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about the CDC posting. Questions commonly asked focused
on outbreak investigation findings, including information
on geographic location of affected areas and specific brand
information for foods linked to outbreaks. The convictions and
beliefs category included any comments that stated a Facebook
user's preconceived notion about the outbreak, the food linked
to the outbreak, or food-handling practices and often included
speculations about outbreak causes. The emotional responses
category included any type of emotional valence; commonly
identified emotions were confusion and a sense of worry. The
promoting another cause category included comments that
were not related to the CDC message but rather supported
another effort, such as advertisements for a product or service,
vaccine hesitancy, or local food movements.
FSAs
Six multistate foodborne outbreak investigations resulted in
an FSA, with a total of 22 (81%) Facebook posts (Table 1). The
number of posts for each outbreak investigation ranged from
one to eight (five for eggs, two for deli ham, five for ground
beef, one for tahini, eight for romaine lettuce, and one for pork
patty). These 22 Facebook posts generated 2,454 comments
(94% of all comments analyzed), with a range of 4 to 1,646
(median of 31) comments per post. One FSA related to a 2018
outbreak of Shiga toxin-producing E. coli infections linked
to romaine lettuce was responsible for 1,646 (67%) of the
2,454 comments. Of these 1,646 comments, 362 (22%) were
analyzed and coded before data saturation was reached for this
post. All other comments (808 comments) for the remaining
21 FSAs were analyzed and coded. A total of 1,170 (48%) of
the 2,454 comments were analyzed and coded, resulting in
eight categories created from 37 unique codes (Table 3).
The eight categories were information sharing, actions,
questions, emotional responses, blame, food specific,
promoting another cause, and unrelated. Five of the categories
were the same as those identified for INs. The blame category
included comments that discussed who was responsible or
accountable for the outbreaks and the illnesses related to
them. Common discussion topics were the lack of government
regulations and/or faults in the food supply chain, including
blaming the country of origin or contamination in the
manufacturing process. The food-specific category included
codes that appeared only for postings associated with the
ground beef or romaine lettuce outbreak posts. Comments
unique to ground beef posts conveyed users' inability to
identify product associated with the outbreak. Multiple
Facebook users stated that they stored their ground beef
without the original packaging, preventing them from using
the lot code information provided in the Facebook post to
identify the potentially contaminated ground beef. Topics of
comments unique to romaine lettuce posts were focused on
in-store product observations (e.g., product still available for
sale after the outbreak announcement), packaging labels that
identified the region in which the romaine lettuce was grown,
and potential sources of contamination (e.g., agricultural water
and fecal contamination from farmworkers). The unrelated
category included comments that did not relate to the outbreak
post, such as jokes and puns.
Comparing categories between INs and FSAs
No meaningful differences were found when comparing
the categories from INs with those from FSAs. Five common
categories were identified between the two types of posts: (i)
information sharing, (ii) actions, (iii) questions, (iv) emotional
responses, and (v) promoting another cause.
DISCUSSION
Risk communication is a critical part of the overall public
health response effort during a foodborne outbreak. Social
media channels such as the CDC's Facebook page provide
a convenient and powerful platform for disseminating risk
messages to an online following of > 3.8 million users. Given
the size of the audience, post creators should know how
users react to and use the CDC Facebook posts so that future
messaging can be adjusted if needed.
When comparing Facebook users' responses to INs with
those to FSAs, many of the same categories of comments
emerged. One explanation could be that there were not
enough INs to compare with FSAs during the period of
interest. More than 4 times as many Facebook posts and 15
times as many comments on Facebook posts resulting from
FSAs compared with those from INs; more differences may
have been detected if the number of Facebook posts and
comments had been similar. Another explanation for this
finding could involve the content of the messages for Facebook
posts that result from INs and FSAs. Although the two types
of Web-based communication tools are distinct, the Facebook
posts that result from them sometimes overlap in message
content. For example, INs for the outbreaks linked to turkey
and cake mix (Table 1) both had recall messaging within their
corresponding Facebook post; recall messaging is more often
associated with an FSA. When to use an IN versus an FSA is
determined by health communicators and investigators that are
involved in the outbreak. Because the course of each outbreak
investigation is unique, the messages in the Facebook posts
resulting from them have the potential to overlap, as seen in
these examples. Given this overlap, readers exposed to this
messaging may not recognize the distinction between FSAs
and INs and are likely to focus on message content more than
the tool used to create the message.
The goal of risk communication during an outbreak is
to inform consumers of actions they can take to protect
themselves; success is associated with timely, accurate
information being disseminated to the appropriate audience
so that the recommended actions can be taken. This evaluation
was conducted to evaluate risk communication success
with a qualitative approach by (i) uncovering ways in which
Facebook users help increase the reach of messaging during
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