CERC Transcript 06 14 2016

Zika CERC Discussion: Male Travelers and Social Pressures

Presenters: Barbara Reynolds, PhD

Date/Time: June 14, 2016 1:00 pm ET

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Operator: 
Welcome and thank you for standing by. At this time, all lines are in a listen-only mode until the question and answer session. If at that time you’d like to ask a question, you may do so by pressing star and then one and recording your first and last name. Today’s call is being recorded. If you have any objections, you may disconnect at this time. I would now like to introduce your host for today’s call, Ms. Barbara Reynolds. You may begin.

Dr. Barbara Reynolds:
Thank you, Lauren and welcome everyone to another in a series of brief discussions on crisis and emergency risk communication, those principles that we may be able to use and apply in our preparation or response to Zika virus. Today I’m going to talk about a really important topic - social pressure. And it’s the first in a couple of weeks of our discussing how to engage our community in the work that we’re doing. And without being too discouraging, I don’t know if any of you saw some of the recent published information - a survey that was done that was talking about how much does the public know about Zika - and we have a ways to go. But I want to reassure you that that’s not untypical. We would expect that until the risk is more imminent and more personal, that most people probably are not paying a lot of attention to Zika and what it may mean for them. And a subset, of course, of that population that’s very interested would be women who are pregnant and women who may become pregnant. And I would suspect that as we go further into mosquito season for us here in the United States, that people will be a little more interested in it. And that can work to our favor, but it gives us at this point a little time to try to adjust the thinking and move people in a direction of positive action for the things that we need to do to try to delay or minimize the impact of the Zika virus among our populations. And what we can do today is talk about some of those steps that we can take and I hope that as we finish up here, our discussion, that someone may be interested in having a little further discussion and ask some questions or give us a point of view. I’m very interested, and I know we all are - in hearing what everybody is thinking and doing around our Zika response as it relates to crisis and emergency risk communication. For those of you who are near a computer and following through with the slides, I’m starting with the slide that you’ll probably see every week from me, which is reminding people that the right message at the right time from the right person can save lives and in this case reduce harm to people. And it’s really important for us to be a full component of our response to Zika and understand the value of our communication, especially if we go about our communication in a way that’s helpful to people, and there are some things that we can do.

On the next slide, I want to remind people what does the public want from us when they’re aware that there is a threat of some sort to them. And that’s the problem is that, you know, when you have something that’s a little slower moving or doesn’t affect all of the population in the same way, then there’s going to be some differences in what people need at any one time. And most of what I talk about in these slides that have to do with crisis and emergency risk communication is talking about in the moment when people are really attuned. They’re paying attention to it. They’re aware that there is a threat. So some of what I’ll talk about is that and some of it will be the persuasive kind of communication has to go on early if we want to engage them to prevent the threat and the risk. And they’re complimentary, but they can be a little different.

So what does the public want from us? Well, frankly, what we should talk about is what do we typically give the public in a preparation to a threat of some sort to their health, to their wellbeing. And mostly what we just want to give them is the facts. We just really want to give them the facts. We’re pretty good at giving them the facts. But the fact is that’s not enough. What we need to do is be able to communicate with people in a way that they feel they’re being empowered in the decision making around what happens to them, to allow them to put themselves sort of in the driver’s seat so to speak. And I think if you look at what we’re talking about related to travel and sexual transmission, we are doing that. We do have a message that very positive in that we’re going to be able to give them not just the facts, but explain to them why we’re doing what we’re doing - why we’re suggesting what we’re suggesting - and allowing them to make some of those decisions. We have and continue to want to treat people like adults - to give them authority over their health decisions - by giving them the choices and then allowing them to decide what works best for them.

In that context though, we have to make sure that we’re not leaving some potential positive action on the table because we haven’t communicated to them in a way that they recognize that they do have some power in the decision making. And next week, when we go into a further discussion about community engagement and community actions - because today we’re talking about individual actions within the community. When we go to the full community behaviors, we’ll discuss just what it means to be empowered from a community point of view. And what we talk about this week will add to next week as we talk about social pressure this week.

So more than anything, we have to empower decision making and one of the ways to do that is to give people enough information to understand why we’re asking them to do what we are asking them to do. And an example of that is that we’re going to be asking travelers - we have already - for people who travel to areas where Zika is circulating - we’ve asked them when they return as travelers, to do two very important things. We’ve asked them that if they are a partner to a pregnant woman that they use a condom correctly every time as they have sex during the pregnancy. And we have explained why that’s important and why it has to be done correctly every time. And we’re also offering that if they want to avoid any risk related to the possibility of Zika transmitting to the fetus, then we should be talking about not having any sex. So that is a for sure way to not transmit Zika to the fetus.

The other thing that we need people to do who are traveling to an area affected by Zika right now is that we need them to use insect repellent upon their return. I think it’s one thing in that travelers are more attuned to listening and picking up some of the things that they can do to protect themselves. But it’s really important to bring that message back - that people who have traveled to that area should be using insect repellent for three weeks and doing everything that they can to avoid being bitten by a mosquito. It’s a little more difficult to help people understand that there are people who are ill who get bitten by mosquitoes who then make other people ill. And there are - actually, people who are infected who then get bitten by a mosquito and then the mosquito infects someone else who may become ill. And when you have a disease where most people may not have serious symptoms, there’s a question mark as whether this threat is relevant to me or not. And what we have to do is work toward our education at this point to help people understand that it is important to them.

In the next slide, I talk about audience relationships to an event. And this is a generic slide that we can use for all kinds of crises. But we should recognize that in any crisis situation, there are some people who are going to feel more related to the crisis setting, to the public health emergency, and there are people who will feel not as connected to it. And what’s important is to not try to ensure everyone is reacting the same way to your message, but make sure that you’re targeting the information in a way that the people who need to act on it most are given the information they need. So sometimes we can do in some health situations a one size fits all communication. But in a situation where pregnant women specifically and their male partners, and travelers who are returning are the ones who we’re asking them to do something, we need to be sure that we’re communicating to them in a way that’s really useful. So it’s worthwhile to kind of do your own circle for your community around audience relationships and ask who’s - who do I need to be talking to now and who can I talk to later on as they become more interested in what’s happening.

What we know is that when people start to believe that there is some sort of threat, they’re eager to take actions to protect themselves and their loved ones. But the big question mark here is, are they aware that there is a threat? Are they conscious of the fact that this means more than for travelers’ health - that there’s really something that could happen in the community along the way. Once we get their attention, we have to go a little bit further. What we know is they will seek information. They will be looking for other sources that it’s not going to be enough for just one organization to be saying this. It’s important that we have partners who will work with us on it. And in, when we give members in focus groups scenarios, different kinds of public health scenarios, you will see that they’re more than anything they are interested in protecting family and friends - loved ones. And I’m telling you this from our generic research because I think it’s going to be very important as we move through some of the things related to social pressure and the Zika response.

And without question, some people, when they’re aware of a threat that’s located in a specific geographic area, they want to leave it. We saw that for radiation and I want some communities to be aware that there may be people who will decide that they want to avoid being in that area completely. And if we’re talking about the potential for local transmission through mosquitoes in a community, we know that the first initial cases of that will be a very confined community area for the most part. And in a few weeks we’ll talk about stigmatization, but we need to recognize that people may think that the way to manage the risk is to just avoid the area completely. Well, we’re telling people to do that in travel - for pregnant women to not travel at all. But it’s going to be a trickier message in areas where Zika is coming for the first time to help them make the best decisions possible. And we also know that people like to take actions which are consistent with crisis and emergency risk communication principles, so that’s not really much of a concern. We think we have some good actions for people to take, so.

I have a slide on risk is risky. So what the heck do I mean there? What I mean is that it can be a little frustrating for us when we’re in this sort of holding pattern, especially within the continental United States where we know its mosquito season. We know that as the summer heats up, more mosquitoes are circulating, as people are traveling back and forth from affected area, that the risk is actually going to change. That right now people may be assuming that the risk is pretty low, but at some point it may become, they may become more aware of the possibility that risk is there. I don’t know how people will react to mosquito bites in your community, but I do know how they’ll react to mosquito bites once they recognize that the Zika is circulating in their area. And it will be a challenge to help people understand where the risk is and where the risk is not. I don’t think we should overemphasize the need to have people recognize the boundaries in an absolute, concrete way because all of us know that boundaries help us but they don’t guarantee us whether a risk is there or not. And we see some of that challenge even as we look at some of the mosquito maps and how people interpret risk based on the mosquito maps. But risks are very much in the eye of the beholder. Some people can look at a threat or a risk and perceive it as much more dangerous, and it is perception more often than not - than others. And to the extent that we help people understand their level of risk, that’s a good idea. But they’re going to be doing those, their own calculations, the probability of harm times the impact of harm. So again, risk will change over time in many of these communities and in fact there will come a time where Zika is circulating now and as steps are being put into place to help respond to that risk and their risk may be going down while in another community the risk is going up. So it’s a very variable situation that we’re trying to communicate in and that’s why community engagement and community-level communication become so important because we can’t just say what the risk is for every one in every situation.

There will be unknown latent effects with the communication that we do about a risk and the steps that we take to try to mitigate those risks. And we need to be open to that and listening for those along the way. When we talk about risk perceptions, understand that people do recognize risk as it’s perceived or discussed in the research and risks in real life. And when it becomes real life risks - when they’ve had experience with something, then the risk is perceived as greater than they might if they’re just seeing it as a theoretical risk in some way.

Exposure versus harm - this one’s going to be a little tricky too because there are some diseases perhaps where anyone who’s exposed is going to have some harm from it. And then we have diseases that people can be exposed, but they don’t have equal harm from that exposure. And so, again, as people calculate risk, they may focus more on the harm that they see in some people and perceive that their exposure means it equals that level of harm. Or the other could be true, is that people will discount the harm that could come from their exposure because they see that the majority of people don’t have harm from the exposure. So again, when you have a population that can be exposed equally to a risk, but the harm from that exposure is going to be different for them, it’s going to make a much more difficult communication effort. And we know that this is a complex response to a disease that we’re learning something about every day. But it has a lot of complexities to it because, again, it’s not one size fits all.

We also know that when people are looking at risk perceptions they are thinking in terms of benefits versus costs, and we’ll talk about that in just a minute. I think it’s important that when we’re talking about Zika and especially Zika as it is transmitted by mosquitoes, that we recognize that there is a shared risk to the community. And whatever we do - when we’re talking about risk perceptions - if we get too interested in just giving the facts and not addressing trust issues, that it can be confusing for people as we move forward.

Next slide - I’m going to talk a little bit about vicarious rehearsal. If you’re following with slides, you’ll know that I talked a little bit about that. It was on the slide around audience perceptions and audience needs. This is a term I coined years to try to explain what happens in a situation where the threat isn’t really here, but people are paying attention to it. And as they pay attention to it, they may rehearse the recommended courses of actions. And unfortunately because the threat isn’t feeling imminent and personal to them, they may rehearse the recommended courses of action and discount them or reject them in some way. So it’s a real delicate dance that we have to do between informing people about the threat and the things that they can do to take action - but not doing it in a way that by the time the threat exists in their community, they’ve already thought about it and rejected it. And there may - there is some evidence in some of the research that perhaps people are doing that and that they may be aware of Zika and be aware of sexual transmission, but may not be interested at this point in taking steps such as using condoms correctly every time to protect a now pregnant woman or a woman who’s attempting to be pregnant from Zika illness, from infection.

So vicarious rehearsal is a situation where people are thinking through what they would do in that situation. It isn’t as depressing as I might be making it out. There is an opportunity when people are doing vicarious rehearsal to in fact get them to believe that as they rehearse the course of action, that that is something that they would do. And again, we’re going to talk about social cognitive learning theory, Albert Bandura’s theory and how we can use that to our advantage in getting people prepared for the possibility of Zika in their community and taking the steps that they need to take. Vicarious rehearsal can happen even in the context of some of the community is in threat and others are not. But it’s more difficult. What we saw with West Nile virus when it marched across the states is that when it became more real because they were actually noting the virus existed in the community, then people were more attuned to taking an action to protect themselves. With vicarious rehearsal, whether that action will be a positive or a negative depends in part on how well we communicate at this point.

