Office of Research and Development Washington, DC 20460

Official Business

Penalty for Private Use

$300

PRESORTED STANDARD

POSTAGE & FEES PAID EPA

PERMIT No. G-35
i

EPA/625/R-06/012 

August 2007 

Risk Communication in Action:


The Tools of Message Mapping


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


Recycled/Recyclable 

Printed with vegetable-based ink on 

paper that contains a minimum of 

50% post-consumer fiber content. 

Processed chlorine free. 
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 endorsement 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. 

ii 
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 technical 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; protection 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 anticipate 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 community levels. 

This publication has been produced as part of the Laboratory’s strategic long-term research plan. It is published 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 

iii 
How to Use this Workbook 

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 
Table of Contents


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


5.1 The Creation of a Message Map Can Be Separated into Eight Steps ...................................... 17


6.0 Message Mapping in Action: Three Examples.................................................................................... 19


6.1 The West Nile Virus: Crisis Summary and Message Maps...................................................... 19


6.2 Bioterrorism (Anthrax): Crisis Summary and Message Maps................................................. 24


6.3 Water Contamination (Cryptosporidium): Crisis Summary and Message Maps..................... 29


7.0 Conclusions ........................................................................................................................................ 35


8.0 Glossary .............................................................................................................................................. 37


9.0 Most Frequently Asked Questions by Journalists During a Crisis...................................................... 39


10.0 References........................................................................................................................................... 41


v 
vi

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 officials feared a repeat of the 1918 flu epidemic, which killed 20 

million people around the world. The Centers for Disease Control 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 vaccinations 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 million doses a week by the middle of November 1976.1 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 following reports from more than ten states of a rare degenerative 

disease, Guillain-Barré 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 vaccinations, 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 expectation.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 communication. 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 highstress, high-concern, or emotionally charged situation; how 

does the organization quantify and convey risk in an appropriate, effective and factual manner? What are the proper actions 

to recommend (or discourage)? How will the public react? Will 

the message change behavior? 

In spite of the challenges, risk communicators have many resources 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 effective tool of risk communication, message mapping. 

Figure 1-1. The swine flu incident was an example of a risk comm

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-Barré syndrome 

and 25 deaths. 

uni1

1.1	 What Is a Message Map? 

A message map is a detailed description of hierarchically organized 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 general 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 information. 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 public 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 information 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 supporting information provide talking points that a speaker can check 

off in order of importance. 

In 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

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 communication 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 expressing concerns, opinions, or reactions to risk messages or 

to the legal and institutional arrangements for risk management.”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 receiver 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 different assessments whereby opinions and risk regulators must 

understand multiple conflicting objectives. For instance, even 

though data overwhelmingly prove that smoking is a carcinogen, 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 outrage; 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 killers 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 Guillain-Barré cases and 25 deaths. 

2.2 Goals of Risk Communication 

Risk analysis experts Ralph Keeney and Detlof von Winterfeldt, of the Institute of Safety and Systems Management at the 

University of Southern California7, conducted extensive discussions with regulatory officials, after which they listed the objectives 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 rationale 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 opposed 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 communication should also change individual behavior. If the 

presentation is about the dangers of carbon monoxide poisoning, one goal would be to persuade some of the audience to indicate that they plan to install a carbon monoxide 

detector in their homes. 

•	 To	 improve	 understanding	 of	 public	 values	 and	 concerns

To do this, risk communicators must consider the difference (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 authorities 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 audience. This will engender the audience’s trust and build up 

your credibility. 

3

•	 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 attempt 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 Covello and Peter Sandman have traced the evolution of risk communication 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 explaining 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 Department 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 partner 

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 livelihoods. The goal of risk communication is not to diffuse public 

concern, but to create an informed public. A scientific experiment 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 hydroelectric 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 meetings, 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 expected to listen. Effective risk communication is a two-way activity.

9 

Rule 3: Be honest, frank, and	open

Organizations should disclose risk information as soon as possible 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 information 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, memorable, easily understandable terms. If organizations don’t simplify, the press will simplify the message at the risk of adding 

misinformation.9 

4

Rule 6: Speak clearly and with	compassion

Technical language and jargon are barriers to successful communication with the public. Clear, non-technical language and 

sensitivity to cultural norms is essential. Personalizing risk data 

along with graphics to clarify the message will enhance public 

understanding.9 

Rule 7: Plan carefully and evaluate performance

Risk communication will be successful only if carefully planned 

and evaluated. Organizations should identify important stakeholders, pretest messages to focus groups, and train staff in 

communication skills.9 

5

6

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 coverage 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 “reliable 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 statement. Researchers have studied the characteristics of risk that 

influence risk perception/outrage. A comparison of characteristics 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 example, causes more dread than heart disease because cancer is 

seen as a terrible way to die. When asked to estimate the average 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 control. 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 crashes, 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 Superfund 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 manmade 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. 

7

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 exposed 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. 

­

Table 3-1. A Summary of Risk Perception Factors14 

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 Virus, 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 communication 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 mistrusted by many.

14 

Underestimate Risk Overestimate Risk 

Not dreaded (i.e. heart disease) Dreaded (cancer) 

Voluntary Coercive (involuntary) 

Natural Industrial 

Scientifically well understood Scientifically unknown 

Known Unknown 

Controllable by the individual Controllable by others 

In the hands of a reliable source Managed by an unreliable source 

Managed in a responsible way Managed in an irresponsible way 

Reversible Irreversible 

Immediate health effects Delayed health effects 

Children not as victims Children as victims 

Moral/ethical Immoral/Unethical 

Not memorable Memorable 

Random/scattered Catastrophic 

Little media attention Much media attention 

Victims statistical Personal impact 

Risk to future generation 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. 

8 
Cost-benefit ratio

If there is a perceived benefit in a specific choice, the risk associated 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 arsenic), 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 imagine, 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 

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 hurricanes 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., carcinogens) more than hazards with immediate health effects.14 

High risk to future generations	

Activities that pose a threat to future generations (e.g., radiation 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 outlined 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. 

