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Chapter Overviews

Chapter One—Basic Clinical Principles covers basic disaster mental health principles and methods, strategies, and best practices for delivering disaster mental health services in an influenza pandemic.

Chapter Two—Viruses covers the types of influenza strains, discusses genetic shift and drift, virulence of different strains, immune system responses, long-term effects, and what we can learn from past epidemics.

Chapter Three—Adaptive Responses covers psychological and behavioral responses to public health recommendations, individual and community factors influencing behavioral and emotional consequences, maximizing adaptive behaviors and supporting key personnel in critical infrastructure functions.

Chapter Four—Risk Management, Quarantine and Isolation covers psychological and behavioral issues related to quarantine, isolation, sheltering, public health education and risk communication.

Chapter Five—Mental Health System Response covers the California disaster response system and the way that mental health services are provided within that system during an influenza pandemic.

Chapter Six—Other Mental Health Considerations covers short and long term presentations of anxiety during and after an influenza pandemic, ways of coping and delivering death notifications.

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Chapter One—Basic Clinical Principles

Key Concepts

No one who is in a pandemic is untouched by it

A wide range of normal stress and grief reactions occur in and follow a severe pandemic

Reactions may disorient victims at a very basic level

Most people pull together and function well during and immediately after a severe pandemic

Coping and adjustment problems tend to manifest later

Many emotional reactions stem from practical problems caused by the pandemic

DMH is often more “practical” than “psychological” in nature

DMH services must be tailored to the people and communities they serve

Natural social support systems are crucial to recovery

Pandemic trauma may be both individual and collective

In a pandemic, there will disruptions to daily living; personal loss; loss of equilibrium to individuals, communities, and geographic regions; economic devastation; and a ripple effect of multiple losses.

Both community and individual responses to a major pandemic disaster may tend to progress according to phases, such as those seen in other types of disaster. These phases are shaped by the interaction of psychological processes and external events. The phases are Heroic, Remedy or Honeymoon, Inventory, Disillusionment, and Reconstruction.

In the Heroic Phase, emotions are strong and direct. People respond to demands for heroic action. Altruism is prominent. People expend major energy in helping others to survive and recover. Family groups, neighbors, and emergency teams of various sorts are key supports.

The Remedy or Honeymoon phase generally extends from 1 week to 3 to 6 months after the disaster. In a pandemic, the end will not be clearly definable. Most likely, it will occur when a month (or some other pre-determined length of time) has passed with no new cases. People will have a strong sense of having shared and survived a dangerous, catastrophic experience. There will be an influx of official and governmental persons promising help. Survivors begin rebuilding their lives, anticipating considerable imminent help. Pre-existing and ad hoc community groups are especially important.

In the Inventory phase, survivors begin to recognize the limits of available assistance. Physical exhaustion sets in due to enormous multiple demands and financial pressures. Unrealistic optimism gives way to discouragement and fatigue.

The Disillusionment phase lasts from 2 months to about 2 years. People have strong feelings of disappointment, anger, resentment, and bitterness. The reality of losses and limits of available assistance become apparent. Disaster assistance agencies and volunteer groups have pulled out or are about to do so; survivors feel abandoned and resentful. There is a loss of “shared community” as survivors concentrate on rebuilding their individual lives. Individuals may have to deal with the pandemic again if it returns the next flu season.

In the Reconstruction phase, survivors realize and accept that they will need to solve the problems of rebuilding their own lives largely by themselves. This phase may last for several years, as survivors’ belief in their own community and their own capabilities returns. Community groups with long-term investments become key. Stressors will abound—family discord, financial losses, bureaucratic hassles, time constraints, lack of recreation or leisure time will complicate matters. Health problems and exacerbations of pre-existing conditions will emerge due to ongoing, relentless stress and fatigue.

There may be a vulnerable point at the anniversary of a pandemic. The 1918-19 influenza pandemic lasted over a year, and some individuals who were not sickened the first time became ill the second time the disease returned to their community. This could have led to retraumatization for some.

Common reactions in the early phase typically include energy, optimism, altruism, hope, a sense of relief (“I survived”), shock, denial and diminished cognitive functioning (such as with viral encephalopathy). Later reactions include multiple grief reactions, a sense that “reality sets in,” sense of loss, fatigue, frustration, cynicism, and diminished cognitive functioning (long-term cognitive changes).

At a community level, paranoia would increase. Mass panic and fear may set in, but history suggests that most people do not panic during any type of disaster. Quarantine and medical isolation would need to be utilized, and discrimination would occur (along with “scapegoating,” or blaming some group or individuals as being the cause of the outbreak). Individually, we would expect to see anxiety, depression, difficulty concentrating, trouble sleeping, paranoia/mistrust, hypervigilance, and obsessive/compulsive responses.

Characteristics of a pandemic also influence these responses. There may be a clearly defined case or there may not; it may take a while for public health authorities to gather enough reported cases to discover the pandemic. There may be no clearly defined end point (it would be measured as time since last case). The impact period is prolonged, which impedes the recovery process. Survivors would be more vulnerable to chronic stress and anxiety.

DMH services recognize the hierarchy of needs. Issues of survival are connected to feelings of safety and security. People may be concerned about not infecting family members and other loved ones. Some people may feel safer being cared for at home rather than in a hospital. Some people may choose to be quarantined in facilities outside the home or hospital, where basic needs are met, but without social support from family and friends.

Serious individual side effects may include Acute Stress Disorder (ASD), Post Traumatic Stress Disorder (PTSD), Major Depression, Dissociative Disorders, increased use/abuse of alcohol and other drugs, and family dysfunction (domestic violence, child abuse, divorce). Vulnerability factors for these disorders include severity of losses; pre-existing or previous psychiatric disorders; previous trauma or repetition of trauma; history of substance use/abuse; intense, prolonged exposure to trauma; and extended overexposure to media attention.

Personal assets and vulnerabilities mitigate and/or exacerbate disaster stress for individuals. Pandemics affect survivors both psychologically and socially, in addition to physically. Pre-existing community structures for social support and resources for recovery vary. Engagement with survivors and the overall community is key to promoting recovery. Program planners, administrators, and providers must appreciate “macro” views of interacting factors.

Key intervention strategies for DMH are to provide human contact when possible and however possible (this may be very difficult with an infectious disease, when many people are wearing personal protective wear, which tends to increase feelings of isolation). Also key are providing basic information to assist in problem-solving; building rapport through supportive listening; performing rapid assessment and triage; building trust through multiple brief contacts; and focusing on strengths, existing resources, and natural support systems. It is important to address crises in manageable doses; talking with a person in crisis doesn’t always mean talking about the crisis. Avoid psychological or psychiatric jargon and the concept of pathology. Assist with everyday tasks, as much as possible. Be a hopeful presence, but don’t offer false assurances. Normalize reactions; validate and affirm emotional responses. Help people understand what they are experiencing—facts and perceptions. Identify helpful coping strategies. Help survivors determine methods by which they can most quickly return to their pre-pandemic level of functioning (or close to that level).

DMH services are provided in a variety of non-traditional settings. With isolation and quarantine, services may have to be delivered in non-traditional ways, such as with telephones and computers. Protective gear will have to be used in face-to-face settings, which tends to make people feel more isolated. Many people will wear masks, thinking that this keeps them from getting germs. (The inexpensive, disposable masks that many people select actually keep them from spreading their own germs.) Increased use of public-service announcements will be a helpful way to spread information, along with”800” crisis lines. Media presentations will also be useful. Frequent telephone contact with those in isolation and quarantine will help lessen the sense of isolation. Web-based applications, such as use of home computers with cameras and telemedicine consultations, will also help provide monitoring of patients.

DMH strategies are meant to provide human contact and basic information to assist in problem-solving; to build rapport through supportive listening; to perform rapid assessment and triage; to build trust through multiple brief contacts; and to focus on strengths, existing resources, and natural support systems. It is vital to remember that DMH is not psychotherapy. DMH is community based, focusing on strengths and coping skills; seeking to restore pre-disaster levels of functioning; accepting content at face value; and validating and supporting. Psychotherapy, in contrast, is office based; focuses on diagnosis and treatment; attempts to change the individual’s personality and functioning; interprets thoughts and behaviors; and questions and examines.

When relating to survivors, it is important to recognize that a survivor’s life may have changed immeasurably and that “returning to normal” may not be possible or desirable, especially if that person has experienced numerous losses. Feelings may be intense, and it may be difficult for survivors to “get down to business,” or “be practical.” An outsider’s view of the situation may be less emotion-laden, but isn’t necessarily more “objective” or “reasonable.” Survivors should be offered information and encouragement; avoid advice or directives. Opportunities to review or process feelings come naturally; pushing victims to move too quickly may be harmful. Recognize and accept your own tolerance for others’ pain. Being aloof, condescending, or telling your own story is rarely helpful.

Ethically, pandemic disasters present clinicians with opportunities for “secondary gain.” Personal limitations and motivations should be examined and recognized. Avoid questionable or unethical practices, such as referring survivors to your own clinical practice; telling a survivor that he or she needs a specific treatment or technique only you can provide; using your knowledge of or a relationship with survivors for personal and professional gain.

Assessment is generally an informal process of noticing survivors’ needs and responding appropriately. Start with practical information and supportive interventions or refer as appropriate. When unsure of the proper response: Support (provide support to the survivor); Consult (review the situation with others); and Return (frequent brief contact builds a relationship and provides more accurate understanding of needs).

Differentiate four general types:

Those in need of practical information

Those who may benefit from a return visit for further contact, support and monitoring

Those who need immediate crisis counseling (supportive listening, debriefing, comfort)

Those who require referrals for severe reactions or chronic mental health conditions

Resources:

Myers, Diane; Wee, David F. Disaster mental health services: A Primer for Practitioners. Brunner-Routledge psychosocial stress series, New York, NY, US. Brunner-Routledge (2005)

American Red Cross—Disaster Services

http://redcross.org/services/disaster/0,1082.0_500.html

CDC—Surviving Field Stress for First Responders

http://www.phppo.cdc.gov/phtn/webcast/stress-05/

SAMHSA—National Mental Health Information Center—Disaster Information

http://www.mentalhealth.samhsa.gov/cmhs/emergencyServices/fpubs.asp

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Chapter Two—Viruses

Key Concepts:

Respiratory infections are the leading causes of death, according to the World Health Organization (WHO); this includes pneumonia and influenza

Other leading causes are AIDS, diarrheal diseases, tuberculosis, malaria, Hepatitis B, and measles

Many pandemics have occurred throughout history. Bubonic plague has made periodic appearances throughout the world, along with smallpox, measles, yellow fever, and influenza. In the US alone, there have been epidemics of yellow fever, cholera, polio, influenza, and AIDS/HIV. Pandemics in the US occur every 10 to 49 years, with an average of 29 years between pandemics. It has been 38-39 years since the last pandemic. Anthony Fauci, Director, National Institute of Allergy & Infectious Disease, NIH, stated last year, “If we had a massive pandemic tomorrow, all of us would be in very serious trouble.”

For perspective, consider that a several centuries ago, bubonic plague was moving through Europe. In 1666 London, Samuel Pepys recorded in his Diary, that in May there 43 deaths of all causes. By June 7, two or three houses were marked with a red cross on the door, a sign of plague. By June 10, Pepys reported that he had heard of plague in London, with 43 deaths that day. For the week of June 15, there were 115 deaths. By the end of June, an estimated 6,137 people had died of plague. July saw a total of 17,036 deaths (1,700 or 1,800 in the last week of June alone), and 31,159 deaths in August in London (6,000 to 10,000 in one week that month). That summer, about 15% of the population of London died.

Pandemic influenza was especially virulent in 1918-1919. It hit especially hard in Philadelphia, Pennsylvania, which did not observe many public health measures. In October 1918, during the first week of the month, there were 706 deaths. In the second week, 2,635 died. In the third week, 4,597 people died (for a total of 7,938 deaths). On October 16, 711 died in one day (more than on any previous day in the city’s history); in New York City, the record was 851 deaths in one day.

Why was the 1918 pandemic so deadly? There were many reasons. The virus was a new strain of H1N1, so there was no natural immunity in the population. The virus prompted an immune response that seemed to derail the body’s typical immune response. The individual’s immune system would instead (or in addition) attack the lungs, filling them with fluid in what is now called a “cytokine storm.” Many individuals also developed secondary bacterial infections. (This virus was possibly similar to the H5N1 avian flu.) Many physicians and nurses were in the military then, not in the community. Technicians and researchers also worked for the military. There were also shortages in many areas due to the war: food, coal for heat, money for supplies. These factors combined to make the virus stronger and deadlier. The H1N1 virus also re-emerged in other outbreaks: 1947-57 in Russia, 1978-79 and again recently in 2009. In the most recent outbreak, the virus seems less virulent.

The Influenza Virus

The influenza virus is enveloped by a negative strand RNA (ribonucleic acid, a type of molecule that is made of a long chain of nucleotide units; RNA viruses can be either positive or negative). Two spike proteins project off of the virus envelope; these two spike proteins are involved in entry and exit of the virus from the host cell. The influenza virus is classified as Orthomyxoviridae. The three known types are A, B, and C. A is the most virulent; B less so; and C is mild. Birds are the primary host for A; A is also found in pigs, seals, horses, ferrets, and humans, and causes widespread epidemics. According to the Centers for Disease Control and Prevention (CDC), there are three known A subtypes of influenza viruses currently in humans: H1N1, H1N2, and H3N2.

Types B and C are primarily human viruses, with occasional isolated cases from animals (not birds); B can cause regional epidemics and severe disease, but they have not caused pandemics, according to the CDC. Type C can cause mild disease. Types B and C are not classified by subtype.

The two influenza proteins (spike proteins mentioned above) are called Hemagglutinen (HA) and Neuraminidase (NA). There are at least 16 subtypes of HA known. This protein helps bind red blood cells together. The relationship between subtype and virulence is not known. This is the distribution of subtypes:

H1: Human, Swine, Bird

H2: Human, Bird

H3: Human, Bird

H4: Seal, Bird

H5, H6: Bird

H7: Seal, Bird, Horse

H8-H16: Bird

The Neuraminidase (NA) protein helps the virus to escape an infected cell and move on to other cells. Influenza medications inhibit NA; it has nine known subtypes, distributed like this:

N1: Human, Swine, Bird

N2: Human, Swine, Bird

N3-N6: Bird

N7: Seal, Bird, Horse

N8: Human, Bird, Horse

N9: Bird

N3 and N7 are found in humans in rare, isolated deaths.

The RNA within an influenza virus is in 8 separate pieces. When the virus undergoes biosynthesis inside a host cell, a viral enzyme copies the viral RNA. The enzyme is an RNA-dependent RNA polymerase (simply, an enzyme that produces RNA) with a high mutation rate. This high mutation rate leads to great variability of the virus’s genetic material, so new strains are consistently being created. Recombination of the virus components is possible because there is more than one reservoir for influenza: bird, pigs and other mammals. The bird reservoir is host to a very diverse population of influenza viruses with hemagglutinen proteins that have never been seen in human strains. Avian flu viruses do not typically infect humans very easily. Both avian and human influenza viruses can infect pigs and other mammals, however. When this happens, recombination between the viruses is possible, forming a new type of virus. New viruses tend to appear in Russia or China. They are classified as EMA (Europe, Middle East, Africa) 1, 2, or 3.

Antigenic drift and antigenic shift are also important in viruses changing. In antigenic drift, each time a virion (mature form of a virus when it is not inside a host cell) attacks a cell and multiplies, its RNA-dependent RNA polymerase induces point mutations into the viral genetic code. These lead to small changes in viral proteins (drift). Antigenic shift, however, is a process that has more dangerous implications for people. Antigenic shift occurs when different influenza viruses infect the same cell at the same time. The viruses may exchange pieces of RNA, forming recombinant strains very different from the original. These flu strains have entirely new hemagglutinen proteins that are very different from those in existing strains. There is no established immunity to these new hemagglutinens.

How does the influenza virus invade and infect? When the virus enters the body, its proteins act as antigens and stimulate the production of defensive proteins called antibodies. Defensive antibodies bind to the antigens on circulating flu virions, preventing them from attacking more cells and marking them for destruction by the body. The virus will trigger a cough or sneeze. A cough or sneeze can expel virus-containing droplets at up to 100 mph. Each droplet contains millions of viruses. As few as 10 viruses are needed to initiate an influenza infection.

Cytokines, as mentioned above, have been implicated in severe reactions to the influenza virus. Cytokines are self-regulatory proteins. Many different types of cells can produce the same cytokine. A single cytokine may act on a wide variety of target cells. Several cytokines may produce the same effect on a target cell (redundancy) and may involve up- and down-regulation of genes and their transcription factors. Types of cytokines are interleukins, colony-stimulating factors, interferons, tumor necrosis factors, growth factors, and chemokines. Cytokines normally activate or signal T-cells and macrophages to fight infection. Macrophages also produce cytokines. In a “cytokine storm,” the feedback loop gets out of control and too many immune cells are activated in one place. This may be due to a new, highly pathogenic invader. Fluids and immune cells accumulate in the lungs, eventually blocking off airways. A healthy immune system may do this, which may be why healthy, young people died in the 1918-1919 pandemic.

Avian influenza, which was a pandemic recently (1996-present), is H5N1, Influenza type A. Other strains have been H1N1 in 1918-1919, 1976, and has apparently emerged again as this is being updated (June, 2009). H2N2 was the type in the 1957 and 1962 epidemics. H3N2 appeared in 1968.