So I want to talk a little bit on the next slide - sources of social pressure. I want to talk a little bit about Albert Bandura’s social cognitive learning theory. And basically that’s a theory that says when people are looking at a potential new threat of some sort and there’s an expectation of action, that the degree of effort and persistence people will put forth in protecting themselves in a situation depends on a number of things. And through his research we were able to discover some things that we can do to increase the possibility that people will put more effort and be more persistent in pursuing a goal or an objective in terms of doing the things that we recommend. And what we know is that people set goals for themselves. They anticipate the likely consequences of perspective action, and then select and create courses of action likely to produce the outcomes that they want, positive outcomes versus detrimental. That sounds pretty straight forward, but the problem is there’s a whole lot of places in that where it can go wrong. We know that, however, purposeful information can make a difference in how people respond to the threat situation.

A central component or thought in social cognitive learning theory is the idea of self-efficacy, the belief that one can execute a behavior that will produce a desired outcome. At some point along the way, for those of us who are not professional athletes, we probably recognized at some point that despite our efforts to do a particular behavior, that we knew that we weren’t going to produce the desired outcome. We weren’t going to be gold medal figure skaters or, I don't know, a hundred meter champions along the way. And so we stopped putting out the effort because we didn’t think we could produce the desired outcome. So self-efficacy actually influences what people attempt to do, and again, the amount of effort that they will invest in it. People with high self-efficacy will chose more difficult tasks and put forth more time and effort in the face of obstacles. And I think that’s important for us to recognize, that if we can do anything to build higher self-efficacy in our population in relationship to what they can do to fight Zika, the more likely they are to put out an effort in the face of obstacles. And one of the things that I always talk about is that we don’t, it’s okay if people are afraid, if they’re feeling anxious or emotional about something that’s a threat that’s happening to them, as long as they don’t fall into hopelessness or helplessness. And the absolute opposite of self-efficacy is a feeling of personal hopelessness or helplessness because they’re not going to put forth time and effort in the face of obstacles if they don’t believe that it’s going to do something for them. So as we learn more about what we can do to protect people and we have a sense of the actions that people can take, we need to work toward that. And I will tell you, we have a high bar on some of these things because we are talking about avoiding mosquito bites and some of the actions that we’re asking people to do, they do cost something. They do have to have, put a real effort into it.

So how can we increase person’s self-confidence about their ability to perform a task and to stabilize that so that they tend to do it over time? Well, we do have some things that we can do. There are four main sources of personal efficacy. Physical and emotional state, so meaning if we have the mindset and the physical ability to do things. Observational learning - so we’re watching other people do something and then, especially the closer the people were observing doing something, we can learn how they do it, but the more they look like us and they can do it, the greater our self-efficacy can be in a situation. And that’s why when somebody in a demographic category is the first to do something, you know, the first 12 year old to row, I don't know, across the sea on their own, then another 12 year old will think that they can do the same thing. So observational learning is a powerful way to help people build self-efficacy. And then mastery experiences are helping people do it themselves, and as they do it more and they’re successful at doing it, they’re more likely to continue to do it. And that’s not the same as a habit, but it is the idea that if I can do this, then I can do it again and I can do it again. If any of you have been snow skiers, we start out on the bunny slope and then we go to the greens and then the blues and someday, if we’re really, really, really good and we’ve mastered the greens and the blues, we might go to a black diamond and even a double diamond run. And part of the reason that we’re able to move toward that is because we’ve mastered the bunny slope. So it all starts with mastery experiences and giving people an opportunity to do things so that they can feel confident that I could do this. Well then, maybe if I could do this and I’m watching other people through observational learning do a little more, I could do a little more. And then, the fourth of the main sources of personal efficacy is social persuasion. So I saved that for last because I want to talk about sources of social pressure basically, social persuasion. In each of these areas, physical and emotional states, observational learning, mastery experiences and social persuasion, all of those together can make a difference in whether people have self-efficacy believe that they can do what they need to do to protect themselves, to have the desired outcome that they’re looking for and to avoid detrimental ones. With all the four sources of building self-efficacy, mastery skills is of course the best. So having people show that they can do something is a power thing along the way. And you may think that in emotional states that if there are strong emotions, that it will reduce peoples’ performance. And that is typically true except when the threat is recognized as real and that it’s important, and if we can put the fear of the threat in context saying it’s appropriate to have these strong emotions, then people can work through those emotions and still be able to do what they need to do.

With social pressure, we have basically, when people are facing a new situation and they have to make a decision, and in this case we are going to be asking people to make a decision, whether they’re going to take the steps that we’re recommending in terms of correctly using every time a condom. If you’re a male traveler returning to a partner who is pregnant or attempting to be pregnant and wanting to assure that during the period of time that there may be an exposure from the virus in the semen, that you don’t want them to do anything but use condoms. Or if you have someone who travels and they’re avoiding mosquito bites while they’re traveling and then when they come back, we’re asking them to continue for a three week timeframe to also avoid mosquito bites by wearing mosquito repellent and doing what they need to do to avoid mosquito bites.

Well in a situation like this, people are going to ask themselves four questions. Believe it or not, if you’re making a decision that you haven’t made on a routine rote basis any time that you’re trying to make a decision for the first time or a decision that you don’t make very often, you mentally go through these four questions whether you realize it or not. You’re going to ask yourself, what will I gain if I make this choice, if I do this thing, if I take the recommendations that the public health people are telling me? What will I gain? You also ask what will it cost me? And frankly, you may ask what it costs me before you even ask what it gains, what you gain because the cost of taking an action can be a big detriment to taking that action. It’s an obstacle. It’s a barrier in some way. Because if there’s not downside to taking a step, remember the old, you know, first do no harm, then it’s okay, people will more likely do it. But if there’s a cost, then you start to do the old weighing of the ratio. Well is what I gain worth the cost? Anyone who’s trying to lose that last five pounds kind of understands what we’re talking about. And then you will ask what do those important to me want me to do and can I actually carry it out?

So when we talk about social pressure, when we’re talking about the steps that we want people to take, we should be trying to do what we can to increase the benefit of that decision and reduce the cost to the individual who will be making that decision. So one of the ways that we can reduce the cost is to make it easier for people to understand what they should be doing. And that might seem self-evident, but sometimes I think in our messaging and in the way we approach our communication, we may make it more difficult for them than we know. What will I gain? Well, often times we tell people what to do, but we don’t explain what the result is of that. So if we’re going to talk to them about protecting pregnant women or protecting the community by ensuring that mosquitoes don’t bite them if they have been infected with Zika, we need to talk about what the gain is, not just don’t do this because we don’t want you to pass it on, but what’s the gain to the community. What’s the gain to the individual? What do those important to me want me to do? That is very powerful, and we have done some interesting health promotion work in other settings by letting people know that if they sacrifice in some way - so they do something that costs them a little bit. But if the people around them want them to do it - if the people who are important to them want them to take this step, they’re more likely to carry it out. And so the persuasion of others in that decision can be very powerful. And I think that in a community who is trying to protect pregnant women and their - from Zika, that it’s really important that we praise the people around them who have to do something that will cost them. And in this case, it would be to think through how to avoid sexual transmission or how to avoid it through mosquito transmission for the community.

And then the fourth thing that someone will ask in a situation like this is can I actually carry it out? Can I do what they’re asking me to do? Well, you would like to think that we’re never asking people to do things that they couldn’t carry out. And I will tell you that there have been times when I have been given recommendations of what I can do to protect myself in public safety situations and I think - eh, kind of vicarious rehearsal, really? If that happened to me, could I actually do it? One of the hallmarks of any of you who have heard me talk about this is when we talk about tornado season and the experts tell you that if you’re in your car and a tornado’s coming your way, that you shouldn’t try to outrun the tornado. You should get out of your car and go into a ditch. And every time I’m told that, I think can I actually do it? Can I carry it out? I’ve done some really bad vicarious rehearsals because in my head I rehearsed it and I think no, I really don’t think I could do that. I couldn’t just jump out of the car and run into the ditch because it’ll be raining and cold and scary and I feel safer in the car, even though I’m not safer in the car, so sometimes logic doesn’t work for us. So if somebody wants me to get in the ditch, then what they have to do is tell me more what I will gain and reduce the cost. So somebody needs to tell me that its people important to me want me to do this and the cost will be I won’t be embarrassed because I got in the ditch but I’ll be considered a smart person and people will applaud me for having done what I needed to do, which is to get in the ditch. That’s a little exaggerated, but that’s the point.

