Behavioral Health Consequences
To An Infectious Disease Outbreak
Stephen Formanski, Psy. D.
Merritt “Chip” Schreiber, Ph. D.
Hospitals “Full-Up”
Hospitals “Full-Up”: the 1918 Influenza
Pandemic
This video shows the implications of
Pandemic Influenza for Bioterrorism
Response. www.hopkins-biodefense.org
The Public Health Goal:
A Balanced Approach
Inspire Preparedness Without Panic
Outline of Presentation
FINISH
Responder Issues
START
Administrative Issues
Medical
&
Clinical Issues
Familiar Communicable Diseases
are No Less Threatening
Consider these World Health Organization statistics:
One-third of the world's population is infected with tuberculosis, and
2 million die from the disease each year. As many as 79% of new
TB infections are "superstrains," resistant to the most common
therapies.
Some 42 million people are HIV positive, and 3.1 million die from
AIDS each year.
Between 3 million and 5 million new cases of influenza are reported
each year, contributing to 250,000 deaths worldwide.
170 million people are chronically infected with the hepatitis C virus,
and 3-4 million are newly infected each year.
Headline Grabbers
Human Immunodeficiency Virus: Acquired Immunodeficiency Disorder (HIV/AIDS)
Severe Acute Respiratory Syndrome (SARS)
West Nile Virus
Avian Flu
Virual Hemorrhagic Fevers (VHF)
Argentine hemorrhagic fever
Crimean-Congo hemorrhagic fever (CCHF)
Ebola hemorrhagic fever
Kyasanur Forest disease
Hendra virus disease
Bolivian hemorrhagic fever
Sabia-associated hemorrhagic fever
Venezuelan hemorrhagic fever
Lassa fever
Hantavirus pulmonary syndrome (HPS)
Marburg hemorrhagic fever
Omsk hemorrhagic fever
Nipah virus encephalitis
Lymphocytic choriomeningitis (LCM)
Hemorrhagic fever with renal syndrome(HFRS)
Tick-borne encephalitis
Rift Valley fever ***
How Bad Was SARS
2003 SARS outbreak appeared to originate in China
Ontario: 375 contacted SARS and 44 died
Demonstrated that earlier warning signs were ignored.
Demonstrated that identified faults were not corrected.
Roughly 30% of quarantined individuals suffered sxs
of PTSD and depression. Duration of quarantine was
significantly related to increase in PTSD sxs.
SARS
Quarantine Lessons Learned
Civic Duty and not legal consequences was the
primary motivation for compliance.
Public Cooperation depends on public
confidence that public health decisions are
made on an independent medical basis
Public Cooperation depends upon public
understanding of what is necessary and the
authorities are keeping everyone informed of
what is happening
SARS Quarantine Obstacles
Fear of loss of income
Poor logistical support
Psychological Stress
Spotty monitoring of compliance
Inconsistencies in the application of
quarantine measures
Problems with public communication
Recommendation for Quarantine
National Pandemic Influenza Planning Landscape
National Strategy and
Implementation Plan
Departmental Plans
Synchronization
Component Plans
… Federal Region Plans
State, Local, and Urban Area
Plans
Private Sector Plans
Pandemic Planning Assumptions
DHHS and the White House Homeland Security
Council (HSC) utilizing historical data from this
century’s pandemics estimated about 20-30% of the
population would be ill. Worst case scenario 40%.
Spread of the Pan flu would be comparable to past
pandemics and the length of the outbreak would be
about 6-8 weeks in a given community.
Even if 30% of a community gets sick, the illness
would be spread over an 6-8 week period. The
average duration of the illness is 10 days.
Even in peak times it is likely that no more than 10%
of the community would be ill at any one time. (caring for
sick family members will raise the absentee rate)
Planning Assumptions: Health Care
• 50% of ill persons will seek medical care
• Hospitalization and deaths will depend on the
virulence of the virus
Moderate (1957-like) Severe (1918-like)
Illness 90 million (30%) 90 million (30%)
Outpatient medical care 45 million (50%) 45 million (50%)
Hospitalization 865,000 9, 900,000
ICU care 128,750 1,485,000
Mechanical ventilation 64,875 745,500
Deaths 209,000 1,903,000
ESF 8 Planning Assumptions at a Glance
Planning for a 1918–like pandemic
Incident of National Significance determined at
US Stage 2
Federal public health and medical assistance
provided to States, Tribes and Territories will be
coordinated by HHS/ASPR
Public health and medical support to Foreign
nations and international organizations will be
coordinated by HHS/ASPR/OGHA and DOS
Cumulative Number of Confirmed Human Cases of Avian Influenza
A/(H5N1) Reported to WHO
1 March 2007
Country 2003 2004 2005 2006 2007 Total
cases deaths cases deaths cases deaths cases deaths cases deaths cases deaths
Azerbaijan 0 0 0 0 0 0 8 5 0 0 8 5
Cambodia 0 0 0 0 4 4 2 2 0 0 6 6
China 1 1 0 0 8 5 13 8 1 0 23 14
Djibouti 0 0 0 0 0 0 1 0 0 0 1 0
Egypt 0 0 0 0 0 0 18 10 5 3 23 13
Indonesia 0 0 0 0 19 12 56 46 6 5 81 63
Iraq 0 0 0 0 0 0 3 2 0 0 3 2
Lao People's
0 0 0 0 0 0 0 0 1 0 1 0
Democratic Republic
Nigeria 0 0 0 0 0 0 0 0 1 1 1 1
Thailand 0 0 17 12 5 2 3 3 0 0 25 17
Turkey 0 0 0 0 0 0 12 4 0 0 12 4
Viet Nam 3 3 29 20 61 19 0 0 0 0 93 42
Total 4 4 46 32 97 42 116 80 14 9 277 167
Total number of cases includes number of deaths.
WHO reports only laboratory-confirmed cases.
All dates refer to onset of illness.
Influenza Antiviral Drugs and Medical
Supplies
Strategy
– Procure 81 million courses
of antivirals
6 million courses to be used
to contain an initial U.S.
outbreak
75 million courses to treat 25
percent of U.S. population
Accelerate development
of promising new antiviral
drugs
Disease Mitigation Measures
Hand washing and respiratory etiquette
Social distancing including the prohibition of
social gatherings
Travel restrictions
Use of masks
Use of antiviral medications
Use of Isolation (confinement of symptomatic patients so they
won’t infect others)
Use of voluntary or involuntary quarantine (the
separation of asymptomic people who may have been exposed to infection
and may or may not become ill)
School closures
Disease Mitigation Measures Feasibility
Hand washing and respiratory etiquette
The influenza virus survives on your hand for 5 minutes or less. This
mitigating measure is advisable.
Social Distancing:
The recommendation is a distance of 3 feet or more. Efficacy of this
course is unknown and in many situations not likely (bus, rail, air travel,
grocery shopping) NYC subway averages 4.7 million riders each day.
Los Angeles Metro area averages 1.3 million riders per day.
Travel Restrictions:
The World Health Organization Writing Group stated
“screening and quarantining entering travelers at
international borders did not substantially delay virus
introduction in past pandemics. . . and will likely be even
less effective in the modern era.”
WHO group on SARS concluded that “entry screening of travelers
through health declarations or thermal scanning at international
borders had little documented effect of detecting SARS cases.”
Disease Mitigation Measures Feasibility
Use of masks
– PPE is essential to curtail the transmission of influenza in
hospitals.
– Patients would be advised to wear surgical masks to
decrease respiratory particles being sent into the air.
– In Asia during the SARS epidemic many people wore
surgical masks in public. Studies have shown the ordinary
surgical masks do little to prevent inhaling small droplets
which may contain influenza. The masks can only be worn
for a short time before the pores of the mask clog with
moisture from breathing and the airflow goes around the
mask.
Disease Mitigation Measures Feasibility
Use of Antiviral Medications:
– The effectiveness and optimal use of antivirals is
uncertain due to several factors
Virus mutation, thus increasing the possibility that
resistance can develop
The available quantities of antiviral for prophylaxis
Logisitical challenges with providing timely tx.
The amount of antivirals used to prevent
infection in 1 healthcare worker is the
equivalent of treating 5-7 ill patients
(prophylaxis w/75mg, BID for 8-10 weeks vs. tx
with 150mg, BID for five days)
Disease Mitigation Measures Feasibility
Antivirals (the good news)
GlaxoSmithKline believes it has developed a
vaccine for the H5N1 deadly strain of bird flu
that may b e capable of being mass produced
by 2007.
-The vaccine has proved effective at two doses
of 3.8micrograms during clinical trials in
Belgium.
Sanofi-Aventis drug company is also working
on a vaccine.
Disease Mitigation Measures Feasibility
Use of Isolation:
– With expected shortages of medical beds, home isolation of
non-critically ill influenza patients is a viable option
– There are several logistical issues that may hamper people
from being able to remain isolated in their home such as: the
provision of basic medical care and obtaining food and
supplies.
– “It may not be easy to persuade those without paid sick
leave (some 59 million persons) to absent themselves from
work, unless employers address this problem directly”
Inglesby et. al.
Disease Mitigation Measures Feasibility
Use of Quarantine:
– The aim of voluntary home quarantine is to keep possibly
contagious, but asymptomatic people out of contact with
others. This raises both practical and ethical issues:
Community implementation raises issue of levels of care and support
required
Compliance issues: Will parents be willing to stay home
? What about college issues: dorming
? What about the homeless population (750,000)
What about the economic concerns of individuals, families and the
community.
Ethical issues:
Healthy individuals staying with infected individuals. Quarantine would
prevent healthy children from being sent to stay with other family
members.
Disease Mitigation Measures Feasibility
Large-Scale Quarantine:
– “The World Health Organization (WHO) Writing
Group, after reviewing the literature and considering
contemporary international experience, concluded
that “forced isolation and quarantine are ineffective
and impractical.” Inglesby, Nusso, O’Toole and Henderson
– It is recommended that Large scale quarantine be
eliminated from consideration.
1918 Flu Epidemic Teaching Valuable Lessons
Actions Taken Apparently Were Effective
By David Brown
Washington Post Staff Writer
Wednesday, December 13, 2006; A04
New analysis of how American cities responded to the killer Spanish flu of 1918 suggests that closing schools, banning large
gatherings, staggering work hours and quarantining households of the ill may have saved tens of thousands of lives. Which of
the many non-pharmaceutical interventions was especially effective in reducing mortality is unknown, but all would theoretically
be available should pandemic influenza again sweep the country. The new findings run counter to previous research that
concluded that the public health measures instituted in 1918 may have delayed or dampened the epidemic in many cities but
probably had little effect on the ultimate death toll. The new data were presented this week to Centers for Disease Control and
Prevention experts, who are helping to draw up guidelines for what local health departments might do during the early stage of
an influenza pandemic, when a vaccine would be unavailable and there would be too few antiviral drugs to go around.
"There is reason for optimism. Even almost 100 years ago, with some very simple tools, there may have been an effect of these
measures," said Martin Cetron, a physician who directs global migration and quarantine at the CDC. In 1918, the public health
responses included isolating the ill, quarantining houses, closing schools, canceling worship services, restricting the size of
funerals and weddings, closing saloons and theaters, restricting door-to-door sales, discouraging the use of public
transportation, staggering the hours of business and factory operations, imposing curfews and, in some places, recommending
the use of face masks in public. Howard Markel, a physician and historian at the University of Michigan Medical School, is
leading a project to analyze the experience of 45 American cities, looking for relationships among flu cases, mortality and public
health measures.
The researchers used a model to determine what the epidemic would have looked like had no measures been taken and
compared that result with a city's actual experience.
– St. Louis closed its schools at a time when flu was causing 21 more deaths per 100,000 people per week than what had
been seen in previous years. That step -- the earliest taken by any of 33 cities analyzed so far -- appears to have reduced
St. Louis's flu mortality by 70 percent.
– Cincinnati responded less quickly, invoking public health measures when excess deaths from flu were 46 per 100,000. It
reduced its potential flu mortality by 45 percent.
– Philadelphia was extremely late, not acting until its excess death rate was 250 per 100,000. That reduced mortality by 28
percent, Markel and his colleagues found.
How U.S. communities would react to a sudden closure of schools is uncertain, although the experience this past fall of one
rural Appalachian county suggests that there may be little opposition over the short term. Yancey County, in rural and
mountainous western North Carolina, closed its 2,559-student school system from Nov. 2 to 13 because of an outbreak of
influenza B. A random survey of households found that 91 percent supported the school board's decision. In half of those
households, all the adults worked outside the home. During that period, one-quarter of them had to take time off from work,
mainly because they were ill themselves or had to care for a sick family member, and not simply to stay with children not in
school, said April J. Johnson of the CDC's Epidemic Intelligence Service, who investigated the outbreak. In only two of 220
households did adults have to pay for extra child care when schools were closed. In most cases, relatives and friends stepped in
to help, Johnson found.
Disease Mitigation Measures Feasibility
School Closure:
The impact of school closings on illness rates is mixed.
– Modeling programs suggest that school closures would significantly
decrease disease transmission. However, closing school for longer than
the usual periods would impact working parents as well as have an
adverse impact on the 29.5 million children who are fed through the
National School Lunch Program.
– Additionally if schools are closed so should malls, churches, and other
gathering sites. If all of these sites are closed, how will this effect
internet use? COOP planning?
– Legal issues associate prolonged closing of schools: school board
meeting and the need for a quorum; compensation & work assignment
of school staff; adequate instruction time; school populations with
special needs populations (IEPs); use of the school as a healthcare
facility (ACF); financial and governance concerns (grants); contracts
(performance clauses); and parental communications (advance
notification on prolonged closures). L. Soronen, JD., National School Board
Association.
Containment Units
Biocontainment Patient Care Units (BPCU)
One approach to containing hazardous infectious
disease in hospital settings is a BPCU.
There are 3 BPCUs in existence in the US
Fort Detrick, MD (3 beds)
Emory University Hospital, Atlanta, Georgia (2 beds)
University of Nebraska Medical Center in Omaha, NE
(10 beds)
BPCU
Diseases that could be handled in BPCUs
include:
– Smallpox
– Monkeypox
– SARS
– Avian influenza
– Viral Hemorrhagic Fevers (VHF)
BPCUs
Psychosocial and Ethical Issues
Here are the recommendations made by the
panel of experts:
– Psychosocial issues should be addressed with the
patient on a regular basis
– Counseling support, educ., and discussion with the
family members are important.
– Personal items brought into the unit will have to be
decontaminated or destroyed
– Psychiatrists should be available for diagnosis and
management of patients with more complicated
psychiatric presentations.
BPCUs
Psychosocial and Ethical Issues for Staff
BPCU workers may experience high levels of stress
and thus MH services should be provided.
Staff training is crucial to minimize fears and dispel
misunderstandings.
Ethical Issues
A shift away from patient centered ethics to a more
institution focused ethical standard (i.e. reason to
withhold/deny medical services)
Incremental changes to standard of care
Usual patient Austere patient
care provided care provided
Low impact High-impact
administration changes clinical changes
Administrative Changes Clinical Changes
to usual care to usual care
Triage set up in Significant reduction in Vital signs checked less Re-allocate ventilators
lobby area documentation regularly due to shortage
Significantly raise
Deny care to those
Meals served by Significant changes in threshold for admission
presenting to ED with
nonclinical staff nurse/patient ratios (chest pain with normal
minor symptoms
ECG goes home, etc.)
Use of non-healthcare Use of non-healthcare
Stable ventilator patients
Nurse educators pulled workers to provide basic workers to provide basic
managed on step-down
to clinical duties patient cares (bathing, patient cares (bathing,
beds
assistance, feeding) assistance, feeding)
Cancel most/all Allocate limited
Disaster documentation Minimal lab and x-ray
outpatient appointments antivirals to select
forms used testing
and procedures patients
Need increasingly exceeds resources
John L. Hick, M.D. Emergency Physician, Hennepin County Medical Center, Chair, Metropolitan Hospital Compact
Alternative Care Sites
Site Selection Tool: www.ahrq.gov/downloads/pub/biotertools/alttool.xls
Risk Communications
To the General Public
Simplicity
Credibility
Verifiability
Consistency
and speed count in an Emergency.
The message must be repeated, come from a
legitimate source, be specific to the emergency,
and offer a positive course(s) of action.
Risk Communications
To Staff:
It is incumbent upon facilities to develop
and implement effective means to
communicate to their workers information
regarding the outbreak, health risks,
containment strategy, and measures to
protect workers, patients, and visitors.
Vaccines, Antivirals and Materiel Assets as of January 5th,
2007
Currently available in the SNS:
– Antivirals:
Tamifu (oseltamivir) 21.6 million regimens with an additional 20,500
regimens of oral suspension
Relenza (zanamivir) 84,000 regimens
– Ventilators
– PPE: 49.7 million Surgical masks and 81.5 million N95 respirators
Additional items that are projected to be procured this year
(2007) include:
– Antivirals:
Tamifu (oseltamivir) 7.9 million
Relenza (zanamivir) 6 million regimens
– Additional PPE: 1.7 million Surgical masks, 23.4 million N95 respirators,
face shields, gowns and gloves
– Additional ventilators
– Syringes and needles
Prepandemic vaccine is not part of the SNS. It was purchased
by HHS and is being held by manufacturers until needed.
Psychological Sequale
Traumatic Grief: Child and/or Adult
Acute Stress Disorder
Post traumatic Stress Disorder (9 % in GP)
Depression
Substance Abuse/Substance Withdrawals
Exacerbation of pre-existing conditions
In some cases alteration in Cognitive abilities.
Increased suicide rates
Increase in domestic abuse
Medication issues
Traumatic Grief
Grief is not the same for every person.
Normal grieving usually includes:
Social Withdrawal
Preoccupation
Even painful emotions
With time, the intensity of grief subsides
Traumatic grief is when the emotions remain high and
the individual gets “stuck” somewhere in the grieving
process.
Traumatic Grief – Symptoms
Recurrent intrusive thoughts of the deceased
Intense loneliness for the deceased
Intense sadness, irritability, anger, or bitterness
Persistent feeling of being dazed, or shocked
Avoidance of activities that remind you of the
deceased
Avoidance of social gatherings
Avoidance of places related to the death
Traumatic Grief has sxs of PTSD, anxiety and
depression that persist over time.
Acute Stress Disorder
What is an Acute Stress Response?
ASR is a transient disorder of significant severity which develops in an
individual without any other apparent mental disorder in response to exceptional
physical and/or mental stress and which usually subsides within hours or days. The
stressor may be an overwhelming traumatic experience involving serious threat to the
security or physical integrity of the individual or of a loved person(s). The symptoms
usually appear within minutes of the impact of the stressful stimulus or event, and
disappear within 2-3 days (often within hours). Partial or complete amnesia for the
episode may be present. There must be an immediate and clear temporal connection between the
impact of an exceptional stressor and the onset of symptoms; onset is usually within a few minutes,
if not immediate. In addition, the symptoms:
(a) show a mixed and usually changing picture; in addition to the initial state
of "daze", depression, anxiety, anger, despair, over activity, and withdrawal may all be seen, but no
one type of symptom predominates for long;
(b) resolve rapidly (within a few hours at the most) in those cases where
removal from the stressful environment is possible; in cases where the stress
continues or cannot by its nature be reversed, the symptoms usually begin to
diminish after 24-48 hours and are usually minimal after about 3 days.
Acute Stress Disorder as a Predictor of
Posttraumatic Stress Symptoms
Acute stress symptoms were found to be an
excellent predictor of the subjects' posttraumatic
stress symptoms 7-10 months after the
traumatic event.
High levels of peritraumatic dissociation and
acute stress following violent assault are risk
factors for early PTSD. Identifying acute re-
experiencing can help the clinician identify
subjects at highest risk.
Pre-disaster Factors for PTSD
Gender:
Women or girls were affected more adversely by disasters than were men or boys for
which women's rates often exceeded men's by a ratio of 2:1
Age and Experience :
Middle-aged adults were most adversely affected. Professionalism and training
increase the resilience of recovery workers, although past trauma per se does not.
Culture and Ethnicity:
Majority groups fared better than ethnic minority groups. There are culturally specific
attitudes and beliefs that may prevent individuals from seeking help.
Socioeconomic Status (SES).
Lower SES was consistently associated with greater post-disaster distress. The effect of
SES has been found to grow stronger as the severity of exposure increases.
Family Factors :
Married status was a risk factor for women. Being a parent also added to the stress
of disaster recovery, mothers were especially at risk for substantial distress. Children
were highly sensitive to post-disaster distress and conflict in the family. When measured,
parental psychopathology was typically the best predictor of child psychopathology.
Pre-disaster Functioning and Personality
Pre-disaster symptoms were almost always
among the best predictors (if not the best
predictor) of post-disaster symptoms. Persons
with pre-disaster psychiatric histories were
disproportionately likely to develop disaster-
specific PTSD and to be diagnosed with some
type of post-disaster disorder.
Within-disaster Factors
Bereavement during the disaster,
Injury to oneself or a family member,
Life threat, panic or similar emotions during the disaster,
Horror,
Separation from family (especially among young people)
Extensive loss of property, relocation or displacement.
As the number of these stressors increased, the likelihood
of psychological impairment increased.
Post-disaster Factors
Stability versus change in psychological
symptoms was largely explained by
stability versus change in stress and
resources.
Attention needs to be paid to stress levels
in stricken communities long after the
disaster has passed
Neurological Disorders Associated
With Infectious Diseases &/or
Medications Used in Tx Regiments
Decreased IQ – HIV/AIDS
Cryptococcal Meningitis – HIV/AIDS
Cortical Dementia – HIV/AIDS
Tuberculosis Dementia – excessive
alcohol use, AIDS, TB
Cerebral Toxoplasmosis – AIDS
Herpes Zoster: Shingles
Neurosyphylis: untreated syphilis
Neurological Problems
Pre-Planned Response to Funerals
Lesson Learned
– The family of SARS victims often were unable
to engage in traditional burial rituals.
Mourners had to stand off in a distance.
For some, there was no closure.
Behavioral Practice Guidelines
Do not provide formal interventions
immediately after the traumatic event.
Perform Psychological First Aid (PFA)
Screen for risk factors from those who
seek professional help.
Timely symptom based assessment.
Provide empirically informed interventions.
Attend to traumatic grief.
Gray, M; Litz, B; Behavior Modification 2005
Outline of Presentation
FINISH
Responder Issues
START
Administrative Issues
Medical
&
Clinical Issues
Administrative Issues
Maintaining licensing requirements
Dealing with travel bans but needing to
respond.
Keeping income flowing (especially for private
practitioners)
Dealing with Insurance companies and sorting
out billable services.
Outline of Presentation
FINISH
Responder Issues
START
Administrative Issues
Medical
&
Clinical Issues
Responder Issues
Line of Duty Death
Great concerns about the wellbeing of
their own family and loved ones
Forced into new and unfamiliar roles
Health care staff accepting an altered level
of care
Triage reversal: taking the least sick first
Fear of contagion/spreading illness
Responder Issues
Prolonged separation from family
Constant pressure to keep performing
A sense of ineffectiveness
Extreme fatigue, sadness, etc
Dealing with issues one has not inoculated
oneself for.
Stigmatization for oneself or family members
Dealing with a mass fatality
Impact on special populations, State Hospitals,
prisons, jails, youth detention facilities, ICE
detention faculties
Questions and/or Comments
Presenter Information
CAPT Stephen Formanski, Psy. D.
United States Public Health Service
ASPR/Regional Emergency Coordinator – Region 3
Merritt “Chip” Schreiber, Ph. D.
Dr. Schreiber is a Reserve Corp Officer in the USPHS
as well as a UCLA psychologist working with the
Center for Public Health and Disasters, School of
Public Health and The National Center for Child
Traumatic Stress, NPIH/David Geffen School of
Medicine, UCLA.