file

RESEARCH ARTICLE
Integrating emergency risk communication

(ERC) into the public health system response:
Systematic review of literature to aid
formulation of the 2017 WHO Guideline for
ERC policy and practice
Ayan Jha ID1, Leesa Lin1, Sarah Massin Short1, Giorgia Argentini1, Gaya Gamhewage2,
a1111111111 Elena Savoia1,3*
a1111111111
1 Emergency Preparedness, Research, Evaluation & Practice (EPREP) program, Division of Policy
a1111111111
Translation & Leadership Development, Harvard T. H. Chan School of Public Health, Boston, MA, United
a1111111111 States of America, 2 Interventions and Guidance, Infectious Hazard Management, Health Emergencies
a1111111111 Programme, World Health Organization, Genève, Switzerland, 3 Department of Biostatistics, Harvard T. H.
Chan School of Public Health, Boston, MA, United States of America
* esavoia@hsph.harvard.edu
OPEN ACCESS
Citation: Jha A, Lin L, Short SM, Argentini G, Abstract

Gamhewage G, Savoia E (2018) Integrating
emergency risk communication (ERC) into the The World Health Organization (WHO) commissioned a systematic review of literature to
public health system response: Systematic review facilitate evidence syntheses for the development of emergency risk communication (ERC)
of literature to aid formulation of the 2017 WHO
guidelines for its member states. The goal of this review was to integrate ERC best practices
Guideline for ERC policy and practice. PLoS ONE
13(10): e0205555. https://doi.org/10.1371/journal. into governmental and non-governmental health systems for all emergencies of public
pone.0205555 health concern, by addressing three questions: (1) to identify best practices for the integra-
Editor: Aram Dobalian, University of Memphis, tion of ERC into national and international public health preparedness; (2) to identify mecha-
UNITED STATES nisms to establish effective intra-agency, inter-agency, and/or cross-jurisdictional
Received: July 23, 2017 information sharing; and (3) to identify methods to coordinate risk communication activities
between responding agencies across organizations and levels of response. The review cov-
Accepted: September 28, 2018
ered scientific and grey literature publications between January 2003 and February 2016,
Published: October 31, 2018
and searches were conducted in 17 English language electronic libraries besides Chinese,
Copyright: © 2018 Jha et al. This is an open access Portuguese and Spanish language databases. A mixed deductive-inductive process was
article distributed under the terms of the Creative
used to synthesize findings across studies through identifying thematic areas. While 8,215
Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in articles were initially retrieved, after a sequential screening process, the final evidence syn-
any medium, provided the original author and theses comprised of 21 articles for question (1) and 24 for questions (2) and (3) combined
source are credited. (due to overlap of themes). The confidence in findings was assessed by the Qualitative Evi-
Data Availability Statement: All relevant data are dence Syntheses (GRADE-CERQual) tool. PRISMA guidelines were followed to the extent
within the paper and its Supporting Information possible given the limitations inherent to a review largely based on qualitative studies. The
files. The data is also available with WHO and has
identified literature was very context-specific and referred to mechanisms, practices from
been cited in text.
the field, and recommendations that were derived from planning or response efforts imple-
Funding: This manuscript is based on the report
mented at the national or local levels in specific countries. Integration of ERC functions into
developed by the Division of Policy Translation and
Leadership Development under Contract Number public health emergency preparedness, planning and response activities was influenced by
201400531: Evidence Syntheses to support the reforming components of the leadership structure when needed, modifying organizational
World Health Organization (WHO) Guidelines on
PLOS ONE | https://doi.org/10.1371/journal.pone.0205555 October 31, 2018 1 / 23

ERC in public health emergencies
Emergency Risk Communication, Department of factors, and nullifying restrictions (including amending laws/ regulations) that might have
Communications, Office of the Director-General, been an obstacle to the timely release of information. Exercises and trainings were recog-
World Health Organization. ES was the project PI
and received funding from the WHO. The WHO
nized as effective strategies to identify the barriers and successes in this process of integra-
(funder) was involved in expert advisory capacity in tion. Key elements to enhance information sharing and coordination across organizations
the methodology, quality assessment and overall included the creation of networks, task-forces and committees across disciplines, organiza-
conduct of this systematic review.
tions and geographic areas. Engagement of local stakeholders was also important to guar-
Competing interests: The authors have declared antee the flow of information up and down the incident command system. On the whole, few
that no competing interests exist.
empirical studies, especially from low- and middle-income countries, related to the WHO
research questions, demonstrating the need for research in these areas. To facilitate an
accurate identification of the gaps, the authors suggest integrating current findings with
case studies across the WHO regions to better understand the specific evidence that is
needed in practice across the multitude of ERC functions.
Introduction
Emergency risk communications (ERC) consist of "the real-time exchange of information,
advice and opinions" between decision-makers, experts and the general public. [1] Over the
last decade, nations have increasingly faced challenges in acquiring, processing and communi-
cating information to protect the physical, social and economic wellbeing of their citizens dur-
ing emergency situations. This challenge is in part due to the lack of evidence on how to best
communicate among responding agencies and with the public. [2]
ERC is one of the eight core functions that World Health Organization (WHO) member
states are required to fulfill as part of the International Health Regulations (IHR) [3]. All types
of public health emergencies, ranging from infectious diseases outbreaks and pandemics to
weather related events and manmade disasters, present national leaders with the challenge of
communicating risk to the affected populations while maintaining trust, transparency and
consistency of messages. While there are existing best practices and training in the field of
ERC, there are few comprehensive, evidence-based, systems-focused principles and guidelines
to support its practice. In response to this need, and recognizing that access to information is a
fundamental right of an affected population, the WHO established a Guideline Development
Group (GDG) in 2015 to steer the development of guidance on ERC for its member states. [4]
This guideline has been recently published by the WHO, and provides advice and direction on
how member states can integrate the best practices of risk communication into critical govern-
mental and non-governmental health systems for all emergencies of public health concern
(natural/man-made disasters, infectious disease epidemics/pandemics, and terrorism). [5]
The WHO commissioned the Emergency Preparedness, Research, Evaluation and Practice
(EPREP) program at the Harvard T.H. Chan School of Public Health to conduct a systematic
review of literature to facilitate evidence syntheses for the development of ERC guidelines for
its member states (the full report has been made available by the WHO). [6] The goal of this
review was to integrate ERC best practices into governmental and non-governmental health
systems for all emergencies of public health concern, by addressing three questions: (1) to
identify best practices for the integration of ERC into national and international public health
preparedness; (2) to identify mechanisms to establish effective intra-agency, inter-agency, and/
or cross-jurisdictional (such as cross-border; national with sub-national jurisdictions, etc.)
information sharing; and (3) to identify methods to coordinate risk communication activities
between responding agencies across organizations and levels of response. It was envisaged that

answering these questions would facilitate the integration of knowledge regarding the effec-
tiveness of ERC practices and structures into the WHO guideline development process.
Recognizing that the evidence answering these questions was more likely to be qualitative
or mixed-methods research, the WHO developed the "Setting, Perspective, phenomenon of
Interest, Comparison, Evaluation of impact" (SPICE) format to facilitate the interpretation of
these questions and guide development of search terminology. The detailed breakdown of the
SPICE format for each question is provided in the published WHO Guideline. [5]
Methods
Evidence acquisition
The review was primarily conducted for all scientific and grey literature in English, Chinese,
Portuguese and Spanish language databases, between January 1, 2003 and February 7–9, 2016
(specific dates mentioned with the list of databases in Tables 1–3). Fourteen scientific and
Table 1. Detailed search strategies for English language scientific databases.

Source Search Strategy
1. Medline (PubMed) ("Disaster Planning"[mesh] OR "Civil Defense"[majr] OR "Disasters"[mesh] OR "Disease Outbreaks"[Mesh] OR
February 7, 2016 pandemic� [tiab] OR epidemic� [tiab] OR outbreak� [tiab] OR disaster� [tiab] OR emergency planning[tiab] OR
emergency preparedness[tiab]) OR "preparedness"[tiab] OR "mitigation"[tiab] OR "influenza, human"[mesh] OR
"ebola"[tiab] OR "terrorism"[mesh] OR "floods"[tiab] OR "earthquake"[tiab] OR "hurricane"[tiab] OR "cyclone"[tiab]
AND ("Communication"[Mesh] OR communication� [tiab]) AND ("Risk"[mesh] OR "Risk Reduction Behavior"[mesh]
OR "Risk Management"[mesh] OR risk[tiab]) AND ("2003/01/01"[PDAT]: "3000/12/31"[PDAT])
2. Cochrane Databases Cochrane Central Register of Controlled Trials: Issue 1 of 12, January 2016
February 7, 2016 Publication Year from 2003 to 2016, in Cochrane Reviews (Reviews and Protocol), Other Reviews, Trials,
Methods Studies, Technology Assessments, Cochrane Groups (0)
Title, Abstract, Keywords:
Disaster AND communication
Outbreak AND communication
Epidemic AND Communication
Pandemic AND Communication
Preparedness AND communication
Terrorism AND communication
3. PDQ-Evidence ("Disaster Planning" OR "Disease Outbreaks" OR pandemic OR epidemic OR outbreak OR disaster OR emergency
February 7, 2016 planning OR emergency preparedness OR preparedness OR mitigation OR influenza OR
Ebola OR terrorism OR flood OR earthquake OR hurricane OR cyclone) AND (communication) AND (Risk OR "Risk
Reduction Behavior" OR "Risk Management")
In: Title or Abstract
Year: 2003–2016
4. WHO Global Health Library ("Disaster Planning" OR "Disease Outbreaks" OR pandemic OR epidemic OR outbreak OR disaster OR. emergency
February 8, 2016 planning OR emergency preparedness OR preparedness OR mitigation OR influenza OR Ebola OR terrorism OR flood
OR earthquake OR hurricane OR cyclone) AND (communication) AND (Risk OR "Risk Reduction Behavior" OR "Risk
Management")
In: Title, Abstract, Subject;
EXCLUDE MEDLINE
(1056 searches); 2003 -present
5. Social Sciences Research Network Search by Title, Abstract, Abstract ID & Keywords; All dates; All SSRN Networks
(SSRN) 1.Disaster >> communication (search within results for Disaster search)
February 8, 2016 2. Hazard >> communication
3. Pandemic >> communication
4. Epidemic >> communication
5. Outbreak >> communication
6. Preparedness >> communication
7. Terrorism >> communication
(Continued )

Table 1. (Continued)

6. Embase (’disaster planning’/exp OR ’civil defense’/exp OR ’disaster’/exp OR ’epidemic’/exp OR ’pandemic’/exp OR outbreak� :
February 8, 2016 ab,ti OR disaster� :ab,ti OR ’emergency planning’: ab,ti OR epidemic� :ab,ti OR pandemic� :ab,ti OR ’emergency
preparedness’: ab,ti) AND (’interpersonal communication’/exp OR ’medical information’/exp OR communication� : ab,
ti) AND (’risk’/exp OR risk: ab,ti) AND [embase]/lim AND [2003–2016]/py
7. CINAHL MH ("Disasters+" OR "Civil Defense" OR "Disease Outbreaks") OR TI (outbreak� OR epidemic� OR pandemic� OR
February 8, 2016 disaster� OR "emergency planning" OR "emergency preparedness") OR AB (outbreak� OR epidemic� OR pandemic�
OR disaster� OR "emergency planning" OR "emergency preparedness")
AND
MH ("Communication") OR TI (communication) OR AB (communication)
AND
MH ("Risk Management") OR TI (risk) OR AB (risk)
2003–2016
8. PsycINFO DE ("Emergency Preparedness" OR DE "Disasters" OR "Natural Disasters" OR "Epidemics" OR "Pandemics") OR TI
February 8, 2016 (outbreak� OR epidemic� OR pandemic� OR disaster � OR "emergency planning" OR "emergency preparedness") OR
AB (outbreak� OR epidemic� OR pandemic � OR disaster� OR "emergency planning" OR "emergency preparedness")
AND
DE ("Communication" OR "Electronic Communication" OR "Interpersonal Communication" OR "Communications
Media" OR "Mass Media" OR "Multimedia" OR "Social Media" OR "Telecommunications Media") OR TI
(communication) OR AB (communication)
AND
DE ("Risk Management") OR TI (risk) OR AB (risk)
Dates: 2003–2016
9. Communication Abstracts TX (outbreak� OR disaster� OR epidemic� OR pandemic� OR "emergency planning" OR "emergency preparedness")
February 8, 2016 AND TX (risk)
10. ERIC DE ("Natural Disasters" OR "Emergency Programs" OR "Civil Defense") OR TI (outbreak� OR epidemic� OR
February 8, 2016 pandemic� OR disaster� OR "emergency planning" OR "emergency preparedness") OR AB (outbreak� OR epidemic�
OR pandemic� OR disaster� OR "emergency planning" OR "emergency preparedness")
AND
DE ("Organizational Communication" OR "Communication (Thought Transfer)" OR "Communication Strategies" OR
"Computer Mediated Communication") OR TI (communication) OR AB (communication)
AND
DE ("Risk" OR "Risk Management") OR TI (risk) OR AB (risk)
11. Applied Social Sciences Index and SU.EXACT("Avalanches" OR "Cyclones" OR "Disasters" OR "Drought" OR "Earthquakes" OR "Ecological disasters" OR
Abstracts (ASSIA) "Famine" OR "Firestorms" OR "Floods" OR "Hurricanes" OR "Natural disasters" OR "Tornadoes" OR "Volcanoes" OR
February 8, 2016 "Disaster management") OR ti (outbreak� OR epidemic� OR
pandemic� OR disaster� OR "emergency planning" OR "emergency preparedness") OR ab(outbreak� OR epidemic� OR
pandemic� OR disaster� OR "emergency planning" OR "emergency preparedness")
AND
SU.EXACT("Communication" OR "Risk communication") OR ti(communication) OR ab(communication)
AND
SU.EXACT("Risk communication" OR "Risk management") OR ti(risk) OR ab(risk)
Dates: 2003–2016
12. Sociological Abstracts SU.EXACT("Disasters" OR "Natural Disasters" OR "Disaster Preparedness" OR "Epidemics") OR ti(outbreak� OR
February 9, 2016 epidemic� OR pandemic� OR disaster� OR "emergency planning" OR "emergency preparedness") OR ab(outbreak� OR
epidemic� OR pandemic� OR disaster� OR "emergency planning" OR "emergency preparedness") AND SU.EXACT
("Organizational Communication" OR "Communication" OR "Computer Mediated
Communication" OR "Publicity") OR ti(communication) OR ab(communication) AND SU.EXACT("Risk") OR ti(risk)
OR ab(risk)
Dates: 2003–2016
13. Web of Science Indexes = SCI-EXPANDED, SSCI, A&HCI, CPCI-S, CPCI-SSH, BKCI-S, ESCI Timespan = 2003–2016
February 9, 2016 TS = ("outbreak� " OR "epidemic� " OR "pandemic� " OR "disaster� " OR "emergency planning" OR "emergency
preparedness")
AND
TS = (communication)
AND
TS = (risk)
14. Russian Academy of Sciences TX (outbreak� OR disaster� OR epidemic� OR pandemic� OR "emergency planning" OR "emergency preparedness")
Bibliographies AND
February 9, 2016 TX (communication� )
https://doi.org/10.1371/journal.pone.0205555.t001

Table 2. Detailed search strategies for English language grey literature databases.
1. Bielefeld Academic Search Title search; Year: 2003–2016; Books/articles/journals/reports/papers/lectures/
Engine theses/reviews/primary
February 8, 2016 data
Disaster AND communication
Outbreak AND communication
Epidemic & Communication
Pandemic & Communication
Preparedness AND communication
Terrorism AND communication
2. PAIS International SU.EXACT("Disasters" OR "Natural Disasters" OR "Disaster Preparedness" OR
February 8, 2016 "Epidemics") OR ti(outbreak� OR epidemic� OR pandemic� OR disaster� OR
"emergency planning" OR "emergency preparedness") OR ab(outbreak� OR
epidemic� OR pandemic� OR disaster� OR "emergency planning" OR "emergency
preparedness")
AND
SU.EXACT("Risk Communication" OR "Communication" OR "Computer
Mediated Communication" OR "Publicity") OR ti(communication) OR ab
(communication)
AND
SU.EXACT("Risk" OR "Risk Communication") OR ti(risk) OR ab(risk)
Date: 2003–2016
3. Policy File risk communication disaster�
February 9, 2016 risk communication epidemic�
risk communication outbreak�
risk communication "emergency planning"
risk communication "emergency preparedness"
subject(crisis management) keyword "risk communication"
Table 3. Detailed search strategies for Chinese/Mandarin, Portuguese and Spanish language databases.
Chinese/ Mandarin: 主题=(风险+危机+应急+重大灾害+埃博拉+甲型流感+SARS+非典+非
1. China Academic Journals Full- 典型肺炎+公共危机+风灾+巨灾+中东呼吸综合症+地震+流感+雪+水
text Database +旱+涝+洪+ 突发公共卫生事件+突发公共事件+风险传播+风险沟通+风
2. China National Knowledge 险信息+危机传播+危机沟通+危机信息+应急传播+应急沟通)� (传播+沟
Infrastructure (CNKI) 通)并且关键词=(突发公共卫生事件+突发公共事件+风险传播+风险沟
February 9, 2016 通+风险信息+危机传播+危机沟通+危机信息+应急传播+应急沟通)-高
校-血-医患-护理-金融-生态-药-信息安全-保险-浅谈-论述-概述-品牌-
HIV-急诊-急救-个人信息-sex 并且年=(2016+2015+2014+2013+2012
+2011+2010+2009+2008+2007+2006+2005+2004+2003) (精确匹配),
Subjects: 预防医学与卫生学,感染性疾病及传染病,急救医学,公安行政
工作,交通管理,社会科学理论与方法,新闻与传媒,图书情报与数字图书
馆,市场研究与信息,管理学,领导学与决策学;No sorting;
Search mode: Single-database search
Portuguese: a) NATURAL DISASTERS AND RISK COMUNICATION (DESASTRES

1. LILACS/SCielo NATURAIS E COMUNICACAO)
2. Mirage—Fiocruz b) EPIDEMICS/PANDEMICS AND RISK COMUNICATION (EPIDEMIAS
February 9, 2016 E COMUNICACO DO RISCO)
c) MASS EVENTS AND COMUNICATION OF RISK (EVENTOS DE
MASSA E COMUNICACAO DO RISCO)
d) OLIMPICS AND FOOTBALL WORLD CHAMPIONSHIP AND RISK
COMUNICATION
Spanish: “Epidemias y pandemias y desastres naturales y grandes eventos y
REDYLAC/SCielo comunicación del riesgo desde el 2003 Liliacs y Scielo"
February 9, 2016
The Portuguese and Spanish search engines cited above did not allow for the use of a complex search string, such as
the one used in Medline. Therefore, multiple search strings had to be used, as described above

three grey literature English language electronic libraries were searched, and specific searches
were carried out for publications in Chinese ("China Academic Journals Full-text" and "China
National Knowledge Infrastructure" databases), Portuguese ("LILACS/SCielo" and "Mirage—
Fiocruz" databases) and Spanish ("REDYLAC/SCielo" database). Manual cross-referencing of
articles judged to be relevant to the questions of interest was also conducted for additional
publications.
Since a key objective was to look for evidence in the low and middle-income countries, the
search strategies in all global databases (like PubMed, Cochrane, WHO Library etc.) were
expanded to also include publications in Arabic, French, Russian, Italian and Japanese, besides
the above-mentioned languages (these additional languages were selected on the basis of lin-
guistic expertise available to the researchers). The web pages of a number of governmental and
non-governmental public health agencies from French, Spanish, and Portuguese speaking
countries, as well as Italy (as the major Italian-speaking nation) were screened. The research
team also communicated with several risk communication experts and academics across USA,
Europe (England, Germany, Switzerland, members of European CDC), Asia (India, China,
Japan, Bangladesh, Vietnam), Latin America (Portugal, Argentina) and the Middle East (Qatar)
to substantiate the understanding of systemic gaps and political-cultural sensibilities in ERC, as
well as to request guidance to find region-specific publications related to the WHO questions.
The articles retrieved from the initial search (n = 8,215) were independently screened by AJ
and SS for English language articles (including English language abstracts of articles in Japa-
nese and German), LL for Chinese articles, ES for Italian language articles, and GA and ES for
Spanish and Portuguese language articles. No articles published in Arabic, French or Russian
languages were identified, though it was possible that the English language abstract of such an
article was included among those retrieved from the global databases. The detailed search
strategies for English, Chinese, Portuguese and Spanish language databases are provided in
Tables 1–3.
In the title review phase, the authors specifically screened for articles including the terms
"communication" or related words (risk/ crisis communication) along with an event of interest
like any natural or man-made disaster, any infectious disease outbreak or epidemic or pan-
demic, or any event of terrorism (or simulation studies on these scenarios). Articles were also
included if the terms "risk management,” "preparedness," "preparedness exercise," or “knowl-
edge” were mentioned in the title. In the next phase, the researchers evaluated 1899 abstracts
to include only: (i) research based on an empirical study [results/recommendations based
on some observation or experiment]; and (ii) research directly or indirectly providing infor-
mation to address at least one of the three WHO questions. This screening ensured that only
articles which clearly violated the above criteria were excluded. Subsequently, 880 full-text arti-
cles were reviewed to determine eligibility for inclusion based on the assessment that they
addressed components of the WHO SPICE breakdown, the details of which can be found in
the published WHO Guidelines (Annex 3: SPICE questions #1, 2 and 6). [5]
To determine if the research was addressing the WHO questions, two reviewers indepen-
dently read the article (with the exception of articles in Chinese language), and based on the
SPICE breakdown identified sentences (in the article) supported by empirical data that would
provide information which directly answered a WHO question or was related to the question
(indirectly answered the question). Subsequently the two reviewers met to discuss their judg-
ment, and in case of disagreement a third reviewer was consulted. Furthermore all articles
deemed to be indirectly related were discussed with the WHO team to make sure the informa-
tion was related to the questions developed by WHO.
Categorization of articles. Study title, first author, year of publication, type of publication
(i.e. journal article, organizational report etc.), country/ region of the study, study design (i.e.

qualitative, quantitative, mixed-methods or case study, with subtypes as applicable), popula-

tion/sample studied or addressed (i.e. general population, affected/ vulnerable groups, stake-
holders etc . . .), the type of disaster/crisis situation described and the phase of disaster (i.e.
prevention, preparedness, response, recovery/rehabilitation) addressed were listed. The objec-
tives of each study were noted, and the key topic area and principal findings and/or recom-
mendations were carefully described. The relevance of an article to one or more of the WHO
questions under consideration was critically judged and differences in opinion were resolved
through consultations (as described earlier).
An article was defined to be "directly relevant" to a specific WHO question if: (1) it had an
empirical study design, and (2) the findings and/or recommendations directly answered that
particular WHO question. If an article did not satisfy both these criteria, it was coded as "indi-
rectly relevant" and not included in the final evidence synthesis.
Methods of evidence synthesis

Four methodological streams were identified to classify and characterize the selected articles:
1) quantitative (randomized group comparison, non-randomized group comparison and
descriptive surveys), 2) qualitative (interviews, focus groups and textual/content analysis), 3)
mixed-methods (use of both quantitative and qualitative techniques) and 4) case studies
(description of the response to a particular emergency/crisis situation). The literature was then
synthesized using the Best Fit Framework Synthesis described by Booth et al. [7] and Barnett-
Page [8], which involves searching for existing theories/conceptual frameworks and creating a
composite framework describing findings within each theme/concept. A mixed deductive-
inductive process was used to synthesize findings across studies, starting with the SPICE com-
ponents for each WHO question to develop the themes, and subsequently adding more the-
matic areas based on the literature.
For question 1, the syntheses of evidence is presented separately for English (n = 6) and
Chinese language (n = 15) publications because of the different types of studies included in the
two languages and difficulties in merging concepts and themes between the two. However,
integration of the themes in a unified synthesis among articles in the two aforementioned lan-
guages was possible for questions 2 and 3, and therefore the evidence syntheses for these two
questions (all language publications) have been presented together.
Quality assessment of the evidence

A number of tools were applied to assess the quality of each study based on the methodology
and study design: the Critical Appraisal Skills Program (CASP) tools were used to assess cohort
studies and qualitative studies (including content analysis) [9], the Mixed Methods Appraisal
Tool (MMAT) for studies using mixed methods [10], the Cochrane risk of bias tool for ran-
domized interventional studies [11], the AMSTAR evaluation for systematic reviews [12], and
the critical appraisal checklist for studies including surveys (The BMJ, Table E) [13]. Subse-
quently, confidence in findings was assessed by the use of the Qualitative Evidence Syntheses
(GRADE-CERQual) tool, and a level of confidence was assigned to each study (high/ moder-
ate/ low/ very low) based on methodological limitations, relevance, coherence and adequacy of
data [14]. The GRADE-CERQual assessment was completed both for individual articles (S1–
S3 Tables) and for the syntheses of findings derived from multiple articles within each WHO
question (Tables 4–6). GRADE principles were adapted for application to descriptive quantita-
tive studies and GRADE CERQual principles were applied to mixed-method studies. Neither
adaptation has been approved by the tool originators. Please refer to the WHO Guideline for
ERC policy and practice 2017 [5] for details.

Table 4. Synthesis of findings across methodological streams–Question 1, English language literature.

Thematic area of Synthesis of findings Citations CERQual assessment
practice of confidence in
evidence
Placement of ERC Renovations of existing organizational structures or creation of new ones are sometimes needed to Yen (2009) Moderate
Functions in achieve a better placement of ERC functions in the national leadership structure. As reported by Hanvoravongchai (Evidence from both
National Leadership Yen et al (2009), following the SARS outbreak, the Taipei City Government initiated a new public (2010) studies was
Structure health plan using an integrated infection control system against emerging infectious diseases individually
(EID). This new system integrated early detection of outbreaks (particularly in hospitals and evaluated to be of
schools), epidemiological investigation, and epidemiologically based public health prevention and moderate confidence
control policies. The renovated Division of Disease Control and Prevention (Taipei’s CDC) also level, with minor
became the core operational unit for implementing crisis management procedures and facilitating concerns on
policy. These systematic upgrades allowed Taipei’s CDC to quickly implement its Multi-Channel methodology and
Mass Risk Communication Program during the 2007 outbreak of Acute Hemorrhagic adequacy of data)
Conjunctivitis. As reported by Hanvoravongchai et al (2010) the integration of national leadership
into public health emergency preparedness planning and response activities in response to
pandemic influenza can be seen through the participation of presidents or prime ministers on
pandemic preparedness committees. In well-established health systems, pandemic preparedness is
integrated within existing mechanisms, notably within the national disaster preparedness
framework. In countries with a weak healthcare system, vertical programs are established to
manage and coordinate pandemic preparedness and response.
Organizational Organizational factors and restrictions need to be modified to facilitate timely release of Cope (2014) Moderate
Proximity of ERC information. Cope et al (2014) noted that a prominent issue in the People’s Republic of China was Chambers (2012) (Evidence from both
Practitioners to the inability of certain departments to release information, a restriction that was noted across studies was
National Health departments and throughout the chain of command, from the local level through to the provincial individually
Leadership and the national levels. The authors recommend increasing the freedom each department has to evaluated to be of
Response release relevant information, which has been reasonably verified, as a way to improve the system. moderate confidence
The broader issue regarding restrictions on how information can be released directly ties into level, with minor
concerns about the timely release of information. Chambers et al (2012) described how during concerns on
pandemic influenza in the UK, the only formal communication channel ‘up the chain of methodology and
command’ was indirect, run through the regional Health Protection Agency (HPA) (Chambers adequacy of data)
et al 2012). The failure to allow information from the frontline to feed up the channels to national
level decision making presented an issue. The UK relied on the Health Protection Agency, a quasi-
independent agency, to lead, coordinate and manage the operational response at the local level—a
role for which it was ill-equipped, given that its main mission is to provide disease surveillance and
epidemiological advice at the national and local levels.
Development of Laws, regulations and frameworks contribute to define the context in which ERC functions and Yen (2009) Moderate
Laws, Regulations, strategies are implemented. In some circumstances amendments may be necessary to facilitate Lam (2008) (Evidence from three
Policies & such functions. Yen et al (2009) report on Taipei’s ability to launch a large-scale SMS campaign as Cope (2014) studies was
Frameworks in a direct result of Taiwan’s Communicable Disease Act (2006). This act allowed government Ikeda (2011) individually
Support of ERC officials to override the people’s right to privacy when responding to epidemic disasters. In this evaluated to be of
Efforts case, the Taipei city government held a contract with Taiwan’s six major mobile phone companies, moderate confidence
which committed them to six free public service messages (per year) to be sent to their users, if level, with minor
deemed necessary by the proper authorities. Lam et al (2008) describe an important achievement concerns on
of the Hong Kong Special Administrative Region Government (HKSARG) when, in 2005, they methodology (Yen,
signed a Cooperation Agreement on Response Mechanism for Public Health Emergencies with the Cope), adequacy of
Mainland Ministry of Health and Macao Health Bureau. Under this Cooperation Agreement, data (Yen, Ikeda) and
when a cross-boundary public health emergency occurs, the Mainland, Hong Kong and Macao coherence (Cope).
forms a joint emergency response group to facilitate sharing of intelligence and expertise. Cope Evidence from one
et al (2014) recommend the need for amendments to the infectious diseases prevention and study (Lam) was
control law of the People’s Republic of China to authorize more freedom for provincial and local evaluated to be of low
public health agencies to release information. This would enhance the ability of local public health confidence level with
agencies to release information and improve risk communications, thereby addressing the barrier significant concerns
in the release of critical health information, reported by many agencies. Ikeda et al (2011) describe on methodology and
a framework of disaster risk governance presented as an implementation strategy for integrated adequacy of data)
risk management that incorporates innovative local coping capabilities that reduce disaster
vulnerability. The framework is supported by a societal platform of disaster risk information called
DRIP, developed in 2006 by the National Research Institute for Earth Science and Disaster
Prevention in Japan as a tool for promoting improved disaster risk governance. DRIP is a societal
platform of disaster risk information that works as a clearinghouse, collecting and disseminating
scientific expertise on risk information from various disaster prevention organizations, fire
brigades, and research institutions.
(Continued )

Thematic area of Synthesis of findings Citations CERQual assessment

practice of confidence in
evidence
Emergency Risk Exercises and training can be conducted to identify barriers and successes in the integration of Lam (2008) Moderate
Communication ERC functions into national and international public health emergency preparedness planning and Hanvoravongchai (Evidence from both
Training/ Exercises response. For example, after the Hong Kong Special Administrative Region Government et al (2010) studies was
to enhance ERC (HKSARG) updated their pandemic preparedness plan, they took part in the 2006 APEC individually
integration Pandemic Response Exercise, which tested communications channels to ensure preparedness evaluated to be of
across Asia-Pacific Economic Cooperation economies in response to emergencies (Lam et al 2008). moderate confidence
Hanvoravongchai et al (2010) describes a number of simulation exercises, mostly tabletop level, with minor
exercises, where officers discuss and manage a hypothetical pandemic situation in a round-table concerns on
manner. For example, Thailand had at least one table-top exercise at both the central level and in methodology and
each province. Vietnam has conducted many simulations for AHI preparedness at national, adequacy of data)
provincial and district levels, as well as at airports and borders. There were also a few regional
(multi-country) table-top exercises coordinated by the World Health Organization, and one table-
top exercise by the Mekong Basin Disease Surveillance Network (MBDS). Only Indonesia and
Taiwan performed full-scale exercises involving real field activities. Indonesia’s full-scale exercise,
in Bali during April, 2008, was the first of its kind in the world. Most exercises reveal that
management and coordination between various players, including non-health sector players,
constitutes a major weakness in preparedness.
Table 5. Synthesis of findings across methodological streams–Question 1, Chinese/ Mandarin literature.

