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.
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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

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The Public Health Goal A Balanced Approach

• Inspire Preparedness Without Panic

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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.

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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)

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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.

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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

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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

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Recommendation for Quarantine
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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
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Pandemic Planning Assumptions

• DHHS and the White House Homeland Security
  Council (HSC) utilizing historical data from this
  centurys 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)

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Planning Assumptions Health Care

• 50 of ill persons will seek medical care
• Hospitalization and deaths will depend on the
  virulence of the virus

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ESF 8 Planning Assumptions at a Glance

• Planning for a 1918like 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

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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

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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 wont 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

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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.

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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.

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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)

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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.

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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.

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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.

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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, OToole and Henderson
• It is recommended that Large scale quarantine be
  eliminated from consideration.

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• 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, Johnson found.

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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.

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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)

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BPCU

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

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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.

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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)

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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.

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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.

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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.

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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

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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
  21
• 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.

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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

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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.

51
Outline of Presentation
FINISH
Responder Issues
START
Administrative Issues
Medical Clinical Issues
52
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

53
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

54
Questions and/or Comments
55
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.