In the Tacoma survey, those who lived the closest to the copper 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 contribute to risk denial.18 In the case of an infectious disease (such 

as AIDS), stigmatization or fear of stigmatization may be so 

9

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 helplessness. 

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, empathetic, 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 Communication, 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, scientists, educators and advisory groups have high credibility and 

promote trust on health, safety, and environmental issues. Media and activist groups have medium credibility, while industry 

and paid consultants have low credibility. 

An example of an industry that regained public trust was Johnson & Johnson Co. during the Tylenol tampering incident of 

1982. The company aggressively removed all Tylenol from retail 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 messages 

•	 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 emotionally charged situations.21 Solutions to the negative dominance 

theory include:23,24 

•	 Balancing negative key messages with positive, constructive 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 doing so makes the audience feel that you are dishonest, unconcerned, 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 presented. In one study, participants were asked to imagine they 

had lung cancer and had to choose between two therapies, surgery 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 format (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 temper, speaking in overly abstract terms, resorting to personal attacks, 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 nonwords28 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 heartbreak. 

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 embodied 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 courage 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 situations people do not comprehend information at their normal 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 children who attended a school with high aircraft noise (from 

London Heathrow airport) versus schoolchildren who attended a school with no aircraft noise, the children chronically 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 theory, both short-term memory and attention span are limited 

by the number of items the mind can consider simultaneously.

32 This is one of the oldest rules of risk communication – 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 Independence’s “Life, liberty, and the pursuit of happiness.” Information 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, examples, and photographs that can enhance audience comprehension. Experiments have shown that effective working 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 statements. This is the 1N=3P rule. This rule is derived from 

the Negative Dominance Theory, which has also been replicated 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 impression 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 ...” 

Table 3-2. General Guidelines for Good Risk Communication 

Below is a table that summarizes general rules for risk communication, taking into account risk perception, risk communication 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 communication. 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. 

In 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 judgment is based more on personal experiences and direct information.19,35 

Good Communication Poor Communication 

Clearly state and estimate the risk 

Ex: “We have a serious and immediate problem requiring attention ...” 

Exaggerate or minimize the risk 

Ex: “No one has anything to worry about”; “It’s time to panic” 

Use clear, non-technical language – write in an eighth-grade reading 

level if talking to the general public 

Use technical language/jargon – for example, filling the speech with 

acronyms (“For the RfD, go to EPA’s IRIS”) 

Use credible sources – government agencies, scientific experts, reliable 

news sources (AP, Reuters, etc.) 

Use non-credible sources – lobbying groups, industries 

Listen to the audience – assume that if one communicates in a clear, 

appropriate manner, the audience will understand 

Ignore the audience’s concerns – a “they won’t understand anyway” 

mentality 

Remain calm – do not get agitated or defensive Get angry – “That’s a stupid question ...” 

Keep messages brief – main message about 25-30 words (and 10 seconds) Make messages long-winded – droning on and on with long lists 

Balance a negative statement with 3 positive statements Use an overload of negative statements, and words like “no,” “never,” 

“nothing” 

Place most important messages first and last Hide most important message in the middle of the speech 

Use visual aids and graphics – charts, videos, pictures, graphs Use impersonal statistics – “the chances of one having an exposure of 

more than 50 ppb is about 1 in 100” 

Repeat messages – three times, to make sure the most important points 

are remembered 

Mention an important message in passing – “Oh, by the way, the hurricane warning is effective immediately ...” 

Speak with a serious tone – it will give the impression of taking the 

audience seriously 

Add humor – can often come off as flippant or be misunderstood as a 

lack of concern 

12

Acronym Text

ATO Agency Tender Official 

CDRL Contract Data Requirements List 

C.F.R. Code of Federal Regulations 

CLIN Contract Line Item Number 

CO Contracting Officer 

CSO Competitive Sourcing Official 

FAIR Federal Activities Inventory Reform 

FAR Federal Acquisition Regulation 

FICA Federal Insurance Contribution Act 

FTE Full-time Equivalent 

FWS Federal Wage System 

GAO General Accounting Office 

GFP Government-Furnished Property 

GS General Schedule 

HRA Human Resource Advisor 

MEO Most Efficient Organization 

OMB Office of Management and Budget 

OPM Office of Personnel Management 

PWS Performance Work Statement 

SCA Service Contract Act 

SCF Standard Competition Form 

SLCF Streamlined Competition Form 

SSA Source Selection Authority 

SSEB Source Selection Evaluation Board 

U.S.C. United States Code 

VERA Voluntary Early Retirement Authority 

VSIP Voluntary Separation Incentive Pay 

Figure 3-7. Filling a speech with acronyms like the ones listed above 

often just confuses listeners. 

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 conference, 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 ultimately 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 communication 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	message 

•	 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 human 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 themselves, and much confusion and misinformation may result. 

Table 3-2 lists some of the Do’s and Don’ts of communicating 

with the media. 

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 creating a message map. The message map is an organized means 

for displaying layers of information. It contains detailed, hierarchically organized responses to anticipated questions or concerns. It helps organizations meet several risk communication 

goals38: 

•	 Identify stakeholders early on in the communication process. 

•	 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 stakeholders. 

•	 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 multiple 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. Supporting messages amplify the key messages, and provide additional facts or details. They can take the form of visuals, 

analogies, personal stories, hotline numbers, and/or citations of credible sources of information. 

Stakeholder: 

Question or Concern: 

Key Message 1 Key Message 2 Key Message 3 

Supporting Information 1-1 Supporting Information 2-1 Supporting Information 3-1 

Supporting Information 1-2 Supporting Information 2-2 Supporting Information 3-2 

Supporting Information 1-3 Supporting Information 2-3 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 newspaper 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. 

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 Key Message 2 Key Message 3 

Vaccination a top priority for: Symptoms Highly contagious 

Supporting Information 1-1 Supporting Information 2-1 Supporting Information 3-1 

Elderly Fever Avoid direct contact with others 

Supporting Information 1-2 Supporting Information 2-2 Supporting Information 3-2 

Health care workers Congestion (cough, sore throat) Avoid sharing food, drinks 

Supporting Information 1-3 Supporting Information 2-3 Supporting Information 3-3 

Immuno-compromised individuals Muscle aches and pain Keep bedding (sheets, linens) clean 

Figure 4-2. Example of an overarching message map. 