Four questions; what will I gain, what will it cost me, what do those important to me want me to do and can I actually carry it out. If you will carry around in your mind those four questions as you’re developing your communication messaging as you’re talking to the people who need this information most, you will have I think at that moment the empathy necessary and the point of view necessary to help people move in that direction. Remember, self-efficacy, the belief that I can do it, is important in the recommendations that we make. And if we’re going to ask people to do something that’s very unusual - that they haven’t done before - then we need to help them master that skill by giving them smaller things that they can do and then move on to the other. I remember when we were preparing for a possibility of pandemic influenza in the United States and we were telling people they might have to close schools for 12 weeks. Well, that just instantly is a reject in most peoples’ minds. But we know that schools can close for a week in some areas because of bad weather. And so help people understand, you know. Could you - for the, you know, have you ever put on insect repellent before you’ve gone out of your house during mosquito season? Well yes, yes I have. Well, when do you do it? Well, mostly when I’m working in the yard. Well, do you think you could take it and just do it for a few days and just do it because you’re out and about? I mean, you, you know, protect yourself from potential mosquito bites, you know, increase the gain for them so it’s not just about providing protection to the community, but some protection to them.

So walk through in your mind what you’re asking people to do and remember these four questions and see if that doesn’t help you think through what your community might want as you go forward. And again, I’ve thrown up a lot of the challenges that happen here, but I’m also giving you some of the thinking that goes behind the messaging that we do in public health emergency situations. So I’ve talked on a bit. I would love to open it up and see, (Lauren), if people have anything they’d like to add to the discussion or any questions that they might have. So (Lauren), if you could get the information out to them about how to ask a question.

Operator:           
At this time, I’d like to begin the formal question and answer session of the call. If you’d like to ask a question, please press one - star then one and record your first and last name. To withdraw your question, you may press star then two. Again, to ask a question, please press star then one and record your first and last name. One moment for the first question.

Dr. Barbara Reynolds:       
Okay, while we’re waiting for any discussion or questions that might come about, I just want to remind everyone that in crisis and emergency risk communication, that we do have some ideas and principles about how to go about this and - be first, be right, be credible is what an institution needs to do in the way that they’re talking to people in the situation. And being credible is a combination of being an expert and being trustful. And I can’t help but remind people that trust is the natural consequence of promises fulfilled. So Lauren, do we have any questions?

Operator:           
First question comes from Kitty K. You may ask your question.

Kitty:                  
Hi, yes. I thank you so much for this information. I - my question is how can we get the slides? I only have access to the phone number and I don’t even know how to get to you on the computer so, for those of us that don’t have access, if we could get that.

Dr. Barbara Reynolds:         
Okay, so if you’re not at a computer right now but you have the means to get to the CDC website through the computer - if you go to CDC.gov/emergency, the slides will be there, but you can also just send us an email at cercrequest - the email address is cercrequest - C-E-R-C request at CDC.gov and we’d be happy to send you the slides. And that goes for anyone else, if they are interested in the slides or if they have a question that perhaps they’re hesitant to ask in the format that we’re in today, please go right ahead and send us an email and we’ll get something back to you personal. Thanks for that question. Are there any other questions?

Operator:           
Next question comes from Larry Hill. You may ask your question.

Larry:                
Good afternoon, Dr. Reynolds.

Dr. Barbara Reynolds         
Hi, Larry. How are you?

Larry:                
Very well, thank you. Hey, my question is about some future guidance maybe. Starting to hear that some of the ladies that now have - they’re pregnant with Zika virus - they’re starting to terminate their pregnancy. Is there some guidance you’re going to be able to help us with as far as responding to those questions when we start getting them?

Dr. Barbara Reynolds         
Well what kind of question do you think you’ll be getting?

Larry:                
Well, some things I know we can’t answer for the public, especially because of our HIPAA and privacy stuff, but I think it’s going to come into some areas where people are going to start saying how often is this happening? How many people who are now deciding to terminate their pregnancies as opposed to that? Or some people may be even asking well what should I do and of course, I’m learning that because somebody gets Zika, it’s not going to have an impact on every single pregnancy. But I think that’s where the questions are going to come about whether or not people should be terminating their pregnancies or not. And of course, I know a lot of that depends on their doctors too. But I think that we’re going to get a lot of questions eventually on that because it’s going to be such a sad situation to hear that.

Dr. Barbara Reynolds         
Yes, so Larry, you’re asking a reasonable question and it’s one that I think that we may face. We’re - we have a pregnancy registry, which means that there are numbers and people will start to look at those numbers. And there may be pressure within a state or a community to start to share those numbers and I don’t know what you normally share in this area. I think that for healthcare providers, that we have been offering specific guidance to them as far as how to council their patients in, who have tested positive for Zika, and ways to monitor their health and the pregnancy as they go forward. But from a public information officer perspective, you know, if the data is there in a way that it can be provided without violating peoples’ privacy, then you provide the data. If they’re asking for the position of, you know, what are you recommending to women who are pregnant, well then we would basically say that if I were in your shoes I’d be saying Zika is a new threat that is raising difficult questions and as we want to understand Zika and what it means to peoples’ health, including adverse birth outcomes, we want to stress that the best way to prevent Zika and the go into that, is to protect women who are pregnant. I would turn that around a little bit. And send them to the pregnancy registry for virus infection, that we need to recognize the disease, again, is raising difficult questions and it’s a complex and highly personal decision. So you have to decide, are you answering that question from a kind of a moral perspective as far as guiding people in their decision making. That I don’t think is the role that we have in the public setting. I do think that that is a role for healthcare providers to work on. Or are you just simply answering the questions about the registry? And I don’t know where the registry questions are going to take us yet. Over time it’ll be something that will become more clear, and I think that we’re all going to struggle with. So your question is really a valid one. I don’t know if I’m giving you much to work with right now, but I do recognize that we’re all going to have to be there, thinking about it.

Larry:                        
I think you’re response about going back to the preventative measures is what we’re going to have to do. And I agree with that and I’m glad you mentioned that because that other stuff is getting into other territory sounds like public information officers should go into, like you just said.

Dr. Barbara Reynolds 
Yes.

Larry:                        
So I think we’re going to have to be aware that is going to become, you know, a hot topic at some point in time for us. Thank you.

Dr. Barbara Reynolds:        
Yes, it could. But I think that you’re at the right point to be thinking about it and asking your leadership how they’re going to answer those questions about, you know, the registry and I don't know if you are sharing publicly how many people in your state are being added to the registry. But people will be interested in outcomes. They’re going to be interested in the aggregates I’m sure at the national level and I assume that they may be on the state level too. And people will make assumptions about that data in ways that may not be accurate, but we’re going to again have to probably revisit this a few times. And in the meantime, there’s nothing wrong with just recognizing that this is a difficult time. It’s raising difficult questions. It’s new and our biggest effort from a public health perspective is to help pregnant protect the fetus and then also if they have tested positive and they are pregnant, to make sure that they’re in a care situation where they’re getting the information that they need. Okay, Lauren, next question.

Operator:            
I’m showing no further questions.

Dr. Barbara Reynolds:        
Okay. We’ve talked a lot today about risk, how people perceive risk. I think we’ve done this for the last couple of weeks. Next week we’re going to go into community engagement, how do we talk to the community about the things that they can do, especially if they’re not in a particular risk situation to begin to anticipate some of the tough questions that may come up around mosquito and vector control and how people will be reacting to that. Questions about when we have our first cases. Questions about the community as we how decide to put out travel advisories or alerts around Zika as it moves domestically into some communities. So community engagement itself will be the topic next week and I look forward to talking to you all then. And (Lauren), we can close out the call.

Operator:            
This concludes today’s call. You may disconnect at this time.