Fulminant influenza is reported during pandemics, and can affect everyone. It manifests in the pulmonary system; antibiotics are ineffective. Influenza viral pneumonia then develops. The severe symptoms are fever, cough, dyspnea, and cyanosis, which lead to death. Other complications of influenza are bacterial superinfections, such as bacterial pneumonia; and decompensation of chronic diseases (pulmonary diseases, heart disease, renal insufficiency, and metabolic disease). Respiratory complications can include upper respiratory infection (otitis media, sinusitis) and lower respiratory infection (exacerbation of asthma or COPD; croup, bronchiolitis; primary viral pneumonia—a rare event); and secondary bacterial pneumonia.

For more information on viruses:

Sompayrac, Lauren. 2002. How Pathogenic Viruses Work. Jones and Bartlett Publishers, Sudbury, MA.

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Chapter Three—Adaptive Responses

Key Concepts:

Viruses will be transmitted more quickly; vaccines may not be available quickly

People will want to receive information from medical personnel they know and trust

Institutions must be open and honest in answering the public’s questions

Policies need to be created to protect all individuals

Psychological and behavioral responses are critical. A massive surge on the medical system is likely. Adherence to public health recommendations will be low. Individual decisions can have grave consequences, and fears of their own risks can cause providers to avoid caring for patients. These will be discussed in more detail below.

A massive surge on the medical system is likely to occur. Viruses will be transmitted more quickly due to more urbanization and to more rapid international travel. Vaccines may not be quickly available (and will take time to develop and manufacture), and antiviral medications may be in short supply, or may lose effectiveness. The elderly, those with chronic conditions, and those individuals with suppressed immune systems are more likely to have more complicated illness and death. If the virus is like the one in the 1918-1919 pandemic, many young people would also be at risk.

Non-pharmaceutical interventions are available, and have been used in other pandemics or outbreaks. Before a vaccine is available, other interventions which have been proven helpful are social distancing; closing places for mass gatherings (schools, movies, etc.), isolation, and quarantine. These all need to be balanced with cultural preferences for independence, autonomy, and needs for basic goods and services. When an outbreak is just beginning and may not have yet been identified, it may be difficult to put these measures into action.

However, we know from past experience that adherence to public health recommendations will be low. People prefer to receive information and support from medical personnel they know and trust; without that, some people will insist that there is no real outbreak or pandemic, that it’s a government conspiracy, etc. Some people will not complete courses of medications; non-compliance or poor compliance is an everyday problem for people taking medications for non-serious illness. Some people will not cooperate with public health measures of containment, isolation or quarantine. During the SARS outbreak in Toronto, the newspapers published a photo of a man in a bar with a large group of people, showing his isolation orders to everyone and the camera. He was arrested shortly afterwards and kept in isolation.

That is an example of individual decisions which can have grave consequences. Some people will reject vaccinations because of rumors regarding side effects, for religious reasons, or for other reasons. Some people will violate quarantine and isolation restrictions. Mass fatalities and economic impacts must also be considered—how will people support themselves and their families if they cannot get to work, or if the worksite is closed? How can goods and services be delivered without exposing people to the virus? Containment measures may also affect religious or cultural rituals surrounding burial and grieving for those who perish. An elderly lady who was interviewed (but not videotaped) for the CME modules recalled the 1918-1919 epidemic, stating that on certain days in her neighborhood, bodies were wrapped in sheets and left outside the house for the city health officials to pick them up. She was instructed not to go near, or touch any of the bundles.

“When your eyes begin to water and your nose turns blue, If your lips begin to quiver, then you’ve got the Spanish Flu.”—Folk saying, 1918

Fear of their own risk can cause providers to avoid caring for patients. Providers do not want to become infected themselves, nor do they want to pass the infection along to their families. About 16% of physicians surveyed during the SARS outbreak in Hong Kong reported spending less time with their patients; some avoided performing physical examinations. Key personnel may avoid working with influenza patients.

Individual or community factors will influence behavioral and emotional consequences. These factors include pre-existing knowledge of the virus; information availability and accessibility; perceptions of equity; perceived trust and faith in institutions; and perceived and/or actual economic impact. For example, it may not be clear at the beginning of an outbreak if cases are due to the seasonal strains of influenza or due to the pandemic strain. General information will need to be provided about what each person can do to prepare and protect loved ones. It will be important to let people know where they can receive accurate information and guidance as the pandemic evolves.

Pre-existing knowledge includes knowing if the cases represent the seasonal influenza or pandemic strains. It is important to provide information about what each person can do to prepare and protect loved ones. Knowing where to receive accurate information and guidance as the pandemic evolves is vital. There is usually a great deal of information available; however, some of it is useless if not downright dangerous.

Information must be readily available and accessible. People will want to know:

What is the likelihood of becoming seriously ill?

What are personal protective actions to take?

What is being done to stop the spread of the disease?

How is appropriate assistance to be accessed?

Equity and the perception of equity are both important. What measures will ensure adequate and equitable resource distribution? Are civil liberties being respected? Are people being treated fairly? Will public health interventions have a differential impact on individuals or groups? These questions must be answered before the next pandemic, and the answers need to be widely available for all who want to see them.

This is part of the perceived trust and faith in institutions. Institutions must be open and honest in answering the public’s questions. Each institution must examine its own “track record” in being open and honest. Each institution and individuals must work on ways they can convey their preparedness and willingness to help.

The economic impact will be both perceived and actual. Avenues for assistance must be well thought out as the pandemic is likely to have an uneven economic impact. Individuals may be deprived of income as institutions close (schools or businesses). How will they meet their own and their families’ basic needs?

“I had a little bird,

Its name was Enza.

I opened the window,

And in-flu-enza.”

