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Featured Article from The ATA Chronicle (November-December 2009)

Role of Medical Linguists in an Influenza Pandemic
By Patricia Thickstun

Medical linguists can expect to play a critical role in the influenza pandemic. Linguists may be called upon to translate and interpret risk and emergency communication, health education materials, and pandemic preparedness plans and associated policies and procedures, including signage for medical facilities. Those working with clinicians will need to describe symptoms, differential diagnosis, and treatment methods accurately. They will also need to become familiar with risk communication principles and message mapping strategies. Most importantly, linguists will facilitate the communication of culturally and linguistically appropriate messages to help people make the best possible decisions about their health and wellbeing during a crisis. It is a job requiring constant research and glossary building. This article presents an overview of some of the major issues related to this topic, including a briefing on the current state of the influenza virus, terminology tips, and risk communication techniques.

Seasonal and Pandemic Influenza: Some Facts
Let’s start off with a few facts. Seasonal influenza circulates each year during the fall and winter in the northern and southern hemispheres, and may occur during any season in the tropics. According to the Centers for Disease Control and Prevention (CDC), every year in the U.S., between 5% and 20% of the population experiences seasonal influenza infection, with an average of 200,000 influenza-associated hospitalizations and 36,000 deaths. During the 2009-2010 influenza season, when both pandemic and seasonal influenza strains are expected to circulate concurrently, the number of influenza cases and deaths attributable to pandemic influenza may significantly add to the morbidity and mortality caused by seasonal influenza.

The Rise of H1N1
In March 2009, an outbreak of an influenza-like illness was reported in Mexico City, and soon thousands were hospitalized with pneumonia. In April, a laboratory test identified a novel influenza strain that combined genes from human, pig, and bird flu in samples collected from two California children that was identical to the virus isolated from hospitalized patients in Mexico. By the end of May, swine flu, as it had come to be known in the media, had affected people in all 50 states and 62 countries. On June 11, 2009, when the World Health Organization (WHO) declared a pandemic, this new influenza virus, known as novel influenza A (H1N1) virus or pandemic A (H1N1), had been reported in 74 countries. According to CDC, as of August 19, 2009, more than 177,000 laboratory-confirmed cases had been identified in 170 countries.

Because this is a new influenza virus, most people have no specific immunity to it, and it is expected that any vaccine will be in short supply for some time to come. To complicate the situation, it is impossible to distinguish pandemic influenza from seasonal influenza infection without a laboratory test. Once you recover from an illness caused by a particular influenza strain, it cannot make you sick again. But unless you develop immunity to both swine flu and seasonal flu, either by recovering from the illness or receiving a vaccine, you could still become ill with influenza.

“Swine flu” gives an incomplete clinical impression. Pigs infected with flu viruses under experimental conditions do get flu symptoms such as nasal discharge, coughing, sneezing, and conjunctivitis. Upon pathological examination, areas of consolidation in the lung (pneumonia) are also found 1. However, direct transmission from pigs to humans is rare. People who work with pigs, especially those with extensive exposure, are at increased risk of becoming infected with swine influenza strains. There is, however, no need to stop eating pork products, as has already happened in many parts of the world. Otherwise, the swine flu in humans feels much like regular seasonal flu. It begins with the usual mild upper and lower respiratory symptoms (sneezing, nasal discharge, and cough), with or without fever or chills, progressing to moderate systemic symptoms, that is, general malaise, fatigue, muscle aches, and pains. This will be the scenario with the vast majority of cases. In the minority, it can also be followed by general debility, vomiting, and severe diarrhea. Pneumonia can occur if the lungs are clinically involved. If the brain is affected, a viral encephalitis-like scenario follows, with severe headache, visual disturbances, confusion, disorientation, and possibly convulsions. Occasionally, death occurs, particularly in patients with underlying health conditions.

Antiviral medication such as oseltamivir, marketed by Roche under the trade name Tamiflu 2, is available by prescription as capsules or in liquid form. It can be used prophylactically in settings where widespread infection could have dire consequences, such as in nursing homes, assisted living facilities, and dormitories. According to CDC, it should be taken within two days of the first symptoms, since it can prevent virus replication.
With the proper information, the general population can take steps to protect themselves. The challenge will be getting this information to the people who are most at risk.

Pandemic Communication

Communication barriers can also impede compliance with treatment plans and therapies for patients. For example, LEP patients can experience adverse effects related to the improper administration of medications. Similarly, LEP employees in health care facilities may encounter challenges in understanding and complying with infection control and human resources policies and procedures related to sick leave.

In a crisis situation, there is a significant risk that not only LEP individuals but also those with other challenges, such as hearing or visual impairment, will not have access to crucial lifesaving information in a timely manner. Medical linguists will have an important role in reducing this risk.