Thematic area of practice Synthesis of findings Citations CERQual assessment
of confidence in
evidence
Utilization of Government These studies discuss how most Chinese government Chen et al, 2013; Chen et al, 2014; Liu et al., 2013; Moderate
Service “Weibo”, for ERC agencies use the micro blog “Weibo,” Chinese twitter, The People’s Public Opinion Monitoring Office (Limited details on
for public communication during normal times and and Weibo Data Center, 2012–2016; Zeng et al, survey items, process,
public health emergencies such as H1N1, H7N9, 2015; Zhang XE et al, 2015; Zhou et al, 2015 and analysis)
terrorist attacks, and the recent Ya’An earthquake, with
the goals of achieving timely, open, two-way
communications, monitoring public opinion,
controlling rumors, addressing public concern, and
improving government services. To effectively control
online rumors, swift response is needed by releasing
official counter-messages and by working with the
police to identify and penalize the sources of rumors,
and by assessing the effectiveness of these
countermeasures by continuing monitoring Weibo.
There might be potential for social media surveillance
to be incorporated into mainstream disease surveillance
and response systems. There has been an ongoing
national effort to expand the use of government Weibo
across the country and to establish a standardized
operation, training and evaluation mechanism for
Chinese government’s Weibo use and service
performance.
Since 2012, People’s Public Opinion Monitoring Office
and Weibo Data Center have routinely published
performance evaluation and best practices on official
microblogs (Weibo) of all levels of the Chinese
government. Guidelines and regulations on
government micro blogging have been developed by
central and local governments and service providers
(e.g. Government Micro blogging Operation
Guidelines] by Sina Corporation, and “Autonomous
Region Government Guidelines on Micro blog Use and
Management” by XinJing.) Reports on government
micro blog use and case studies on lessons learned and
best practices have been developed and are
disseminated on a biannual basis.
(Continued )

Thematic area of practice Synthesis of findings Citations CERQual assessment

of confidence in
evidence
Collaboration between the These studies examine collaboration between the US Hao et al, 2009; Ma, 2010; Shao et al, 2014; Song Moderate
US and Chinese CDCs CDC and China’s CDC to enhance the China’s efforts et al, 2016; Xie et al, 2011; Zhang et al, 2011 (Limited details on
towards building ERC capacity and integrating ERC survey items, process,
into public health emergency preparedness activities. and analysis)
China’s CDC has conducted assessments of ERC
capacity and needs at local public health agencies, and
identified barriers and possible solutions. Training
materials have been created and tested among local
CDC staff. It was found that there was a demonstrated
need to develop an official ERC guideline by
conducting needs assessments and reviews of the laws
and regulation that guide the work of ERC (Hao, 2009,
Ma, 2010; Zhang, 2011). Chinese public health
professionals have been developing and revising the
ERC guidelines and integrating them into current
emergency preparedness plans.
Integration of national These studies look at 12320, the only official health Jiang et al, 2012; Wang et al, 2010; Zhang XE et al, Moderate
health hotline into hotline in China set up by China’s MoH. 12320 has 2015 (Limited details on
emergency preparedness been integrated into the emergency response system survey items, process,
system and tested as an important channel of communication and analysis)
during the 2008 formula contamination crisis, the 2008
Beijing Olympics, the 2009 A(H1N1) pandemic, and
the recent measles campaign. As a direct two-way
communication channel between the government and
the public, 12320 was considered a trusted channel of
communication by the public. It offered health
consultation directly to the public, acted as an
important emergency risk communications agent and
had taken on the role of gathering public reaction data.
It has been highly valued by China’s MoH and helped
shape the ERC strategies.
Due to its ease of access and two-way communication,
12320 played an integral role in ERC and public
opinions monitoring during the A (H1N1) pandemic
and the recent measles vaccination campaigns. Since
then, efforts are being made to integrate 12320 into the
existing public health response system and to develop a
protocol to monitor future public reactions/opinions
during routine public health activities and public health
emergencies. 12320 provides services including
infectious disease prevention and control, health care
consultations and public health legal consultations in
China’s provinces, municipalities and autonomous
regions.
For the overall conduct of this systematic review, the PRISMA guidelines were followed to
the extent possible given the limitations inherent to a review largely based on qualitative stud-
ies [15].
Results
Characterization of the literature
Among the 8,215 articles retrieved, 5,946 were in English (may have included other language
publications that had English abstracts), 1,415 in Chinese, 481 in Portuguese and 373 in Span-
ish. Through title screening, 6,316 (77%) articles were excluded, while 1,899 (23%) abstracts

Table 6. Synthesis of findings across methodological streams–Questions 2 & 3 (combined).

Thematic area of Synthesis of findings Citations CERQual assessment of confidence in evidence
practice
Creation of task The creation of task forces and committees with key stakeholders has Chess Moderate
forces/committees to been described as a mechanism for improving or facilitating information (2007) (Evidence from four different studies (Clarke,
enhance ERC sharing between national and sub-national authorities and between Clarke Schraagen, Bharosa 2010 and Holmes) was
agencies. The creation of a bioterrorism task force at the county level in (2006) individually evaluated to be of moderate confidence
New Jersey was described by Chess (2007) as an important mechanism Nowell level with minor concerns on methodology and
for enhancing risk communications and trust among representatives of (2015) adequacy of data. Evidence from remaining three
different agencies during the 2001 Anthrax incidents. Clarke and Chess Schraagen studies (Chess, Nowell, Howard) was evaluated to
(2006) describe the utilization of an Emergency Operations Committee (2010) be of low confidence level (methodology/ data
(EOC) during a university’s response to the Anthrax incidents. In Bharosa concerns), but the same evidence is reinforced by
addition a number of components for the effective operation of (2010) the other four studies.)
networks, taskforces, and committees were identified. These include: the Howard
importance of existing relationships between responders prior to an (2012)
incident (Nowell 2015), the role of network teams, as opposed to Holmes
hierarchical teams, for improved decision making (Schraagen 2010), and (2009)
the importance of information exchange and distribution between
decision-making units (Bharosa 2010). They also include the importance
of a Public Information Officer (PIO) for improved information
dissemination (Howard 2012), and the role media should play for
effective communication in an emerging infectious disease outbreak
(Holmes 2009). Schraagen et al (2010) hypothesized that network teams
work faster and arrive at more correct decisions than hierarchical teams
Network structures. They allow teams to exchange information quickly,
monitor each other’s performance, and build mutual trust. Network
teams were found to perform faster than hierarchical teams, while
maintaining the same level of accuracy in relatively simple
environments. In relatively complex environments, network teams
arrive at correct decisions more frequently than hierarchical teams.
Holmes et al (2009) describe the importance of engaging media
representatives immediately in discussions about potential emerging
infectious disease outbreaks, including the role media should play and
how the public health community can help them fulfill that role.
Networks to enhance Regional disease surveillance networks may provide a useful mechanism Gresham Moderate
information sharing for information sharing. (2009) (Evidence from both studies was individually
Gresham et al. describes the Middle East Consortium on Infectious Moore evaluated to be of moderate confidence level with
Disease Surveillance (MECIDS), a regional disease surveillance network (2011) minor concerns on methodology and/or adequacy
of public health experts and ministry of health officials from Israel, the of data)
Palestinian Authority, and Jordan. MECIDS unites public health officials
of differing Middle Eastern nationalities and contributes to regional
health and stability by engaging in regular cross-border information
exchange, conducting regular executive board meetings, performing
laboratory and risk communications training, and implementing
innovative communication technology. During H1N1, the MECIDS
partners agreed to prompt and coordinated border and airport
screening, laboratory testing, information exchange, and common
communication strategies. This coordination can be largely contributed
to the existence of both trust and well-exercised national and regional
pandemic preparedness plans, which were initially established within
this network.
Moore and Dausey describes the Mekong Basin Disease Surveillance
(MBDS), a cooperating network of six countries to collaborate on sub-
regional infectious disease surveillance and control—Cambodia, China
(originally just Yunnan province and, since 2008, Guangxi Province as
well), Lao People’s Democratic Republic, Myanmar, Thailand and
Vietnam. During the H1N1 pandemic, MBDS health leaders perceived
their pandemic responses to be effective in areas that, prior to the
creation of the network, were considered problematic. Participants
noted the ability of their country level surveillance systems to exchange
information efficiently within the country and the importance of MBDS
for enabling timely coordinated regional response to detect disease at
cross border sites and prevent the spread of the virus across countries.
(Continued )

Thematic area of Synthesis of findings Citations CERQual assessment of confidence in evidence

practice
Use of information Tools and platforms can be used as information systems to share Celik (2010) Moderate
systems to enhance information. Celik et al. (2010) describes enhancements in the use of the Seyedin (Evidence from seven different studies (Ipe, Bharosa
ERC communication infrastructure by comparing the response to two (2011) 2009, Leonard, Thiago, Kapucu, Militello and
earthquakes that occurred in Turkey, and underlines the importance of Ipe (2010) Chang) was individually evaluated to be of
organizational learning, as well as investments in information Bharosa moderate confidence level with minor concerns on
technology, to enhance capacity for the search for, acquisition and (2009) methodology and/or adequacy of data. Evidence
exchange of information. Seyedin et al. (2011) describes the types of Leonard from remaining two studies (Celik from Turkey and
databases and information system in Iran should include for effective (2014) Seyedin from Iran) was evaluated to be of low
communications in emergency management. Ipe et al. (2010) describes a Thiago confidence level (adequacy of data concerns).)
surveillance system used in the US, named the Medical Electronic (2013)
Surveillance and Intelligence System (MEDSIS), and analyzes the role of Chang
stakeholders in the exchange of information through this system. (2013)
Bharosa et al (2009) reviewed the flood management system, named Kapucu
Flood Information and Warning System (FLIWAS), for improved (2006)
Dutch-German cooperation in flood scenarios. FLIWAS was developed Militello
to optimize the exchange of information during threatening high water (2007)
situations within and between water management and calamity
management organizations. Leonard et al. (2014) describes different
mechanisms of communication in relation to volcanic eruptions in New
Zealand abased on the audience (i.e. scientists, emergency managers,
media, public, etc.). Thiago et al. (2013) describes the role of social
networks and mobile phones in alerting and preparing people to avoid
or face natural disasters in a region of Brazil. Collaboration between
government and Civil Defense in rapidly testing and developing new
channels of communication was found to be successful in terms of
quantity and quality of information shared both within the organization
and with the target population. Based on survey results of a sample of
first responders for a disastrous typhoon in Taiwan in 2009, Chang and
Wang (2013) present the official information sharing and coordination
operations and an emergency management information system (EMIS)
in Taiwan. The authors also discuss what needs to be done, or is
currently being done, to improve the system.
Kapucu et al. (2006) describes how the lack of an integrated information
system greatly limited the coordinated response of agencies (police, fire
department and port authority) following the World Trade Center
terrorist attack in New York city.
In contrast to the more technical operating platforms, Militello et al
(2007) suggests that low cost, paper based tools, including notebooks,
whiteboards, and telephone books, provide important tools for
communication and can support asymmetric knowledge in an
Emergency Operations Center (EOC). Often times, EOC teams are
made up of individuals with differing levels of experience in regards to
crisis management, familiarity with emergency response tools and
procedures, which can make it difficult to effectively utilize electronic
tools without onsite support.
Local stakeholders’ Engagement of local stakeholders is important for the effectiveness of Ardalan Moderate
engagement the ERC strategy. The literature presents examples of mechanisms for (2009) (Evidence from five different studies (Ardalan, Cole,
the engagement of local stakeholders in communication efforts. Ardalan Cole (2014) Shepherd, Gultom, Lei) was individually evaluated
et al. (2009) describe the use of Village Disaster Taskforces, which act as Shepherd to be of moderate confidence level with minor
operational units in an early warning mechanism for flooding in Iran. (2014) concerns on adequacy of data. Evidence from one
Cole et al. (2014) describes the importance of using existing social Gultom study (Mulyasari) was evaluated to be of low
networks in small municipalities for disaster risk reduction activities. (2014) confidence level (method and data concerns).)
Shepherd et al. (2014) addresses the issue of communicating with Mulyasari
culturally diverse communities, and the need for centralizing resources (2013)
that can be used to facilitate communication with these groups. Gultom Lei (2015)
et al. (2014) describes the use of a community based communication
system in Indonesia to facilitate the response to volcanic eruptions.
Mulyasari et al. (2013) describes the role of networks of women in
facilitating communication for all hazards in Indonesia. Lei (2015)
describes the barriers to effective information sharing and response
coordination among agencies during a highway emergency and
proposes possible solutions.

Fig 1. The flow of literature [adapted from the PRISMA flow diagram 2009]. E = English, C = Chinese, P = Portuguese, S = Spanish.
https://doi.org/10.1371/journal.pone.0205555.g001
were reviewed, leading to 880 (11% of all retrieved) full text articles for further scrutiny. After
the final stage appraisal, 21 full text articles were selected for Question 1 (6 in English and 15
in Chinese), and 24 more for Questions 2 and 3 combined (21 in English, 2 in Chinese and 1
in Portuguese). Fig 1 depicts the step-wise flow of literature.
Among the 21 articles identified as related to question (1), 6 (28.5%) were qualitative, 6
mixed-methods, 5 (24%) quantitative and 4 (19%) case studies. Most articles focused on ERC
in China, Hong Kong and Taiwan (18, 86%), while the others covered ERC in Cambodia,

Indonesia, Japan, Laos, Vietnam, Thailand and UK (1 each, with overlap). Twelve (57%) of
these 21 articles addressed all hazard situations (general disasters), while 9 were based on pan-
demic influenza and other infectious disease outbreaks. Tables 4 and 5 summarize the evi-
dence. S1 and S2 Tables list the individual study findings within methodological streams and
evaluation of confidence.
Among the 24 articles included for the final evidence syntheses for questions (2) and (3)
combined, the majority (12, 50%) were qualitative in design, with 5 (21%) case studies, 4
(17%) quantitative and 3 (12%) mixed method approaches. Seven (29%) articles focused on
the US, and 3 each on Netherlands and China (including Hong Kong and Taiwan). Other
regions represented included Asia (Cambodia, Vietnam, Thailand, Indonesia, Laos, and
Myanmar), the Middle East (Turkey, Iran, Israel, Palestine, and Jordan), Australia, New Zea-
land, Canada and Brazil. Among the disaster-types, 7 (29%) articles addressed all-hazard situa-
tions, 4 addressed pandemic influenza/infectious diseases, 3 described floods, 2 each addressed
hurricanes/ tornados, volcanos, terrorism and anthrax scares, and 1 each described a wildfire,
earthquake or other major accident. Table 6 summarizes the evidence. S3 Table lists the indi-
vidual study findings within methodological streams and evaluation of confidence.
Evidence synthesis: (1) How can ERC best be integrated into national and international
public health emergency preparedness planning and response activities?
English language literature

The articles identified as relevant to this question presented examples of mechanisms that
might lead to the integration of ERC functions into the leadership structure. Such mechanisms
were summarized under four themes: (1) placing ERC functions into the national leadership
structure [16, 17]; (2) creating organizational proximity of ERC practitioners to national
response leadership [18, 19]; (3) developing laws, regulations, policies, and frameworks in sup-
port of ERC [16, 18, 20, 21]; and (4) the use of trainings and exercises as a mechanism for test-
ing the effectiveness of the system [17, 20] (cross cutting theme).
Restructuring of existing organizational components of agencies engaged in preparedness
and response efforts, as well as developing novel intra- and inter-agency coordination frame-
works were often needed to achieve integration of ERC functions into the national prepared-
ness/disaster response leadership. Yen et al. [16] described how a new public health policy by
the Taipei City Government formed the basis for implementing an integrated infection control
system to respond to emerging infectious diseases during the aftermath of the SARS outbreak
in 2003. The Taipei Division of Disease Control and Prevention was reformed to function as
the nodal unit for implementing crisis management programs and policies, including integra-
tion of early outbreak detection through hospital-based and school-based surveillance, prompt
epidemiological investigations and preventive responses. These structural reforms allowed the
Division to launch a swift response during the 2007 acute hemorrhagic conjunctivitis outbreak
through its multi-channel, mass risk communication program. In the same context, it was Tai-
wan’s Communicable Disease Act of 2006 which facilitated Taipei’s ability to launch large-
scale SMS campaigns in 2007, as this Act provided the necessary legal platform to allow gov-
ernment agencies to override people’s right to privacy (government could use cellular service
providers to send out six free public service messages per year) when responding to epidemics
or disasters.
Assessing pandemic influenza preparedness in six Asian countries (Cambodia, Indonesia,
Laos, Taiwan, Thailand and Vietnam), Hanvoravongchai and colleagues [17] observed that in
nations with well-functioning health systems, pandemic preparedness was integrated within
existing mechanisms such as national disaster preparedness frameworks; while those with

weaker systems relied heavily on vertical programs for coordination and response. The team
further described the importance of simulation exercises in these countries that demonstrated
the gaps in coordination between the various stakeholders (health sector and beyond). Thai-
land ensured at least one table-top exercise at the central level and in each province; Vietnam
covered airports and borders, in addition to administrative levels; Indonesia conducted a first-
of-its-kind full scale preparedness exercise in Bali in 2008. Furthermore, the WHO and the
Mekong Basin Disease Surveillance (MBDS) Network coordinated several regional cross-
country exercises.
Cope [18] noted that the lack of authority to release information to the public was a critical
barrier to ERC throughout the the chain of command in the Chinese public health system. On
the other hand, shared public health intelligence between the Hong Kong Special Administra-
tive Regional Government, Mainland (China) Ministry of Health and Macao Health Bureau
facilitated functioning of joint emergency responses in the event of cross-boundary public
health emergencies. [20] DRIP, a societal platform for disaster risk information which facili-
tated the acquisition and dissemination of scientific expertise on risk information from a large
number of governmental/non-governmental agencies and research institutions, was utilized as
a major tool in Japan’s disaster risk governance. [21]
Quality assessment. For each of these thematic areas, the overall synthesized evidence
was considered to be of moderate confidence level (GRADE-CERQual). Most of the contribu-
tory publications (to each area) were individually judged to have only minor concerns regard-
ing methodology, and/or adequacy of data, and/or coherence; hence these articles individually
provided evidence of a "moderate" confidence level. The confidence in the pooled evidence is a
reflection of such a majority of articles.
Chinese language literature