--Children’s jump rope rhyme, 1918-1919

Maximizing Adaptive Behavior Change

There are many ways to maximize adaptive behavior changes:

Create a website to serve as the authoritative central source of information for multiple audiences (an example is www.pandemicflu.gov)

Designate a multidisciplinary multi-agency task force of experts to create educational material for the website

Gather knowledge about pre-existing community beliefs and needs

Create feedback mechanisms within communities (use community and business leaders; include funeral home employees, an often-overlooked resource)

Gather information about pre-existing community resources and plans for detecting and responding to a pandemic

Assess existing social networks and identify potential opinion leaders from among natural leaders in the community

Utilize multiple communication channels (TV, radio, web, billboards)

Seek to use existing systems for disseminating information such as through the workplace or schools (existing newsletters or community bulletin boards)

Create media programming (positive role-modeling, self-care tips)

“Cover up each cough and sneeze. If you don’t, you’ll spread the disease.”

“Obey the laws and wear your gauze. Protect your jaws from septic paws.”

--Slogans, 1918-1919

Reduce social and emotional deterioration and improve functioning. To facilitate recovery, have guidance available to help people move from:

--Helplessness to efficacy (self and collective)

--Loss to connectedness

--Fear to calming

--Risk to safety

--Despair to hope

In a mass casualty event, approximately 4-20 friends and family are affected for every physical victim, in a spiraling risk. For each primary victim, there are the next of kin, emergency response personnel, and the general public (which includes friends, acquaintances, etc. of the victim).

Key personnel in critical infrastructure functions need support in various ways, such as:

Create policies for protecting lower-income individuals, families and businesses

Ensure that appropriate actions are taken to provide shelters for displaced persons, financial/economic relief, childcare, delivery of food and supplies, medication, compensation for lost wages,etc.

Special populations will need extra aid; these groups may be overlooked

Conduct exercises which include the full array of issues relevant to a pandemic (including religious, cultural/ethnic, mental health)

Create just-in-time training opportunities for specific skills required as a pandemic influenza evolves and key personnel shortages emerge

Train leaders within the response community on the importance of stress management and psychosocial support for their workforce

Establish appropriate work-rest schedules for personnel in critical infrastructure positions, including responders and health care providers

Facilitate support for and address needs of the responders’ family members

Websites:

American Psychological Association’s Help Center—The Road to Resilience

http://www.apahelpceter.org/featuredtopics/feature.php?id=6

Centers for Disease Control and Prevention—Role of containment measures

http://www.metroke.gove/health/isoquarantine/cdc/

CDC—Crisis and emergency risk communication course

http://cdc.gov/communication/emergency/cerc.htm

Project Liberty

http://www.projectliberty.state.ny.us/educational.htm

Sandman, P.M., and Lanard, J. Fear of Fear

http://www.psandman.com/col/fear.htm

SARS Scientific Research Advisory Committee, Geneva, Switzerland

http://psandman.com/articles/who-srac.htm

www.pandemicflu.gov

www.dhspandemic@dhs.gov

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Chapter Four—Risk Management, Quarantine and Isolation

Key concepts:

Communication needs to be available and open

The public is a willing, capable partner

Specialists from different disciplines will need to work together

Quarantine and isolation may be difficult to achieve, but may be essential to limiting the extent of a pandemic

Requirements of Risk Management

Effective information processing

Proactive development of response objectives, strategies and priorities

Effective communication under high-threat conditions

Consistent, accurate information from a trusted source that does not mix reassurances with facts

Information that supports authorities’ credibility and the public’s confidence

Recent Research Findings

The public mistrusts information and reassurance from the government. People would rather talk with someone they know who wants what is best for them, such as their own health care provider. The majority of people would risk exposure to a disease to be with and care for their loved ones. People say that they would also voluntarily go into isolation to reduce the risk of exposure for their loved ones.

When numerous agencies are involved, it is vital to answer these questions first:

Which agency takes the lead?

Who directs or coordinates activities?

Who is the public information officer?

Who is the primary spokesperson?

How will interagency coordination be accomplished?

Remember that agencies involved with animals could have valuable information.

Risk management involves essential tasks: ongoing, frank communication; a working relationship with media, volunteers, elected officials, emergency responders, public information officers, hospitals, and surrounding communities; messages in multiple languages; websites, handouts, pre-recorded information and phone banks may be very useful.

The public wants to be involved. This helps to build a sense of community. People are more likely to respond positively if they have been involved in the planning. People want to learn and to help. Provide them with information on how to minimize the risk of disease transmission. Demystify the process. Instruct the public in personal protective practices. Capitalize on existing civic, occupational, business, information and social networks (such as churches, workplaces, neighborhoods, schools, and community centers). Enlist the general public as a capable partner. Remember that the “general public” is a matrix of networks organized around social institutions and relationships.

Public groups provide ways to disperse information, such as telephone hot lines and rumor-reporting systems. Think beyond the hospital for pandemic care; home based treatment and supportive care will be needed. Provide information, which is as important as providing medicine. Encourage social distancing. People can be encouraged to wear masks to prevent their spreading of the disease. In the most recent epidemic, people did wear masks, but mostly because they thought it would keep them from getting the disease. Critical components of a response are effective leadership and delivery of clear, credible, timely information. Consider what people are willing to do and make provisions for them to do it. The public needs reassurance, descriptions of the response measures underway, instructions in personal and collective protective measures, and messages of hope.

Roles of Specialists

Infectious disease specialists could provide correct information quickly and credibly to prevent or counter inaccurate information from other sources. Health authorities should also be open and candid about the limits of available information and resources. Credibility gaps can open very quickly, which sends individuals to alternative and probably less accurate sources of information.

Stopping or limiting a pandemic requires public health professionals and government leaders to nurture the public’s trust and confidence. Trust depends on communication and debate, as a society, on the more ethically complex dimensions of disease containment. If public gatherings become impossible, use telephone trees, newsletters, and the Internet for communication. Use mass media, the Internet, multilingual materials, and culturally relevant messages endorsed by those with local respect and authority.

Risk Management Objectives

The objectives of risk management are to limit death and suffering through proper preventive, curative, and supportive care. Those who are most vulnerable will need to be tended to the most. Civil liberties need to be defended using the least restrictive interventions to contain the infectious agent. Preserved economic stability by managing financial impacts on victims, cities, neighborhoods and businesses.