16 
5. Creating a Message Map38 

A message map can be one of the most useful of risk communication tools. It is important, however, to create well-constructed 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 influential 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 situation 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 concerns

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 questions, 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) Overarching questions: “What do people need to know?” 

2) Informational questions: “What is the budget for your response?” 

3) 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 generated 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 legislative 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 brainstorming 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 supporting facts, information, or proofs for each key message. Suppose for a message map about influenza one key message was, 

“All high-risk groups must be vaccinated.” The supporting messages 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 The presentation sequence should follow these guidelines:22 

map for this key message. 

1. Introduction

Step 6: Conduct	testing Perceived empathy is a vital factor in establishing trust and 

The sixth step of message mapping is to conduct systematic building credibility, and it is assessed by your audience in 

pre-testing. The message testing should start by asking experts the first 9-30 seconds. Include a statement of concern, a 

on the topic at hand, who were not involved in the original mes­ statement of organizational intent, and a statement of pursage-mapping process, to validate the accuracy of the informa­ pose and plan for the meeting. 

tion. Subsequently, the message map should be tested on focus groups that are representative of target stakeholders. (For 2. Key messages and supporting	data

instance, supposing the message map was about influenza, a Stress the three key messages you want the public to have in 

focus group could be elderly citizens planning to get the flu mind after the meeting. Then mention the supporting data, 

vaccine.) which amplifies, clarifies, or bolsters the key messages. 

Step 7: Overarching Message Map39 3.After the presentation

An Overarching Message Map contains the organization’s core After the speaker has given all the information contained in 

messages. The Overarching Message Map addresses: the message map, he must answer questions from the media and stakeholders. The speaker should prepare before­

•	 What people most need to know about the issue or	topic hand answers to some common, anticipated questions and 

•	 What to put in the opening statement at a presentation or	 concerns from the press and stakeholders. 

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. Bridging 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 concerns are treated seriously. Audiovisual aids are often very helpful in a presentation. 

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 Australia. 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%) clinical 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 meningoencephalitis 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 determined to be the common cause of the encephalitis outbreaks 

among both birds and humans.42 

The ArboNET surveillance system was established by the Centers 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 symptoms 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 accompanied by gastrointestinal symptoms. The acute illness usually 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 victims. 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 DEET.

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. ArboNET 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 conditions 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. 

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 Key Message 2 Key Message 3 

West Nile Virus transmitted by infected mosquitoes Health effects of West Nile Virus are: There are simple steps people can take to 

avoid infection 

Supporting Information 1-1 Supporting Information 2-1 Supporting Information 3-1 

Mosquitoes become infected from biting infected birds 80% of all infections are asymptomatic Spray with DEET 

Supporting Information 1-2 Supporting Information 2-2 Supporting Information 3-2 

Blood-blood transmission also possible Uncomplicated West Nile Virus fever: 20% Wear long-sleeved clothing 

Supporting Information 1-3 Supporting Information 2-3 Supporting Information 3-3 

Human-to-human contact not believed to be a 

mode of transmission 

Encephalitis, Meningitis, Meningoencephalitis: 

1 out of 150 cases, usually in elderly (<1%) 

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 Key Message 2 Key Message 3 

A West Nile Virus epidemic in the U.S. in the 

summer of 2002 

West Nile Virus transmitted by infected mosquitoes There are simple steps people can take to 

avoid infection 

Supporting Information 1-1 Supporting Information 2-1 Supporting Information 3-1 

4,156 cases of West Nile Virus in 39 states and 

the District of Columbia 

Mosquitoes become infected from biting infected birds Spray with DEET 

Supporting Information 1-2 Supporting Information 2-2 Supporting Information 3-2 

Of the cases, 71% neuroinvasive, 28% uncomplicated, 1% unspecified, 284 (< 7%) fatal A flavivirus – a virus transmitted by mosquitoes Wear long-sleeved clothing 

Supporting Information 1-3 Supporting Information 2-3 Supporting Information 3-3 

First U.S. cases discovered in New York City, 

1999 

Virus originally from Eastern hemisphere 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 Key Message 2 Key Message 3 

First cases of meningoencephalitis in NYC, 

1999 

Deaths of birds occurring in NYC area Virus determined to be West Nile Virus 

Supporting Information 1-1 Supporting Information 2-1 Supporting Information 3-1 

719 patients with reports of meningitis and encephalitis West Nile infection among birds more geographically widespread than among humans Mosquito with WNV bite birds 

Supporting Information 1-2 Supporting Information 2-2 Supporting Information 3-2 

62 of these 719 patients were confirmed West 

Nile Virus cases 

Flavivirus isolated from birds Mosquitoes with WNV also bite humans 

Supporting Information 1-3 Supporting Information 2-3 Supporting Information 3-3 

Illness resembled St. Louis encephalitis, as 

well as other outbreaks of encephalitis in Europe and Israel 

Virus determined to be the common cause of 

the bird/human illnesses 

Although most cases of WNV are asymptomatic, 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 uncomplicated 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 Key Message 2 Key Message 3 

Older people are more at risk for serious illness Most infections are not life-threatening About 1 in 150 infections develop meningitis, 

encephalitis, or meningoencephalitis 

Supporting Information 1-1 Supporting Information 2-1 Supporting Information 3-1 

Incubation period is 2-14 days 80% of all infections are asymptomatic Muscle weakness often the first symptom 

Supporting Information 1-2 Supporting Information 2-2 Supporting Information 3-2 

Eventual clinical symptom is a neuroinvasive 

illness 

20% have mild illness, called West Nile Fever, 

often accompanied by gastrointestinal symptoms 

Encephalitis and meningoencephalitis most 

fatal 

Supporting Information 1-3 Supporting Information 2-3 Supporting Information 3-3 

About 20% or one-fifth of people over 70 died. 