So how can linguists working in a medical setting best prepare themselves for the current flu season? The following sections offer some tips detailing where to find the latest terminology associated with influenza, as well as some ideas for improving the chances that the information you are responsible for conveying will be understood by those you are assisting.

Research Terminology
The first step of being prepared is to become familiar with the latest terminology. Get into the habit of reading medical journals and reports and visit websites of the major health organizations. Such reports are published regularly online in CDC’s Morbidity and Mortality Weekly Report 4 . As the outbreak of the 2009 H1N1 influenza virus continues, clinical details from hospitalized patients have emerged. Linguists can use this information to identify terminology and develop glossaries. For example, CDC reports that pneumonia and dehydration have been the most common admission diagnoses for H1N1 patients. Underlying medical conditions include chronic lung diseases, conditions involving immunosuppression, cardiac disease, diabetes, pregnancy, and obesity. Common symptoms are fever, myalgia (muscle pain), cough, and shortness of breath. Emesis and diarrhea have also been reported, particularly in children. To give an idea of the vast amount of terminology that can be mined from this material, the following extract (with key words in bold) is from a typical case report compiled from actual cases.

On April 15, a woman aged 33 years at 35 weeks’ gestation with a one-day history of myalgia, dry cough, and low-grade fever was examined by her obstetrician-gynecologist. She had been in relatively good health, although she had a history of psoriasis and mild asthma. She had been taking no medications other than prenatal vitamins. Rapid influenza diagnostic testing performed in the physician’s office was positive.

On April 19, she was examined in a local emergency department, with worsening shortness of breath, fever, and productive cough. She experienced severe respiratory distress, with an oxygen saturation of approximately 80% on room air and a respiratory rate of approximately 30 breaths per minute. A chest radiograph revealed bilateral nodular infiltrates. The patient required intubation and was placed on mechanical ventilation. On April 21, the patient developed acute respiratory distress syndrome (ARDS). The patient began receiving oseltamivir on April 28. She also received broad-spectrum antibiotics and remained on mechanical ventilation. The patient died on May 4 of multiple organ dysfunction syndrome (MODS).

On April 19, the white blood cell count (WBC) was elevated as was aspartate transaminase (AST) and creatine phosphokinase (CPK). On April 25, a nasopharyngeal swab specimen indicated an unsubtypable influenza A strain by real-time reverse transcriptase-polymerase chain reaction (rRT-PCR). Direct immunofluorescent antibody (IFA) staining was negative for influenza A. On April 30, a repeat nasopharyngeal specimen was collected, which was positive by rRT-PCR for novel influenza A (H1N1) virus 5.

Know What to Expect on the Job
Crisis management will be just as important as language skills during an emergency situation, such as one caused by pandemic influenza. Linguists will not only perform their routine duties, but they may also be asked to provide additional services, which will escalate their stress level. They may be asked to staff hotlines or to translate emergency communications or press releases quickly. The sources of stress may be personal as well as professional. For example, finding childcare may become challenging if schools and daycare facilities are suddenly closed. Concerns about the health and well-being of sick family members may become overwhelming as pandemic morbidity and mortality continue over an extended period. Dr. Betsy Gard provided excellent suggestions for recognizing and dealing with stress in her article, “The Role of Interpreters During a Disaster,” in the July issue of The ATA Chronicle 6.

Familiarize Yourself With
Emergency Preparedness Plans

If you are employed in a clinical setting, you can reduce stress by becoming familiar with your facility’s pandemic influenza preparedness policy and response plan. This plan will tell you when to stay home from work and return to work if you are sick, which infection control precautions you should take while at work, and what types of new signage will be posted in the facility.

You can obtain clarification on current policies and procedures regarding pandemic influenza infection control, isolation precautions, and personal protective equipment (PPE) from the facility’s infection control/risk management department. The department should also have a plan for what will be done if or when the recommended PPE is not available. Be aware that PPE is the last line of defense against transmission of airborne infection, and that other strategies (engineering controls, administrative controls, and vaccine) are all part of a facility’s comprehensive strategy to protect patients, employees, and visitors. Here are the questions you should be asking:

• Have pandemic influenza signs been posted in your facility?

• Have they been translated into the languages represented in your facility’s client and employee populations?

• Are LEP, visually impaired, or hearing impaired workers employed in your facility?

If these questions remain unanswered, consider stepping outside your role as a linguist and stepping into your role as an involved community member. When the opportunity arises, determine if members of your ethnic/linguistic community who experience communication challenges are aware of and understand the facts about pandemic influenza. Have the infection control policies and procedures been translated or made accessible? You can play an important role in facilitating pandemic influenza risk communication to help the people around you stay healthy.

