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In most outbreak situations there is a degree of fear, panic and confusion among the affected community members and even among healthcare workers. With viral haemorrhagic fever outbreaks, like Ebola, there is great anxiety because of the associated high death rates. Clear communication from the start of the outbreak helps to reduce myths and rumours that lead to confusion and panic. Direct communication with affected communities, using contextually appropriate modes and methods, can help to correct misunderstandings about the routes of transmission and share information on preventing disease spread. It is also useful to the local authorities (government departments or ministries of health) to have regular, accurate updates and feedback from the affected communities on the situation for planning purposes.
Good communication with the public is very important for sharing accurate information to reduce panic and confusion during a disease outbreak.
The first step in managing any outbreak is to alert all the local stakeholders, e.g. department of health, laboratories, clinicians (doctors/nurses), and community leaders. A small core group of people (the outbreak team) should be formed to plan the investigation and management of the outbreak. The outbreak team may consist of a local government/ministry of health representative, a doctor, a nurse, and a field epidemiologist. Ideally one person should be nominated to act as the local spokesperson to represent the outbreak team and communicate and share important information with other stakeholders.
For an individual facility (e.g. an Ebola Treatment Unit) or the local district’s ministry of health, a list of key stakeholders (usually members of the outbreak team) should be drawn up. These key individuals should meet regularly (ideally daily) to discuss progress and problems encountered during the local outbreak response. Accurate and detailed minutes of these meetings should be kept to allow for reporting and to draw up lists of further actions required for outbreak management. In the event of large and/or multi-country outbreaks (as in the current Ebola outbreak), all the locally collected data on disease cases, contacts and deaths may also need to be shared with other organisations involved in outbreak management, e.g. WHO (the World Health Organisation).
It is absolutely essential to involve the affected communities as soon as possible after confirmation of the outbreak. By working together with community leaders and members, the outbreak team can achieve several aims:
Most communities have formal or informal leadership structures in place. This will vary from place to place but may include multiple individuals or organisations such as:
It may be difficult for an outsider to identify community leaders. By asking a representative number of community members to name their local ‘leaders’ it usually becomes clear which individuals or organisations are respected and trusted in the area. If not, a few simple questions can help, such as, ‘Who do people here go to for advice?’ and ‘When this community has had a problem in the past, which people have helped address it?’ or ‘Who gets things done?’
The most senior member/s of the outbreak team (preferably only one local person, who speaks the language of the area) should approach the community leader/s for help. Local customs for engaging with community leaders should be respected. In some cultures, a small gift (e.g. food) may be customary when visiting local leaders, while in others this may be considered offensive. The outbreak team should aim to convey some key messages and obtain advice from the community leader/s:
Once the community leader/s have agreed to assist, they could potentially help with many outbreak management activities:
Early involvement with integration of the knowledge of the affected community builds trust in the outbreak team. It also provides community leaders and residents with a sense of ‘ownership’ of both the problem and the solution (i.e. by being actively involved in preventing and reducing spread of the disease). In many cases, community members are also more likely to understand and accept disease prevention methods (e.g. safe burials) if the recommendation comes from a respected local leader.
Aside from using local leadership structures and word of mouth, the following mediums should be considered to share important health messages regarding the outbreak:
All available forms of media should be used to share important health messages.
Traditional burial practices in some West African countries involve washing and touching of the corpse by family members and people attending the burial. This traditional practice has been linked to many cases of Ebola transmission and is thought to play a major role in spreading Ebola. In order to avoid this risk, healthcare workers and ministries of health are trying to encourage communities to practise so-called ‘safe burials’. A safe burial is a burial with special precautions taken to prevent the spread of Ebola. This concept is at odds with social and cultural rituals, and so the procedure should be clearly explained to the community and affected family members, by the community leader/s with reinforcement by health promoters and other community health workers.
The following key messages should be communicated (through multiple channels) regarding the safe burial of suspected or confirmed Ebola deaths:
It is very important to persuade communities to practise safe burials.
The main challenges of community involvement may include:
For diseases like Ebola, there is serious stigmatisation of individuals and families infected or affected by Ebola. Ebola survivors returning to their communities may be shunned or even chased away by community members, who do not understand disease transmission. On discharge, Ebola survivors should be accompanied home by a healthcare worker (or community health worker/health promoter) to explain to the family/community that they are no longer infectious. It is often helpful for the community to witness the healthcare worker shaking hands or hugging the survivor, and even for the survivor to be given a certificate stating they are cured. Most Ebola survivors will need ongoing care and support in the weeks following discharge to ensure food security, provide psychological support and establish successful re-integration into the community. In some cases, Ebola survivors have been recruited to help with:
Community education about Ebola is an important way to reduce or avoid stigma.
A small rural village in Guinea has been affected by the Ebola outbreak, with several community members reportedly becoming infected and dying after participating in the traditional burial rites for a person who died from Ebola. The nearby Ebola Treatment Unit sends an outbreak team to investigate the deaths and meet with community leaders.
The outbreak team may consist of a local government/ministry of health representative, a doctor, a nurse, and a field epidemiologist. The most senior member/s of the outbreak team (preferably a local person, who speaks the language of the area) should approach the community leader/s for help.
They should find out from local community members who the main respected and trusted ‘leaders’ are in the village. They should check if there are local customs for engaging with community leaders. In some cultures, a small gift (e.g. food) may be customary when visiting local leaders, while in others this may be considered offensive. The outbreak team should approach the village leader/s humbly and respectfully, and be willing to both share and receive advice on how best to deal with the outbreak. They should be prepared to discuss and dispel rumours about the outbreak by sharing information about the outbreak with the community honestly and often.
The outbreak team should aim to convey some key messages and obtain advice from the community leader/s regarding:
The following key messages should be communicated regarding suspected or confirmed Ebola deaths: