publications/WHO_CDS_2005_28/en/
World Health Organization. Outbreak communication planning guide. 2008. Available online at
http://www.who.int/ihr/publications/outbreak-communication-guide/en/
World Health Organization. Effective media communication during public health emergencies.
2005. Available online at
http://www.who.int/csr/resources/publications/WHO_CDS_2005_31/en/
World Health Organization. Preguntas más frecuentes en relación al ZIKV.
http://www.who.int/features/qa/zika/es/index4.html
Pan American Health Organization/World Health Organization. Guide to Surveillance of Zika Virus
Disease and its Complications. ISBN 978-92-75-31894-2. Washington, D.C., 2016.
World Health Organization. Psychosocial support for pregnant women and for families with
microcephaly and other neurological complications in the context of Zika virus. Interim guidance for
health-care providers. WHO, Geneva, 2016.
Pan American Health Organization / World Health Organization
Pan American Health Organization / World Health Organization
ISBN: 978-92-75-11938-9
525 Twenty-third Street, NW
Washington, DC 20037, EUA
Tel: +1 (202) 974 –3000
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