Deaths occurred in people averaging 77 years 

old 

Acute illness typically lasts one week, but patients report prolonged fatigue 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 Key Message 2 Key Message 3 

Remove standing water Wear protective clothing Use insect repellent 

Supporting Information 1-1 Supporting Information 2-1 Supporting Information 3-1 

Remove old tires which collect water and serve 

as breeding grounds for mosquitoes 

Wear long sleeved shirts Repellents containing DEET are recommended 

Supporting Information 1-2 Supporting Information 2-2 Supporting Information 3-2 

Empty or clean flower pots and bird baths 

daily 

Wear long pants Use 23% DEET 

Supporting Information 1-3 Supporting Information 2-3 Supporting Information 3-3 

Empty and clean cat/dog water bowls daily Especially at dawn and dusk 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 Key Message 2 Key Message 3 

Surveillance – monitor possible outbreaks 

(ArboNET) 

Source reduction – reduce opportunity Chemical control – use pesticides 

Supporting Information 1-1 Supporting Information 2-1 Supporting Information 3-1 

Larval mosquito surveillance Reduce breeding ground Larvaciding – killing larvae 

Supporting Information 1-2 Supporting Information 2-2 Supporting Information 3-2 

Adult mosquito surveillance Water management Adulticiding – killing adult mosquitoes 

Supporting Information 1-3 Supporting Information 2-3 Supporting Information 3-3 

Virus surveillance Personal prevention measures 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 Key Message 2 Key Message 3 

Virus indigenous in Europe, Africa, Asia, and 

Australia 

Detected in NYC in 1999 Mode of introduction into United States unknown 

Supporting Information 1-1 Supporting Information 2-1 Supporting Information 3-1 

West Nile Virus first isolated in 1937 Also detected in birds in North America Mosquito-borne transmission 

Supporting Information 1-2 Supporting Information 2-2 Supporting Information 3-2 

Epidemics in Israel and South Africa Extended its range to much of the East Coast 

of the United States 

Blood-blood transmission also possible 

Supporting Information 1-3 Supporting Information 2-3 Supporting Information 3-3 

Horses also infected 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 system 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 anchorman Tom Brokaw’s office, another to Senator Tom Daschle’s office. This caused 22 cases of anthrax infection.47 To date 

the culprits behind the anthrax attacks have not been found. 

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 sporeforming 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 domestic 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 fibers. In the early 1900s, human cases of inhalational anthrax 

also occurred in the United States in conjunction with the textile 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 several locations via the U.S. Postal Service. It wasn’t until October 

2, 2001, that a physician recognized a possible case of inhalation 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. Evidence 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, inhalation, or gastrointestinal. Most (95%) cases occur cutaneously 

24

when the bacterium enters the skin. This can occur during handling 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 treated, 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 consumption of contaminated meat and is characterized by an acute inflammation 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 results in death in 25% to 60% of cases. 

The most common treatment for anthrax is antibiotics, usually 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: surveillance, 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 capacity laboratories—including clinical, military, veterinary, 

agricultural, water, and food-testing laboratories—to 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 national 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 providers to make sure they have the supplies they need (antibiotics, 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 countermeasures (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 duration of an antibiotic regimen. An article published in Nature 

written by Ron Brookmeyer, Elizabeth Johnson, and Robert 

Bollinger, 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 distribution.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 Key Message 2 Key Message 3 

Anthrax bioterrorism event in fall 2001 Symptoms of anthrax infection Three methods of transmission 

Supporting Information 1-1 Supporting Information 2-1 Supporting Information 3-1 

Anthrax spores transmitted through postal service letters Inhalation: initial cold-like symptoms, progressing to severe breathing problems, death Inhalation (lungs) 

Supporting Information 1-2 Supporting Information 2-2 Supporting Information 3-2 

22 cases, 5 deaths (all from inhalation) Cutaneous: raised itchy bump that resembles 

a bite or skin infection 

Cutaneous (skin) 

Supporting Information 1-3 Supporting Information 2-3 Supporting Information 3-3 

Treatable with antibiotics if diagnosed early 

enough 

Gastrointestinal: nausea, loss of appetite, fever, severe diarrhea 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 Key Message 2 Key Message 3 

Anthrax bioterrorism event in fall 2001 Anthrax spores transmitted through postal 

service letters 

Letters sent to media and political figures 

Supporting Information 1-1 Supporting Information 2-1 Supporting Information 3-1 

22 people were infected Letters sent to Florida, NYC, and D.C. American Media Inc. 

Supporting Information 1-2 Supporting Information 2-2 Supporting Information 3-2 

11 inhalation cases, 11 cutaneous cases All of the identified letters mailed from Trenton, 

NJ 

Tom Brokaw 

Supporting Information 1-3 Supporting Information 2-3 Supporting Information 3-3 

5 deaths, all from inhalation of anthrax Sender of letters is still unknown 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 Key Message 2 Key Message 3 

October 2, 2001 – first diagnosis October 4, 2004 - Evidence of B. anthracis at 

American Media Inc. 

October 9, 2004 - First cutaneous case of anthrax recognized 

Supporting Information 1-1 Supporting Information 2-1 Supporting Information 3-1 

Patient awoke October 2 with nausea, vomiting, and confusion Second AMI employee diagnosed on October 

5 

Patient worked in mail-room for anchorman 

Tom Brokaw 

Supporting Information 1-2 Supporting Information 2-2 Supporting Information 3-2 

Patient worked at American Media Inc. Second employee worked in the mailroom Marked by skin lesions 

Supporting Information 1-3 Supporting Information 2-3 Supporting Information 3-3 

Patient died October 4 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 transmission: cutaneous, inhalation, and gastrointestinal. The supporting information describes the symptoms and prognosis of the cutaneous anthrax, inhalation anthrax, and gastrointestinal anthrax. 

Stakeholder: Public/Media 

Question or Concern: What are the health effects associated with anthrax? 

Key Message 1 Key Message 2 Key Message 3 

Cutaneous Inhalation Gastrointestinal 

Supporting Information 1-1 Supporting Information 2-1 Supporting Information 3-1 

Small sore that develops into a blister, then a 

skin ulcer 

1-6 day incubation period; biphasic illness 

– having two distinct phases 

Consumption of contaminated meat 

Supporting Information 1-2 Supporting Information 2-2 Supporting Information 3-2 

Treated with antibiotics First phase: flu-like symptoms, then rapid deterioration Nausea, loss of appetite, bloody diarrhea, fever, stomach pain 

Supporting Information 1-3 Supporting Information 2-3 Supporting Information 3-3 

Usually not fatal Second phase: rapid deterioration, and death. 

Can be fatal 

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 workers. 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 Key Message 2 Key Message 3 

Mail Postal workers56 If you have been exposed ... 

Supporting Information 1-1 Supporting Information 2-1 Supporting Information 3-1 

Do not open suspicious mail Wear protective, impermeable gloves Call the doctor right away 

Supporting Information 1-2 Supporting Information 2-2 Supporting Information 3-2 

Keep mail away from face when opening it; do 

not sniff 

Avoid touching eyes, skin, or other mucous 

membranes 

Antibiotic treatment 

Supporting Information 1-3 Supporting Information 2-3 Supporting Information 3-3 

Wash hands afterwards Wear long-sleeved clothing and pants to prevent skin exposure 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 message 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 Key Message 2 Key Message 3 

Surveillance Education Equipping (Bioshield Act) 

Supporting Information 1-1 Supporting Information 2-1 Supporting Information 3-1 

State and local governments General public awareness Safe laboratories for testing 

Supporting Information 1-2 Supporting Information 2-2 Supporting Information 3-2 

Health departments, hospitals Postal workers Antibiotics 

Supporting Information 1-3 Supporting Information 2-3 Supporting Information 3-3 

National electronic tracking database Physicians so they can better recognize the 

clinical symptoms 

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-compromised individuals were most at risk. 

Cryptosporidiosis - a background:

Cryptosporidiosis is a disease caused by the protozoan Cryptosporidium 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 contaminate water sources, which is the suspected cause in the Milwaukee outbreak. Cryptosporidium is often found in rivers, lakes, 

and streams contaminated with animal feces or which receive 

wastewater from a sewage plant. Prevalence of cryptosporidiosis among calves and other livestock is particularly high. 

Overall there are three pathways of fecal/oral transmission/infection: 

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 challenging contaminant to control. The parasite is protected by 

an outer shell that makes it resistant to chlorine-based disinfectants. 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 

Figure 6-6. The protozoan Cryptosporidium parvum. 

Cryptosporidium parvum oocysts have been recognized as a 

human pathogen since 1976.60 In 1982, the number of reported 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 6-7. 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 consistently 0.45 NTU or higher, with a peak of 1.7 NTU on March 

28 and 30.62 

Meanwhile, on Thursday, April 1, 1993, a pharmacist in Milwaukee 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 Milwaukee residents to boil their water, and the southern plant was 

closed on April 9. Overall an estimated 403,000 people were infected, 4,400 people were hospitalized, and 111 people died.62 

Clinical features of	cryptosporidiosis:

Cryptosporidiosis is transmitted by ingestion of oocysts excreted in the feces of humans or animals. Cryptosporidiosis has 

three methods of transmission: 1) via water and food; 2) animal 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 Cryptosporidium. 

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 symptoms will typically last for about 1 to 2 weeks. However, in persons 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 effective – 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” 

Figure 6-8. The Southern plant of Milwaukee Water Works predo

nantly serves the southern part of the city. In 1993 water from 

southern plant became contaminated with Cryptosporidium oocy

causing many hospitalizations, especially in the elderly and immu

compromised. As the picture above shows, there were less gastroin

tinal hospitalizations in the northern and central areas of the city. 

mi

the 

sts, 

notes

­

­

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 reservoir 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 turbidity of filtered water exceeds 0.3 NTU.

62 

Watershed protection is another method of preventing contamination. Septic system regulations and control of runoff into surface 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 Key Message 2 Key Message 3 

Outbreak of cryptosporidiosis in Milwaukee High risk groups are: Symptoms and precautions 

Supporting Information 1-1 Supporting Information 2-1 Supporting Information 3-1 

From contaminated water supply Immuno-compromised (HIV+, diabetes) Watery diarrhea most common symptom. Can 

also have nausea, fever, vomiting 

Supporting Information 1-2 Supporting Information 2-2 Supporting Information 3-2 

Two water treatment plants: southern and 

northern 

Elderly Incubation period: 2-10 days 

Supporting Information 1-3 Supporting Information 2-3 Supporting Information 3-3 

Southern plant reported increased turbidity on 

March 21 

Young children 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 contaminated 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 Key Message 2 Key Message 3 

Outbreak of cryptosporidiosis in Milwaukee From contaminated water supply 403,000 people infected 

Supporting Information 1-1 Supporting Information 2-1 Supporting Information 3-1 

Cryptosporidium is a protozoan (oocyst) Southern plant reported increased turbidity on 

March 21 

April 7 – stool samples from seven adults confirmed cryptosporidiosis 

Supporting Information 1-2 Supporting Information 2-2 Supporting Information 3-2 

Released from feces into water supply Two treatment plants: southern and northern Watery diarrhea main symptom 

Supporting Information 1-3 Supporting Information 2-3 Supporting Information 3-3 

Oocyst resistant to chlorine treatment, can live 

outside the body for long periods of time 

Notice on April 7 to boil water 111 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 Key Message 2 Key Message 3 

Pharmaceutical sales Water-treatment plant (MWW) Absenteeism 

Supporting Information 1-1 Supporting Information 2-1 Supporting Information 3-1 

Milwaukee pharmacist noticed a rise in OTC 

anti-diarrheal medicine 

Increased turbidity noted March 21, 1993 at 

southern plant 

Among teachers, students, and hospital workers 

Supporting Information 1-2 Supporting Information 2-2 Supporting Information 3-2 

Normal sales: $30/day Normal turbidity: 0.45 NTU Absentees all had gastrointestinal illness 

Supporting Information 1-3 Supporting Information 2-3 Supporting Information 3-3 

After April 1 sales: $500-$600 a day Outbreak period turbidity peaked at 1.7 NTU 

(March 28 and 30, 1993) 

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 Key Message 2 Key Message 3 

Watery diarrhea Three modes of fecal-oral transmission High risk groups 

Supporting Information 1-1 Supporting Information 2-1 Supporting Information 3-1 

Incubation period: 2-10 days Eating/drinking contaminated food or water Immuno-compromised, elderly, children under 

the age of 2 

Supporting Information 1-2 Supporting Information 2-2 Supporting Information 3-2 

Symptoms last 1-2 weeks Animal-to-person (feces from animal somehow 

gets into food/water) 

Illness can be very serious and prolonged, with 

no known treatment 

Supporting Information 1-3 Supporting Information 2-3 Supporting Information 3-3 

Can have dehydration, nausea, fever, stomach 

pain, vomiting. Some people show no symptoms 

Person-to-person 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 Key Message 2 Key Message 3 

Safe-drinking water habits Good hygiene/sanitation Animals 

Supporting Information 1-1 Supporting Information 2-1 Supporting Information 3-1 

Pay attention to public announcements about 

contamination 

Wash hands, especially after bowel movement 

or changing diapers 

Avoid touching farm animals 

Supporting Information 1-2 Supporting Information 2-2 Supporting Information 3-2 

Filter water (NSF rated for “cyst approval” or 

pore size of one micron or less) 

Practice safer sex Avoid touching the stool of pets 

Supporting Information 1-3 Supporting Information 2-3 Supporting Information 3-3 

Boil water for persons that are immunocompromised Wash/cook food 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 Key Message 2 Key Message 3 

Water treatment Watershed protection Public awareness and surveillance 

Supporting Information 1-1 Supporting Information 2-1 Supporting Information 3-1 

Filter municipal water supplies Septic system regulations (septic tanks not allowed to run into lakes) Monitor turbidity levels 

Supporting Information 1-2 Supporting Information 2-2 Supporting Information 3-2 

Ozone treatment is effective Runoff control Boil water for high risk groups 

Supporting Information 1-3 Supporting Information 2-3 Supporting Information 3-3 

Milwaukee plant automatically shuts down if 

turbidity exceeds 0.3 NTU 

Difficult to do, especially around rural areas 

with a lot of cattle and other livestock 

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 Key Message 2 Key Message 3 

Inadequate water treatment Inadequate diagnosis Three main vulnerable populations 

Supporting Information 1-1 Supporting Information 2-1 Supporting Information 3-1 

Cryptosporidium oocysts passed through 

city’s filtration system 

Diagnosed often as viral gastroenteritis or “intestinal flu” Elderly (often in nursing homes) 

Supporting Information 1-2 Supporting Information 2-2 Supporting Information 3-2 

Marked turbidity in southern water treatment 

plant 

Many patients do not seek treatment for diarrhea Immuno-compromised (HIV+, etc.) 

Supporting Information 1-3 Supporting Information 2-3 Supporting Information 3-3 

Northern plant not affected No known treatment Very young children 

34

7. Conclusions


Risk communication is a relatively new concept of communicating 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 individuals, 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 institutional arrangements for risk management.

5 

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 reverse situation. An important factor to consider in all risk communication situations is risk perception. As a general rule, the 

public tends to underestimate risks that are: not dreaded, voluntary, 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 public tends to overestimate risks that are: dreaded, involuntary, industrial, 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. 

In addition to applying risk perception information, risk communication 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, limiting oneself to three key messages) and can be applied to many 

situations, as shown in the examples in this paper. It helps organizations meet several risk communication goals: 

•	 Identify stakeholders early on in the communication process. 

•	 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 stakeholders. 

•	 Develop	 key	 messages	 and	 supporting	 information	 in	 a	

context of 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 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 information. 

This template can be used during news conferences, presentations, or any area where the risk of a hazard needs to be communicated. 

35

36

8. Glossary


Arbovirus – 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. 

Biphasic – Having two distinct stages (as in an illness). 

Bridging – A method used in risk communication to reiterate and clarify key points. For example, “I 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, yellow 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 connection 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 example 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 microscopic, eukaryotic organisms, such as amoebas, ciliates, 

flagellates, and sporozoans. 

Radon – A toxic, colorless gas that comes from the decay of radium and uranium found in the soil/earth/rock. This toxic, colorless 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 importance 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 information 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 appears and the higher the measured turbidity. 

37

38

9. Most Frequently Asked Questions by Journalists During a Crisis22 

1.	 What is your name, title, job responsibilities and qualifications? 

2.	 Can you tell us what happened, and when and where it happened? 

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 scenario? 

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? 

38. 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, J.S. and Halpin, T.J. Guillain-Barré syndrome in 

recipients of a New Jersey influenza vaccine. JAMA 1980; 

243(24):2490-94. 

2	 Langmuir, A.D., et al. An Epidemiologic and Clinical Evaluation of Guillain-Barré Syndrome Reported in Association with the Administration of Swine influenza vaccines. 

American Journal of Epidemiology 1984; 119(6):841-79. 

3	 Remember the Swine Flu Epidemic? Lessons the U.S. 

Could Learn From How it Reacted to the 1970’s Threat, by 

Robert Bazell, Chief Science and Health Correspondent of 

NBC News. Accessed March 13, 2006 at the URL: http:// 

msnbc.msn.com/id/10353351/ 

4	 Centers for Disease Control (CDC)’s homepage about the 

Avian Flu. Accessed March 13, 2006 at the URL: http:// 

www.cdc.gov/flu/avian/ 

5	 National Research Council (1989). Improving Risk Communication. Washington DC: National Academy Press. 

6	 Sandman, P.M. Risk Communication: Facing Public Outrage. EPA Journal; 1987: 21-22. 

7	 Keeney, R.L. and von Winterfeldt, D. Improving Risk Communication. Risk Analysis. 1986; 6(4):417-424. 

8	 Sandman, P.M. and Covello, V.T. “Risk Communication: 

Evolution and Revolution,” in Solutions to an Environment 

in Peril. Johns Hopkins University Press, 2001, pp. 164­

178. 

9	 Covello, V. and Allen, F. Seven Cardinal Rules of Risk 

Communication. Washington (DC): Environmental Protection Agency (US); 1988. 

10	 Arvai, J.L. Using Risk Communication to Disclose the Outcome of a Participatory Decision-Making Process: Effects 

on the Perceived Availability of Risk-Policy. Risk Analysis. 

2003; 23(2): 281-289. 

11	 McDaniels, T.L., et al. Democratizing Risk Management: 

Successful Public Involvement in Local Water Management Decisions. Risk Analysis 1999; 19(3): 497-510. 

12	 Slovic, P. Perceptions of Risk. Science. 1987; 236: 280­

285. 

13	 Nibsett, R. and Ross, L. Human Interference: Strategies 

and Shortcomings of Social Judgment. Englewood Cliffs, 

NJ: Prentice Hall, 1987. 

14	 Sandman, P.M. “Risk Communication” in Encyclopedia of 

the Environment. Boston, MA: Houghton Mufflin, 1994, 

pp. 620-623. 

15	 Denberg, T.D., et al. Women’s Misconceptions About Cancer Screening: Implications for Informed Decision-Making. Patient Education and Counseling 2005; 57(3): 280­

285. 

16	 Environmental Protection Agency (EPA). Toxic Air Pollutants: About Air Toxics, Health and Ecological Effects. Accessed at the URL: http://www.epa.gov/oar/toxicair/newtoxics.html, on March 23, 2006. 

17	 Baird, B. Tolerance for Environmental Health Risks: The 

Influence of Knowledge, Benefits, Voluntariness, and Environmental Attitudes. Risk Analysis. 1986; 6(4): 425-435. 

18	 Centers for Disease Control (CDC). Crisis Emergency and 

Risk Communication. October 2002. 

19	 Coleman, C.L. The influence of mass media and interpersonal communication on societal and personal risk judgments. Communication Research 1993; 20(4): 611-628. 

20	 Covello, V.T., et al. The Determinants of Trust and Credibility in Environmental Risk Communication: An Empirical Study. Risk Analysis 1997; 17(1):43-54. 

21	 Covello, V.T. Trust and Credibility in Risk Communication. 

Health and Environment Digest 1992; 6(1): 1-4. 

22	 Association of State and Territorial Health Officials 

(ASTHO). Communication in Risk Situations: Responding 

to the Communication Challenges Posed by Bioterrorism 

and Emerging Infectious Diseases. Accessed at the URL 

http://www.astho.org/index.php?template=risk_communication.html, on December 8, 2005. 

41

23 Maslow, A.H. Motivation and Personality. New York, NY: 38 Environmental Protection Agency (EPA). Draft Report: 

EPA Sponsored Workshop for Water Utilities on Water Se

curity and Message Mapping. March 2005, Atlanta, GA. 

39 Covello, V.T. Risk Communication, Message Mapping, and 

Bio-terrorism: A New Tool for Communicating Effectively 

in Public Health Emergencies and Crises. To appear in Bioterrorism: Preparedness and Response: Ensuring Public 

Health Readiness. San Francisco, CA: Jossey-Bass Pub

lishers, 2005 (in press). 

40 O’Leary, D.R., et al. The Epidemic of West Nile Virus in 

the United States, 2002. Vector-Borne and Zoonotic Diseases 2004; 4(1): 61-70. 

41 Smithburn, K.C., et al. A Neurotropic Virus Isolated from 

the Blood of a Native of Uganda. American Journal of 

Tropical Medicine 1940; 20: 471-92. 

42 Nash, D., et al. The Outbreak of West Nile Virus Infection 

in the New York City Area in 1999. New England Journal 

of Medicine 2001; 344(24): 1807-1814. 

43 CDC: Arbovirus Home at the Division of Vector-Borne In

fectious Diseases. Found at the URL: http://www.cdc.gov/ 

ncidod/dvbid/arbor/index.htm on December 1, 2005 

44 Campbell, G.L., et al. West Nile Virus. The Lancet Infectious Disease 2002; 2(8): 519-529. 

45 U.S. Department of Health and Human Services, Centers 

for Disease Control and Prevention. Epidemic/Epizootic 

West Nile Virus in the United States: Guidelines for Surveillance, Prevention, and Control. 2003. Accessed at the 

URL: http://www.cdc.gov/ncidod/dvbid/westnile/resourc

es/wnvguidelines2003.pdf, on December 1, 2005 

46 Columbia University’s Introduced Species Summary: West 

Nile Virus, accessed at the URL: http://www.columbia. 

edu/itc/cerc/danoff-burg/invasion_bio/inv_spp_summ/ 

WestNile.html, on December 3, 2005 

47 CDC. Anthrax: What You Need To Know. Accessed URL 

at: http://www.bt.cdc.gov/agent/anthrax/needtoknow.asp, 

on December 8, 2005 

48 Cieslak, T.J. and Eitzen EM. Clinical and Epidemiologic 

Principles of Anthrax. Emerging Infectious Diseases 1999; 

5(4): 552-555. 

49 Jernigan, J.A., et al. Bioterrorism-related Inhalational An

thrax: The First 10 Cases Reported in the United States. 

Emerging Infectious Diseases 2001; 7(6): 933-944. 

50 Christopher, G., et al. Biological Warfare: A Historical Perspective. JAMA 1997; 278: 412-417. 

51 Gursky, R.E., et al. Anthrax 2001: Observations on the 

Medical and Public Response. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science 2003; 1(2): 

97-110. 

Harper and Row, 1970. ­

24 Covello, V.T. Risk perception, Risk communication, and 

EMF exposure. Tools and Techniques for Communicating 

Risk Information. In: Matthes R, Bernhardt JH, Repacholi 

MH, ed. Risk Perception, Risk Communication, and Its 

Application to EMF Exposure: Proceedings of the World 

Health Organization/ICNRP International Conference ­

(ICNIRP). Vienna, Austria: International Committee on 

Non-Ionizing Radiation Protection, 1998: 179-214. 

25 McNeil, B.J., et al. On the Elicitation of Preferences for 

Alternative Therapies. New England Journal of Medicine 

1982; 306:1259-1262. 

26 Tan, S.B., et al. Risk Perception is Affected by Modes of 

Risk Presentation among Singaporeans. Annals Academy 

of Medicine 2005; 34(2): 184-187. 

27 Terry, W.S. Serial Position Effects in Recall of Television Commercials. Journal of General Psychology 2005; 

132(2): 151-163. 

­

28 Gupta, P. Primacy and Recency in Non-word Repetition. 

Memory 2005; 13(3-4): 318-324. 

29 Demaree, H.A., et al. Primacy and Recency Effects Found 

Using Affective Word Lists. Cognitive & Behavioral Neurology 2004; 17(2): 102-108. 

30	 The Quotations Page. Quotations from Winston Churchill,	

accessed at the URL: http://www.quotationspage.com/ 

quotes/Sir_Winston_Churchill/, on December 8, 2005 

­

31 Haines, M.M., et al. A Follow-up Study of Effects of 

Chronic Aircraft Noise Exposure on Child Stress Respons

es and Cognition. International Journal of Epidemiology 

2001; 30: 839-845. 

32 Rader, M.H. Dealing With Information Overload. Personnel Journal 1981; 60(5): 373-375. 

33 Mousavi, S.Y., et al. Reducing Cognitive Load by Mixing 

Auditory and Visual Presentation Modes. Journal of Educational Psychology 1995; 87(2): 319-334. 

34 Wicker, F.W., et al. Negative Dominance in Hedonic Integration of Noun-Noun Pairs. Motivation and Emotion 

1979; 3(2): 129-141. 

35 Walhberg, A.A.F. and Sjoberg, L. Risk Perception and the 

Media. Journal of Risk Research 2000; 3(1): 31-50. 

36 Kristiansen, C.M. Newspaper Coverage of Diseases and 

Actual Mortality Rates. European Journal of Social Psychology 1983; 13: 193-194. 

37 Slovic, P. Informing and Educating the Public About Risk. 

Risk Analysis 1986; 6(4): 403-415. 

­

­

42

52 Ingelesby, T.V., et al. Anthrax as a Biological Weapon, 

2002. JAMA 2002; 287(17): 2236-2252. 

53	 CDC:	Emergency	Preparedness	and	Response:	Questions	

and Answers about Anthrax, accessed at the URL: http:// 

www.bt.cdc.gov/agent/anthrax/faq, on December 9, 2005 

54 U.S. Food and Drug Administration (FDA). Project 

Bioshield: Protecting Americans from Terrorism, by Mi

chelle Meadows. Accessed at the URL: http://www.fda. 

gov/fdac/features/2004/604_terror.html, on December 9, 

2005 

55 Brookmeyer, B., et al. Public Health Vaccination Poli

cies for Containing an Anthrax Outbreak. Nature 2004; 

432(7019): 901-4. 

56 CDC Health Advisory: CDC Interim Recommendations 

for Protecting Workers from Exposure to Bacillus anthracis in Work Sites Where Mail is Handled and Processed. 

Distributed via the Health Alert Network on October 21, 

2001. 

57 Smith, H.V. and Rose, J.B. Waterborne Cryptosporidiosis. 

Parasitology Today 1990; 6(1): 8-12. 

58 Fayer, R., and Ungar, B.L.P. Cryptosporidium spp. and 

Cryptosporidiosis. Microbiology Review 1986; 50(4): 458­

83. 

59 Soave, R. and Armstrong, D. Cryptosporidium and Cryp

tosporidiosis. Reviews of Infectious Diseases 1986; 8(6): 

1012-1023. 

60 Nime, F.A., et al. Acute Gastroenteritis in a Human Being 

Infected With the Protozoan Cryptosporidium. Gastroenterology 1976; 70:592-8. 

61 CDC. Outbreak of Cryptosporidiosis Associated with a 

Water Sprinkler Fountain. MMWR 1998; 47(40): 850-860. 

62 William, R., et al. A Massive Outbreak in Milwaukee of 

Cryptosporidium Infection Transmitted Through the Pub

lic Water Supply. New England Journal of Medicine 1994; 

331(3): 161-167. 

63 Rodman, J.S., et al. Pharmaceutical Sales: A Method of 

Disease Surveillance? Environmental Health 1997; 8-14. 

64 Duranek, D.D. Cryptosporidiosis: Sources of Infection and 

Guidelines for Prevention. Division of Parasitic Controls, 

CDC. Accessed at the URL: http://www.cdc.gov/ncidod/ 

dpd/parasites/cryptosporidiosis/crypto_sources_of_infect. 

htm, on December 2, 2005 

65 Meisel, J.L., et al. Overwhelming Watery Diarrhea Asso

ciated With a Cryptosporidium in an Immunosuppressed 

Patient. Gastroenterology 1976; 70(6): 1156-60. 

66 Ferreira, M.S. and Borges, A.S. Some Aspects of Proto

zoan Infections in Immuno-compromised Patients – a Re

view. Memorias do Instituto Oswaldo Cruz 2002; 97(4): 

443-457. 

67 Naomova, E.N., et al. The Elderly and Waterborne Cryp

tosporidium Infection: Gastroenteritis Hospitalizations be

fore and during the 1993 Milwaukee Outbreak. Emerging 

Infectious Diseases 2003; 9(4): 428-425. 

68 CDC’s Fact Sheet: Preventing Cryptosporidiosis: a Guide 

for People with Immunocompromised Individuals, ac

cessed at the URL: http://www.cdc.gov/ncidod/dpd/para

sites/cryptosporidiosis/factsht_crypto_prevent_ci.htm, on 

December 1, 2005 

69 Avery, B.K., et al. Cryptosporidium: a water-borne patho

gen. Accessed at the URL: http://edis.ifas.ufl.edu/SS189, 

on December 9, 2005 

70 New York City Department of Environmental Protection. 

Important Information for Consumers of the New York 

City Croton Water Supply System, accessed at the URL: 

http://www.nyc.gov/html/dep/html/press/crotonpn.html, 

on December 15, 2005 

71 Environmental Protection Agency (EPA). Indoor Air – Ra

don,	Frequent	Questions.	Accessed	at	the	URL:	http://www. 

epa.gov/radon/radonqa1.html, on December 15, 2005 

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