Behavioral Health Consequences To An Infectious Disease Outbreak

1. Behavioral Health Consequences To An Infectious Disease Outbreak Stephen Formanski, Psy. D. Merritt “Chip” Schreiber, Ph. D.

2. Hospitals “Full-Up”: the 1918 Influenza Pandemic This video shows the implications of Pandemic Influenza for Bioterrorism Response. www.hopkins-biodefense.org Hospitals “Full-Up”

3. The Public Health Goal: A Balanced Approach Inspire Preparedness Without Panic

4. Outline of Presentation FINISH Responder Issues START Administrative Issues Medical & Clinical Issues

5. 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.

6. 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 ***    

7. 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.

8. SARSQuarantine 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

9. 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

10. Recommendation for Quarantine

11. National Pandemic Influenza Planning Landscape National Strategy and Implementation Plan Departmental Plans Component Plans Synchronization Federal Region Plans … State, Local, and Urban Area Plans Private Sector Plans

12. 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)

13. Planning Assumptions: Health Care • 50% of ill persons will seek medical care • Hospitalization and deaths will depend on the virulence of the virus

14. 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

16. 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

17. 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

18. 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.”

19. 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.

20. 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)

21. 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.

22. 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.

23. 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.

24. 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.

25. 1918 Flu Epidemic Teaching Valuable LessonsActions 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, Johnsonfound.

26. 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.

27. 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)

28. BPCU • Diseases that could be handled in BPCUs include: • Smallpox • Monkeypox • SARS • Avian influenza • Viral Hemorrhagic Fevers (VHF)

29. BPCUsPsychosocial 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.

30. BPCUsPsychosocial 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)

31. Incremental changes to standard of care Usual patient care provided Austere patient care provided Low impact administration changes High-impact clinical changes Administrative Changes Clinical Changes to usual care to usual care Triage set up in lobby area Re-allocate ventilators due to shortage Significant reduction in documentation Vital signs checked less regularly Meals served by nonclinical staff Significantly raise threshold for admission (chest pain with normal ECG goes home, etc.) Significant changes in nurse/patient ratios Deny care to those presenting to ED with minor symptoms Nurse educators pulled to clinical duties Stable ventilator patients managed on step-down beds Use of non-healthcare workers to provide basic patient cares (bathing, assistance, feeding) Use of non-healthcare workers to provide basic patient cares (bathing, assistance, feeding) Allocate limited antivirals to select patients Cancel most/all outpatient appointments and procedures Disaster documentation forms used Minimal lab and x-ray testing Need increasingly exceeds resources John L. Hick, M.D. Emergency Physician, Hennepin County Medical Center, Chair, Metropolitan Hospital Compact

32. Alternative Care Sites Site Selection Tool: www.ahrq.gov/downloads/pub/biotertools/alttool.xls

33. 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.

34. 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.

35. 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.

36. 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

37. 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.

38. 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.

39. 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.

40. 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.

41. 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.

42. 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.

43. 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.

44. 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

45. 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

46. Neurological Problems

47. 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.

48. 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

49. Outline of Presentation FINISH Responder Issues START Administrative Issues Medical & Clinical Issues

50. 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.