Why Risk Communication Matters
Medical linguists are talented and resourceful professionals. Spoken and sign language interpreters routinely facilitate client access to health care services with on-site and over-the-phone interpreting. Translators work on intake and consent forms, instructions for medical procedures, discharge and medication instructions, advance directives (living wills and “do not resuscitate” orders), hospital policies, and medical records. They may also work with health education materials, fact sheets, brochures, posters, and facility signage. This involves utilizing effective risk communication techniques.

Risk communication is an approach for communicating effectively with diverse audiences in emotionally charged situations of high stress and high concern 7. Goals of risk communication include:

• Tailoring communication that addresses the emotional response to an event.

• Empowering the target audience to make informed decisions.

• Encouraging constructive responses to a crisis by influencing attitudes, decisions, and behaviors.

• Providing guidance on appropriate protective behaviors and actions.

Written pandemic influenza risk communication plans have been prepared by international and national health agencies including WHO 8 and the U.S. Department of Health and Human Services 9. Key elements address questions such as “What needs to be done?” “Who needs to know?” and “Who needs to act?”
The key here is to be prepared, not scared. Providing clear information is essential for calming fears and building trust. People need to be informed about what is known as well as what is not yet known about a pandemic influenza outbreak. This helps to slow the spread of the disease and gives people the facts and peace of mind.

Message Maps
One of the challenges of risk communication is to overcome communication barriers caused by mental noise. According to mental noise theory 10, when people are upset or under stress, they have difficulty hearing, understanding, and remembering information, which significantly reduces their ability to process it. Mental noise can be overcome by developing messages that are brief and understandable within a message map framework 11. Message maps are used to develop key risk communication messages that respond to underlying concerns and specific questions. These messages are developed by distilling complex information into easily understood messages, and are usually written at a reading level at least four grade levels below the average reading level of the target audience.

A message map has several layers. The first identifies the target audience and the specific question or concern to be addressed. The second layer contains three key messages that respond to the question or concern. The third layer provides groups of three supporting facts for each key message. (See Figure 1.)

Figure 1: Message Map

Stakeholder/Target Audience: Media, General Public

Question/Concern: What can be done to limit the spread of the influenza virus?

Key Message 1

Key Message 2

Key Message 3

Washing your hands helps to prevent the spread of the influenza virus.

Cover your coughs and sneezes.

Stay home if you are sick.

Supporting Fact 1-1

Supporting Fact 2-1

Supporting Fact 3-1

Use soap and water or alcohol-based hand sanitizer.

Use a disposable tissue to cover your coughs and sneezes.

People who have the flu usually have a high fever and muscle aches.

Supporting Fact 1-2

Supporting Fact 2-2

Supporting Fact 3-2

Rub all parts of the hands for at least 20 seconds.

Avoid coughing or sneezing into your hands.

Rest, drink fluids, and take non-aspirin pain relievers.

Supporting Fact 1-3

Supporting Fact 2-3

Supporting Fact 3-3

Wash your hands after coughing and sneezing and before eating.

Covering coughs and sneezes when you are sick helps prevent others from catching the flu.

Stay home when you are sick to prevent spreading influenza to others.

The messages are presented in three short sentences that convey three key messages, ideally of nine words each or 27 words total. Each primary message has three supporting messages that can be used to provide context for the issue being mapped. Note that supporting messages are not listed in logical or chronological order. Because people in stressful situations tend to remember only the first and last messages, supporting messages are arranged so that the most important messages occupy the first and last positions. Thus, using message maps in risk communication optimizes the likelihood that risk information will be heard, understood, and remembered.

Message Maps in Action
Message maps can be used for developing health information materials, a frequently-asked-questions section on a website, fact sheets, telephone hotline scripts, and press releases. Understanding the target audience is essential to effective risk communication. To convey successful messages that bridge the gap between experts and members of the target audience, it is essential to know what and how the target audience thinks. It is necessary to identify and understand pre-existing beliefs before they can be explicitly addressed. This is where linguists can make significant contributions to facilitating risk communication. For example, you may be asked to convey information based on a message map that relies on germ theory. If germ theory is not a common concept in the ethnic/linguistic groups represented in the target audience, you can be instrumental in developing a different strategy appropriate for getting the information to this target audience.

Examples of pandemic influenza message maps can be found at  and  As you read guidelines and recommendations, be aware of the ways the following words are usually used.

• Must: an absolute requirement.

• Should: recommended and ought to be done if possible.

• May: allowed to.

• Can:able to.

• Might: there is a possibility something could exist or happen.