Discourage scapegoating, hate crimes, and stigmatization of certain groups or locales as “contaminated” or unhealthy. Support individuals and the larger community to rebound from traumatic, tragic, unpredictable events. Provide mental health support to all who need it. Proactively develop priorities, response objectives, and strategies. Provide consistent, accurate information and ongoing frank discussion. Maintain credibility.

Quarantine and isolation

There are certain communicable diseases for which federal isolation and quarantine are authorized and are set forth through executive order of the President: cholera, diphtheria, infectious tuberculosis, plague, smallpox, yellow fever, viral hemorrhagic fevers, severe acute respiratory syndrome and influenza caused by novel or re-emergent influenza viruses that are causing, or have the potential to cause, a pandemic.

Quarantine issues

History

Quarantine has been used extensively throughout history, all over the world, as a tool to manage some infectious disease outbreaks. There has been no large-scale human quarantine in the US during the past 8 decades. Under quarantine, surveillance may be conducted to insure that individuals strictly adhere to public health measures. This involves close medical or other supervision of contacts to permit prompt recognition of infection or illness but without a restriction of movement. Quarantine exists at local, state and federal levels. It would be extremely difficult to quarantine wild birds, which could be spreading the virus through migration.

Many states require proof of a contagious disease, with person-to-person transmission and a risk of serious illness or death, before laws are enforced. Quarantine is usually authorized through a public health order; some states require a court order before an individual is detained. Many state laws are outdated, however. Some do not reflect current scientific understanding of disease or current treatments. They were also often enacted for a particular disease.

When quarantine is imposed, there may be questions, such as:

What happens to the family members of those who are quarantined?

Who establishes and lifts the quarantine?

Is quarantine voluntary or required?

How are people who have an infectious disease going to be transported to medical treatment?

How can public health officials work with different cultures regarding their beliefs in the transmission of illness?

Are there large-scale quarantine plans?

Is there training for public health staff?

Where may people be quarantine other than their homes?

Is there a reasonable plan of implementation, maintenance and removal of quarantine?

Is there a plan for transportation issues?

How are necessities to be provided?

What are the health risks to those quarantined but not symptomatic?

How are they monitored?

What will happen to the individual’s financial and employment status?

Are resources available to enforce the quarantine?

Can a quarantined group be confined for the duration during which they can transmit the disease?

Who monitors and how?

What are the consequences if the public disobeys quarantine orders?

What are the consequences of restricting commerce and transportation to and from the quarantine areas?

The specific mechanism of disease transmission must drive the disease containment strategy.

Isolation

Isolation involves separating persons who have a specific infectious illness from those who are healthy. This restricts movement to stop the spread of that illness. Authority for isolation is from various levels of government (local, state, and federal), and may also be voluntary. Isolation allows for focused delivery of specialized health care to infected people. They may be cared for in their homes, hospital, or designated health care facility. Levels may vary greatly among states.

For More Information:

Centers for Disease Control and Prevention

www.btc.cdec.gov

Disaster Mortuary Operational Response Team

www.dmort.org

National Disaster Medical System

www.oep-ndms.dhhs.gov

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Chapter Five—Mental Health System Response

Key Concepts:

Endemic refers to the habitual presence of a disease within a given geographic area

Epidemic refers to the occurrence in a community or region of a group of illnesses of similar nature, clearly in excess of normal expectancy, and derived from a common or from a propagated source

Pandemic refers to a worldwide epidemic

A disaster is a large scale catastrophe regardless of cause; it has sufficient severity and magnitude to warrant federal assistance to support state, local and relief organization response efforts. Assistance is required to alleviate damage, loss, hardship, and suffering.

Recent Pandemics

The first cases of H5N1 (avian influenza) were noted in 2003. As of June 1, 2009, according to the WHO, there were 433 laboratory-confirmed cases, with 262 deaths since 2003. This is a case-fatality rate of 60%. The greatest number of cases was in 2006, with 115 cases and 79 deaths. The Severe Acute Respiratory Syndrome (SARS) outbreak led to 8096 cases, with 774 deaths over the entire outbreak, with a case-fatality ratio of 9.6%, and includes only cases whose death is attributed to SARS (from November 1, 2002 to July 31, 2003). Currently, the H1N1 virus, Influenza A, has resulted in 19,273 cases worldwide with 117 deaths (as of June 3, 2009). The case-fatality rate so far is less than one percent (.06%).

All the states have disaster classifications and levels. In California, for example, Level 1 is considered a minor to moderate incident prompting a local government response, such as a local outbreak which is quickly contained. Local resources are adequate, and a mental health response may not be required. An example would be a local outbreak of a mild disease (such as chicken pox), which is contained locally and quickly. Level 2 is considered a moderate to severe incident prompting a regional response. A “Local Emergency” is proclaimed by county government, and may require mutual aid from other counties. A mental health response is likely. An example is an outbreak of a severe virus (SARS-like) in a multi-county region. At Level III, a major incident prompting a state and federal response has occurred. Local and state resources are overwhelmed; a “State of Emergency” is proclaimed by the governor. A request is made for a “Presidential Major Disaster Declaration.” A mental health response is typical; it may be short-term or long-term duration. An example is a severe influenza with a higher than normal mortality, affecting primarily young and healthy individuals, and occurring over a large geographic region. A severe influenza pandemic would have a potential for a high number of casualties; limited availability of treatments; limited effectiveness of treatments; overwhelmed hospital and medical systems; and misperceptions about transmission would be common.

States must have emergency plans. These plans are available at each state’s official website. Information is also available through the Robert Wood Johnson Foundation, in their 2008 report, “Ready or Not? Protecting the Public’s Health from Diseases, Disasters and Bioterrorism,” published with the Trust for America’s Health.

California’s Example

In California, for example, the state emergency plan establishes general policies to guide statewide emergency management activities. It assigns specific responsibilities to state agencies, and provides guidance on interagency coordination. State planners estimate that California health care facilities will need to provide care for an additional 54,000 patients. Funds cover medical supplies and equipment for 20,000 hospital beds for alternate care sites; 2,400 ventilators; 300 million N95 masks for health care workers; three 200-bed mobile field hospitals; and antiviral medications. Different departments within the state government have worked on pandemic planning for schools; developed a brochure and fact sheets in 12 languages on influenza, isolation and quarantine; conducted risk communication trainings on influenza pandemic with local health departments; and produced public service announcements on pandemics.

National Response

Federally, the National Incident Management System (NIMS) works with states to manage pandemics. Each state also has its own system (SIMS in California). NIMS guidelines must be followed by all levels of government and all response organizations. There are also VOADs (Volunteer Organizations Active in Disasters), which partner with and supplement the lead government agencies. Examples are the American Red Cross; Lutheran Social Services Disaster Response; Catholic Charities USA; National Organization for Victim Assistance; and the Salvation Army.

NIMS

The National Incident Management System (NIMS) contains 1) a Command and Management component, 2) a Preparedness component, and 3) a Resource Management component.

Command and Management is comprised of the Incident Command System, Multi-agency Coordination System, and a Public Information System. Preparedness is made up of Planning, Training and Exercises, Standards and Certification, Mutual Aid and Information and Publications components. Resource Management works to identify and type resources, certify and credential personnel, and to inventory, acquire, mobilize, track and recover supplies.

A severe influenza pandemic would produce numerous societal effects. In the 1918-1919 pandemic, young healthy people had the highest number of fatalities. With the next pandemic, we simply don’t know who will be most affected. In a typical influenza season, the very young and elderly usually experience the highest fatality rates. In a pandemic, there may be forced closure of most public gatherings; probable adverse public behavior (such as breaking of quarantine); sensationalized and pervasive media coverage; and periods of enforced isolation may be possible. The psychological impact may be delayed in onset, as everyone is first occupied with helping loved ones survive. Continuing fear, worry, and anxiety may occur in the general population; a second wave of the pandemic could intensify these feelings. There is potential for long-term inter-generational effects, as were seen from the 1918-1919 pandemic.

The National Response Plan establishes a comprehensive, all-hazards plan integrating multiple response sectors:

Homeland security and emergency management

Law enforcement and fire departments

Public works

Public health

Emergency medical services

The private sector

For Federal Disaster Mental Health funding, a Presidential Major Disaster Declaration must be made and a demonstrated need for disaster mental health services must exist. The state department of mental health applies for FEMA CCP (Crisis Counseling Program) funds on behalf of declared counties. County mental health departments implement FEMA CCP services through contracts with community-based organizations.

FEMA CCP Core Services include outreach; crisis counseling; screening and assessment; information and referral; public education; and stress management interventions. Services are provided to anyone who lives or works in the declared disaster area, first response personnel, and disaster workers. Services are offered in care and shelter sites; neighborhoods, homes, businesses, and gathering places (though in a pandemic, public gatherings could be curtailed); town hall meetings and public forums; medical triage centers; government offices, businesses; schools and social activity centers.

These are the FEMA CCP principles:

Interventions are psycho-educational in focus

Mental health diagnoses/labels are avoided

Services are tailored to target populations and community-based needs

Reactions to stress are validated

Experiences are normalized

There are many benefits to the FEMA CCP program: reduced stigma (recovery focus versus a mental health or counseling focus); no cost to disaster survivors or communities; neighborhood and community based; avoids diagnosis and other limitations of formalized psychotherapy.

For further information:

California Department of Mental Health:

http://www.dmh.ca.gov/disaster/default.asp

FEMA:

http://www.fema.gov/nims

Center for Mental Health Services:

www.mentalhealth.samhsa.gov/cmhs/EmergencyServices/default.asp

National Response Plan:

www.his.gov/dhspublic/interapp/editorial/editorial_0566.xml

NIMS Training:

http://training.fema.gov/EMIWeb/IS/is700.asp

VOADs:

American Red Cross

www.redcross.org

Lutheran Social Services Disaster Response

http://ldr.org

National Organization for Victim Assistance

www.trynova.org

Catholic Charities USA Disaster Response

www.catholiccharities.usa.org

Salvation Army

www.salvationarmyusa.org

Emergency Medical Services Authority

www.emsa.ca.gov

California Department of Health Services

www.dhs.ca.gov

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Chapter Six—Other Mental Health Considerations

Key Concepts:

Pandemics have major impacts on life for many individuals

Pathology is affected by the degree of exposure to the pandemic, scope of the pandemic, death toll and individual coping skills

Existing pathologies will worsen, such as personality and mood disorders and substance abuse

There are many factors affecting the delivery of death notifications

Group Responses: Normal Survival Reactions

People will experience a loss of confidence in government and other institutions. They will have anger at authority figures. There will be scapegoating, social isolation and demoralization. Despite all this, adaptive, helpful, prosocial behaviors are typical, not rare.

Group Responses: Abnormal Survival Reactions

Mass panic rarely occurs. People will experience symptoms of anxiety and arousal, which may be misattributed to the effects of medical illness.

Normal Immediate Responses

People will have strong emotions. They will show signs and symptoms of autonomic arousal. Initially, people may show improved cognitive performance (e.g., focusing is adaptive for responders). Later, as stress persists, cognition may fail (e.g., disorganized thinking, or a “fight or flight” response). This may be confused with actual cognitive problems from the influenza virus, rather than stress.

Normal Short Term Responses

This phase lasts from one week to several months. Intrusive symptoms begin: recollection of the event, and nightmares occur. There are signs of autonomic arousal: startle response may be exaggerated or occurs in response to minor stimuli, hypervigilance, and insomnia occur. Primary care physicians may see increased visits for symptoms such as dizziness, headaches, nausea, and fatigue. Anger, irritability, apathy, grief, mourning and social withdrawal are common.

Normal Long Term Responses

This phase may last up to a year or more; it may occur if the pandemic continues and returns to the individual’s community. Survivors may feel disappointed and resentful if hopes for aid and restoration are not met. The sense of community may weaken as individuals focus on their personal needs. Most people will rebuild their lives and focus on future challenges. Some will experience post traumatic psychiatric symptoms, as well as extended grief and mourning. Retraumatization may occur as the next flu season begins, even if the outbreak is not as severe.

Anxiety Disorders

Marked psychological and biological reactions are expected after a disaster. Primary and emergency care clinics will likely see stress-related emotional and physical symptoms or worsening of existing health conditions (especially among victims without mental health care). About 30% of exposed individuals will display either Acute Stress Disorder (ASD) or Posttraumatic Stress Disorder (PTSD), experiencing flashbacks or nightmares; emotional numbing; persistent symptoms of autonomic arousal; desire to avoid reminders of the trauma; and dissociation (e.g., memory loss).

PTSD

Longitudinal studies indicate that PTSD can be chronic and delayed in onset. Secondary stressors play an important role in the development of PTSD. There are numerous risk factors for developing PTSD.

Other Disaster-Related Problems

Other problems associated with disasters are depression, grief, bereavement, increased domestic violence, increased substance abuse, and mood disorders. Patients may report fatigue, trouble sleeping, loss of appetite, or irritability rather than anxiety or depression. Grief/bereavement are different from depression in the following ways:

Grief/Bereavement

Symptoms

Depressed mood

Thoughts of joining loved one(s)

Hears loved one’s voice

Course

Main symptoms <8 weeks; lessens somewhat

over time

Depression

Symptom

Depressed mood and 4-5 other symptoms

Thoughts of suicide

Auditory hallucinations

Course

Deteriorating without treatment

Studies of disaster survivors suggest long-term depression, anxiety, other mood disorders and feelings of guilt. These are associated with increased substance abuse, violence in interpersonal relationships, and increased risk of suicide. Census data show that those in utero during the 1918-1919 pandemic later showed higher drop-out rates, greater likelihood to go on disability, and greater likelihood to retire early. Survivors may lose their sense of safely. The economics of a community may be permanently harmed, contributing to a sense of hopelessness.

Community Response

Hospitals and communities must develop emergency plans and practice them to reduce the likelihood of chaos and behavioral problems after a disaster. (Most hospitals now do have emergency plans, which are a requirement for federal funding.) Hospitals, clinics, and emergency departments will most likely be overwhelmed with people seeking treatment. Members of various professions are more likely to be affected by a high death toll: health care workers, mortuary workers, funeral home and cemetery employees, and nursing home employees.

Coping Styles

Coping styles are the behavioral and psychological methods that people use to master, tolerate, reduce, or minimize stressful events.

Types of Coping Styles

Problem vs. Emotion Focused; Active vs. Passive; Dangerous vs. Avoidant

Problem-focused coping strategies use actions intended to alleviate stressful circumstances. Emotion-focused coping strategies involve efforts to regulate the emotional consequences of stressful or potentially stressful events. Active coping involves behavioral or psychological responses designed to change the nature of the stressor itself. Passive coping involves activities or mental states that prevent directly addressing stressful events. (Passive coping may also include activities that may provide more information without leading to action.) Dangerous coping involves attempting to be closer to the event. Avoidant coping involves engaging in activities to get one’s mind off the event, instead of taking appropriate actions. Both of the last two methods may expose an individual to greater danger.

Delivering Death Notifications

Death notifications are usually delivered by staff from the Medical Examiner’s Office. When the ME’s office is overwhelmed, other physicians, mental health specialists, and law enforcement officials may be asked to assist in notifying the next of kin. A pandemic may raise additional issues of isolation and quarantine; if so, follow public health guidelines. Keep in mind that a loved one’s death is one of the deepest traumas a person can experience. The news can be traumatizing, with a powerful impact, both emotionally and physically. The impact may be immediate or delayed.

The way the news is given can greatly influence how people accept the loss. Deliver the news in person, if at all possible, in a quiet place with no interruptions. Deliver the news before it’s reported in the media. Provide all information available, even if little is known. Include a telephone number to call for more information, if possible.

Ideally, a team of two should provide the news (one man and one woman). This is for mutual support and practical reasons. If the deceased is someone known to you, don’t underestimate the effect of this fact on your own reactions; make sure you have your own support.

Learn as much as you can beforehand; the Medical Examiner’s office will have the most information. Family members usually will want to know as much as possible. The family also needs to know what information may be released to the media, if any. No information should go to the media until the family members have been notified.

What to Say

Don’t rush. Be sensitive to the effect of your words. Be clear and honest. Use simple, direct language. The people you are talking to most likely already suspect that they are going to hear bad news. It’s perfectly alright to state that you have some bad news for them. Use the individual’s name; you may also refer to “your loved one.” Let them know how sorry you are about what has happened, with such phrases as:

“I can’t begin to imagine how you may be feeling right now.”

“Please accept my condolences on the death of (name).”

“I’m so sorry that we are meeting under these tragic circumstances.”

Debriefing for Professionals

Meet as soon as possible afterwards. Ask each other what went right and what went wrong about the meeting with the family. Share personal feelings and concerns; what you have done is stressful, difficult, and can be depressing. Support each other.

In mass casualties, various groups can assist, such as the Disaster Mortuary Operational Response Team from the National Disaster Medical System. In a pandemic, however, all resources may be stretched beyond capacity. Keep in mind that many hospitals do not have plans developed for dealing with mass casualties from a pandemic.

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Acronym List

ARC: American Red Cross

CAHAN: California Health Alert Network

CDC: Centers for Disease Control and Prevention

COOP: Continuity of Operations Plan

DMH: Disaster Mental Health OR Department of Mental Health

EIS: Epidemic Intelligence Services

FEMA-CCP: Federal Emergency Management Agency—Crisis Counseling Program

HRSA: Health Resources and Services Administration

NDMS: National Disaster Medical System

NIAID: National Institute for Allergy and Infectious Diseases

NIMS: National Incident Management System

SAMHSA: Substance Abuse and Mental Health Services Administration

SEMS: Standardized Emergency Management System (California)

VOAD: Voluntary Organizations Active in Disasters

WHO: World Health Organization