The articles identified to respond to question (1) described practices across three functional
areas: (1) how various government agencies used the micro-blogging platform "Weibo" for
ERC [22–28]; (2) integration of a national health hotline into the emergency preparedness and
management system [27, 29, 30]; and (3) collaboration between the US and Chinese CDCs to
build ERC capacity across the country [31–36].
Government agencies in China utilized the social media platform "Weibo" (biggest Chinese
micro-blogging platform, often referred to as “Chinese Twitter”) for public communication
during normal times as well as in public health emergencies (like H1N1, H7N9, terrorist
attacks, and the Ya’An earthquake) with the goals of achieving timely, open, two-way commu-
nications, monitoring public opinion, controlling rumors, addressing public concerns and
improving government services. There had been a consistent national effort to expand the use
of Weibo across China, and to establish a standardized operation, training and evaluation
mechanism for its service performance. [22–28] In order to effectively control online rumors
during health or humanitarian crises, a swift response was mounted by releasing official
counter-messages, working with law enforcement to identify and penalize sources of rumors,
and assessing the effectiveness of these counter-measures through continuous monitoring of
Weibo.
A national hotline service (12320, China’s only such call-in facility) was developed by the
Ministry of Health (MoH) and integrated into the emergency response system. This was suc-
cessfully tested as an important channel of communication during the 2008 formula contami-
nation crisis, 2008 Beijing Olympics, 2009 A(H1N1) pandemic, and the recent measles
campaign. [27, 29, 30] This hotline has helped shape national ERC strategies such as develop-
ing protocols to monitor public reactions and opinions through providing a direct, two-way

communication between health agencies and the public. and has facilitated public health con-
sultations across China’s provinces, municipalities and autonomous regions.
Within China’s governance framework, these novel approaches had helped integrating
ERC as a system response involving multiple agencies and the target (affected) population.
Further, the Chinese CDC had been working in close collaboration with its US counterpart to
conduct assessment of ERC needs at local public health agencies, through conducting tabletop
and functional exercises. [31–36]
Quality assessment. Similar to synthesized evidence from English language publications,
the overall synthesized evidence was considered to be of moderate confidence level (CERQual)
for each of these three functional areas.
Evidence synthesis: (2) What are the best mechanism(s) to establish effective intra-agency,
inter-agency, and/or cross-jurisdictional (such as cross-border; national with sub-national
jurisdictions, etc.) information sharing for emergency risk communication? and (3) What are
the best practices and protocols to ensure coordination of risk communication activities
between responding agencies across organizations and levels of response?
The articles (in English, Chinese, and Portuguese) identified to respond to these two ques-
tions (combined) presented examples of mechanisms to enhance information sharing and
coordination. Such mechanisms were summarized under three themes: (1) creation of task
forces/committees [37–43] and networks [44, 45] to enhance ERC, and their elements of func-
tionality); (2) use of information systems to enhance ERC (tools and platforms) [46–54]; and
(3) mechanisms to facilitate local stakeholders’ engagement in ERC [55–60].
The formation and functioning of collaborative platforms like task forces, networks and
committees had been attributed to facilitate efficient information sharing between national
and sub-national authorities, as well as between agencies. Chess et al. [37] cited the role of a
bioterrorism task force in New Jersey, USA which served as a platform for ERC sharing
between partner agencies like public health and law enforcement during to the 2001 Anthrax
incidents. The diverse agencies had developed mutual trust through this pre-existing task
force, and this lay the foundation for improved intersectoral coordination and intelligence
exchange. It had been pointed out that emergency responders were far more likely to trust and
interact with people/agencies with whom they had an existing professional relationship, and
such networking improved agility in carrying out emergency response measures. [39, 40] Spe-
cific roles for Information Managers and/or Public Information Officers at local agencies had
been proposed to be improve intra-agency coordination. [41, 42]
Gresham [44] described the collaborative health information sharing network, Middle East
Consortium on Infectious Disease Surveillance, between Israel, Jordan and the Palestinian
Authority. This forum brought together politically divergent states and served as a platform to
boost regional health intelligence exchange, capacity development through laboratory and risk
communications training, and implementation of innovative communication technology.
This partnership greatly assisted cross-border preparedness (including airport and border
screening, laboratory testing) and ERC strategies during the H1N1 pandemic, building on pre-
existing trust and thoroughly exercised national/regional emergency plans and protocols. Sim-
ilarly, the MBDS Network between Cambodia, China (originally just Yunnan province and,
since 2008, including Guangxi Province), Lao People’s Democratic Republic, Myanmar, Thai-
land and Vietnam served as a platform to coordinate sub-regional infectious disease surveil-
lance and control. Regional-level coordinated preparedness and prevention efforts led to
better control of the pandemic within the participating countries. [45]
The literature provided several examples where planned investment in communication
infrastructure including better operationalization of wireless communication channels,
increased coordination between responding agencies, and better understanding of

communication needs improved the overall disaster management. This was specifically dem-
onstrated during the response to two earthquakes, three months apart, in Turkey. [46] Thiago
et al [51] described the successful collaboration between the government and Civil Defense in
Brazil which led to the development and rapid testing of novel channels of ERC utilizing social
networks (Facebook, Twitter) and mobile phones. Funded by the European Union, the Flood
Information and Warning System along the Dutch-German border had optimized communi-
cation between water-management and crisis-management agencies. [49] On the other hand,
Kapucu [53] described how the absence of an integrated information system greatly hindered
coordinated response of agencies (police, fire department and port authority) following the
World Trade Center terrorist attack in New York City. Chang et al. [52] studied the process of
information sharing and coordination within Taiwan’s emergency management information
system during the catastrophic 2009 typhoon. They recommended identification and designa-
tion of an agency that had the best geographic reach (in this case, the police) to lead the process
of ERC sharing. Militello [54] had observed that, given the diverse levels of knowledge and
experience of different teams at an emergency operations center (EOC), low-cost substitutes
like notebooks, whiteboards, and telephone books, in addition to electronic tools, could greatly
improve functional efficiency by removing any asymmetric skills barriers.
Different mechanisms were proposed to engage local stakeholders in formulating and
implementing ERC strategies. Ardalan [55] suggested formation of Village Disaster Taskforces
through community participation in Iran, to function as operational units in the early warning
mechanism by facilitating spread of ERC to the lowest levels of the chain. Cole et al. [56] pro-
posed that community emergency management coordinators should look to utilize existing
social networks in small rural municipalities for public education and disaster risk reduction
activities. Citing the example of 2011 Brisbane floods (Australia), Shepherd [57] emphasized
the need to address culturally and linguistically diverse populations through the incorporation
of appropriate ERC materials into centralized resources. Gultom [58] described a community-
based risk information sharing network in Indonesia, the Merapi Circle Information Net-
works, which developed local radio stations and recruited trusted community representatives
to harness ground resources in order to be better equipped in emergency preparedness. A
study from Badung, Indonesia found that the Women’s Welfare Association leaders were in a
unique position to act as key facilitators in the early warning system at sub-district, city or
ward levels of governance. [59]
Quality assessment. Similar to the evidence syntheses for Question 1, for each of these
thematic areas the overall synthesized evidence was considered to be of moderate confidence
level (CERQual).
Discussion
The functioning of ERC is intricately linked to the varying political and cultural landscapes
present across nations. Therefore, in some circumstances, centralized ERC systems may
work better than localized ones, or vice versa. Researchers had noted that decentralized
health systems (e.g. as in Indonesia) faced greater challenges in implementing preventive and
outbreak response measures, and the level of efficiency depended heavily on local political
commitment. [17] In contrast, there was a need for increased decision-making power at the
level of provincial and local public health agencies in China to enable them to release critical
ERC to the public, circumventing barriers in organizational hierarchy. [18] Hence, issues
like political goodwill and leadership, as well as the structure of the national health system
(degree of centralization) are to be considered as key factors in planning and policy-making
for ERC.

The development of ERC policies and capacities through regional partnerships and guide-
lines seemed to be well received. For example, the European Union (EU) had enacted legisla-
tion on a cross-border integrated emergency response system, including coordination and
information exchange between constituent nations. The Health Security Committee (HSC)
Communicators’ Network under the EU provides crisis communication expertise and guid-
ance as part of a comprehensive strategy for the successful management of public health
threats. The information-sharing protocol is implemented through the establishment and acti-
vation of a list of contact points within the EU, the European CDC and the WHO. [61]
Geographic variations in capacity and practice of ERC strongly necessitated the formulation
of evidence-based universal guidelines by the WHO to help member states develop frame-
works to integrate ERC as a system response during emergencies of public health concern.
Such communication needs to be transparent, timely and based on the best available scientific
evidence, in order to ensure the maximal physical, social and economic well-being of citizens.
The identified literature referred to mechanisms, practices from the field, and recommen-
dations that were derived from planning or response efforts implemented at the national or
local levels in specific countries, but did not provide direct evidence of transferability to other
contexts. Factors that seemed to be related to the integration of ERC functions in national and
international public health emergency preparedness, planning and response activities included
renovation of components of the leadership structure when needed, modification of organiza-
tional factors, nullifying restrictions that might hinder the timely release of information, and
amendments to laws and regulations where feasible. Exercises and trainings were recognized
as strategies to identify barriers and successes in the integration of ERC functions into pre-
paredness, planning and response efforts. Key elements to enhance information sharing and
coordination across organizations included the creation of networks, task-forces and commit-
tees across disciplines, organizations and geographic areas. The functionality of information
systems was a key element for the sharing of information by tailoring such systems to the
needs of the users. Engagement of local stakeholders was equally important to guarantee the
flow of information up and down the incident command system.
Despite conducting a very thorough literature review across multiple language databases,
the authors felt that more sensitive approaches may be needed to gather useful evidence in a
non-Western non-English context, for example, when conducting region-specific case studies.
It was observed that the Chinese language articles tended to be succinct in the methodology
section and elaborative about policy or program implications, with an emphasis on status
report and actions taken or recommendations for future steps. This utility-driven approach
might be useful in offering actionable information to practitioners on the ground in the con-
text of China, but presented a challenge in quality assessment. With the Spanish and Portu-
guese language publications, there was a general paucity of empirical literature on ERC. Risk
communication in emergency preparedness was mainly addressed by the social health, com-
munication and technology, and human sciences fields; very little of this work was produced
by researchers or practitioners working in public health. In addition, differences in organiza-
tional response structure, especially in Latin America, contributed to this overall finding.
On the whole, few empirical studies, especially from low- and middle-income countries
were related to the WHO research questions. The authors attempted to circumvent this short-
coming by searching databases in Chinese, Portuguese and Spanish, as well as relaxing the
strict definition for empirical literature to include more case studies and to reflect a broader
distribution of country experiences and knowledge. However, this observed bias against
empirical studies from low- and middle-income countries may be partly due to the limitations
of the authors in their ability to assess a broader range of languages. Furthermore, the fact that
ERC is still not precisely-defined as a field of research meant that there were challenges in

identifying sensitive search terms and keywords that would incorporate the varied disciplines
that cover this field. It is probable that in addition to differences in terms across disciplines,
terms may also differ across nations, and even among professionals trained in similar
disciplines.
The authors believe that the lack of empirical studies across the questions solicited by the
WHO demonstrates an overall need for research in these areas. However, an accurate identifi-
cation of research gaps should be achieved by integrating the results of this review with case
studies across the WHO regions to better understand what type of evidence is needed in prac-
tice across the multitude of ERC functions. Such an approach may ensure that research is pro-
duced in the topic areas of greatest need for practice.
Supporting information
S1 Table. Individual study findings within methodological streams and evaluation of con-
fidence–Question 1, English language literature.
(PDF)
fidence–Question 1, Chinese/ Mandarin literature.
(PDF)
fidence–Questions 2 & 3 (combined).
(PDF)
S4 Table. PRISMA 2009 checklist.
(DOCX)
Acknowledgments
The Harvard EPREP team gratefully acknowledges the support provided during formulating
literature search strategies and in retrieving articles by Mr. Paul Bain, librarian at the Francis
A. Countway Library, Harvard University and Mr. Tomas Allen, librarian at the WHO. We
are also grateful to the experts in ERC who shared with us their experience and knowledge dur-
ing the interviews, and helped us identify additional sources of grey literature; and to Mr.
Noah Klein for editorial support.
Author Contributions
Conceptualization: Gaya Gamhewage, Elena Savoia.
Data curation: Ayan Jha, Leesa Lin, Sarah Massin Short, Giorgia Argentini, Elena Savoia.
Formal analysis: Ayan Jha, Leesa Lin, Sarah Massin Short, Giorgia Argentini, Elena Savoia.
Funding acquisition: Elena Savoia.
Investigation: Gaya Gamhewage, Elena Savoia.
Methodology: Ayan Jha, Leesa Lin, Sarah Massin Short, Gaya Gamhewage, Elena Savoia.
Project administration: Leesa Lin, Gaya Gamhewage, Elena Savoia.
Resources: Ayan Jha, Sarah Massin Short, Giorgia Argentini, Gaya Gamhewage.
Software: Ayan Jha, Sarah Massin Short.

Supervision: Ayan Jha, Sarah Massin Short, Gaya Gamhewage, Elena Savoia.
Validation: Ayan Jha, Leesa Lin, Sarah Massin Short, Giorgia Argentini, Elena Savoia.
Visualization: Gaya Gamhewage, Elena Savoia.
Writing – original draft: Ayan Jha, Leesa Lin, Sarah Massin Short, Giorgia Argentini, Gaya
Gamhewage, Elena Savoia.
Writing – review & editing: Ayan Jha, Leesa Lin, Sarah Massin Short, Giorgia Argentini,
Gaya Gamhewage, Elena Savoia.
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RESEARCH ARTICLE

Integrating emergency risk communication

Citation: Jha A, Lin L, Short SM, Argentini G, Abstract

PLOS ONE | https://doi.org/10.1371/journal.pone.0205555 October 31, 2018 1 / 23

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Table 1. Detailed search strategies for English language scientific databases.

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Source Search Strategy

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Portuguese: a) NATURAL DISASTERS AND RISK COMUNICATION (DESASTRES

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qualitative, quantitative, mixed-methods or case study, with subtypes as applicable), popula-

Methods of evidence synthesis

Quality assessment of the evidence

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Table 4. Synthesis of findings across methodological streams–Question 1, English language literature.

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Thematic area of Synthesis of findings Citations CERQual assessment

Table 5. Synthesis of findings across methodological streams–Question 1, Chinese/ Mandarin literature.

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Thematic area of practice Synthesis of findings Citations CERQual assessment

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Table 6. Synthesis of findings across methodological streams–Questions 2 & 3 (combined).

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Thematic area of Synthesis of findings Citations CERQual assessment of confidence in evidence

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English language literature

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Chinese language literature

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PLOS ONE | https://doi.org/10.1371/journal.pone.0205555 October 31, 2018 20 / 23

explanation and elaboration. BMJ. 2009; 339:b2700. Epub 2009/07/23. https://doi.org/10.1136/bmj.

PLOS ONE | https://doi.org/10.1371/journal.pone.0205555 October 31, 2018 21 / 23

PLOS ONE | https://doi.org/10.1371/journal.pone.0205555 October 31, 2018 22 / 23

PLOS ONE | https://doi.org/10.1371/journal.pone.0205555 October 31, 2018 23 / 23

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