Linguists can use their risk communication skills to serve as volunteers in their communities. ATA has partnered with the American Red Cross to develop a nationwide volunteer network of professional interpreters. For more information, see In addition, the Medical Reserve Corps has teams of local volunteer medical and public health professionals who contribute their skills to such efforts as immunization clinics and staffing influenza hotlines. Visit their website at

Know the Facts, Ignore the Hype
For the most complete information on influenza, both general and specific, visit the Centers for Disease Control and Prevention at (enter “flu” in the search slot [includes videos]), or use an online resource like Google Scholar or PubMed (

1. Sreta, D, et. al. “Pathogenesis of Swine Influenza Virus (Thai Isolates) in Weanling Pigs: An Experimental Trial.” Virology Journal (Volume 6, 2009), 6-34, (Accessed October 13, 2009).

2. “Oseltamivi,”

3. Census 2000 Evaluation A.5.a, “Analysis of the Linguistically Isolated Population in Census.” September 30, 2003,  (Accessed October 13, 2009).

4. “Novel Influenza A (H1N1) Virus Infections in Three Pregnant Women: United States, April-May, 2009.” U.S. Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report 2009 (Number 18, Volume 58), 497-500, (Accessed August 16, 2009).

5. “Intensive Care Patients With Severe Novel Influenza A (H1N1) Virus Infection - Michigan, June 2009.” U.S. Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report 2009 (Number 27, Volume 58), 749-52,  (Accessed August 19, 2009).

6. Gard, Betsy. “The Role of Interpreters During a Disaster.” The ATA Chronicle (American Translators Association, July 2009), 19.

7. Covello, Vincent T., and F. Allen. “Seven Cardinal Rules of Risk Communication” (Washington, DC: U.S. Environmental Protection Agency. Policy Document OPA-87-020, 1988).

8. Pandemic Influenza Preparedness and Response: A WHO Guidance Document,  (Accessed August 20, 2009).

9. U.S. Department of Health and Human Services Pandemic Influenza Plan Supplement 10 Public Health Communications,             (Accessed August 20, 2009).

10. Covello, Vincent T. “Risk Perception and Communication.” Proceedings of the North
American Conference on Drift Spray Management (1998),  (Accessed August 20, 2009).

11. Covello, Vincent T. “Risk Communication: Principles, Tools, and Techniques.” Global Health Technical Briefs,   (Accessed August 20, 2009).


Facts to Know

Epidemic: The occurrence of cases of human illness in a community or region in excess of the number of cases normally expected for that disease in that area at that time.

Outbreak: Sudden occurrence of an epidemic in a limited geographic area.

Seasonal: The appearance of disease at a particular time of the year.

Pandemic: An epidemic that affects a large area, usually hemisphere-wide or worldwide.

Pandemic influenza: Novel influenza to which all or most of the population is susceptible.

What is required for pandemic influenza infection to spread?

• Infectious agent: pandemic influenza.

• Susceptible hosts: people who have never been exposed to this new pandemic influenza and have no immunity.

• Means of transmission: infected people who are coughing and sneezing. The influenza virus can be transmitted either directly or indirectly.

Direct transmission occurs when infectious respiratory droplets produced by coughs or sneezes are inhaled through the nose or mouth. Indirect transmission occurs when fingers and hands that have come in contact with a surface contaminated with infected respiratory secretions touch the eyes, nose, or mouth.


Related Links

British Columbia Pandemic Influenza Preparedness
Information on pandemic influenza translated in Chinese, Punjabi, Spanish, French, and Vietnamese.

Centers for Disease Control and Prevention
H1N1 Swine Flu Information
Background, general information, and surveillance updates.

Centers for Disease Control and Prevention
Health Topic A-Z

Dictionary of Medical Abbreviations
One-stop access to U.S. Government H1N1, avian, and pandemic flu information, and frequently-asked-questions in Spanish, Chinese, and Vietnamese.

H2P Humanitarian Pandemic Preparedness at the Community Level
Low-literacy multilingual communication tools in English, Spanish,
Portuguese, and French.

A large collection of medical and health related dictionaries and glossaries in Spanish and English.

Medical Translation Blog


Pandemic Treatment Planning


World Health Organization Phase 5 Pandemic Alert
The World Health Organization issued a Phase 5 pandemic alert on April 29, 2009, which is characterized by human-to-human spread of the virus into at least two countries in one WHO region.

World Health Organization
Ten Things You Need to Know about Pandemic Influenza

Patricia Thickstun, an ATA-certified French-English translator, began translating while pursuing research at the Institut Pasteur-Paris and a doctorate in immunology at Université de Pierre et Marie Curie (Paris VI). At the Texas Department of Health, she was a hospital epidemiologist and directed a tuberculosis molecular epidemiology surveillance project and the Office of Language Services. A freelance medical and technical translator, she currently works at the Texas Health and Human Services Commission. She served as assistant administrator of ATA’s Medical Division (2007-2009), and was recently elected division administrator. She has given presentations on pandemic influenza at ATA’s 2006 Annual Conference and the 2009 Joint Mid-Year Conference of the Interpreters and Medical Divisions. Contact: