Executive Summary, Mental Health and Behavioral Guidelines for Response to a Pandemic Flu Outbreak, Submitted by the Mental Health Section, APHA

Prepared by a team from the Center for the Study of Traumatic Stress, Uniformed Services University School of Medicine: Robert Ursano, MD; Derrick Hamaoka, MD; David Benedek, MD; Nancy Vineburgh, MA; Carol Fullerton, PhD; Harry Holloway, MD; and Dori Reissman of the Centers for Disease Control and Prevention.


It is only relatively recently that attention has been focused on the mental health impact of disasters. Previously, concerns related to immediate physical health and community infrastructure risks in the aftermath of disasters had overwhelmed considerations of the short- and long-term mental health consequences of disasters, or the extent to which mental health played a role in the impact of a disaster. In the arena of the health impact of natural disasters, the majority of data available relate to weather or geologic events. In contrast, there is almost no data on the mental health impacts of outbreaks of disease.

Necessary Elements to a Public Mental Health Response to Pandemic Flu
· While there have been relatively few large outbreaks to inform an appropriate response to a potential pandemic flu, the existing data on infectious disease outbreaks, data from natural disasters, and public mental health principles can be brought to bear on the development of such a response. Public mental health measures must address numerous areas of potential distress, health risk behaviors, and psychiatric disease.
· Areas of special attention include: (1) the role of risk communication; (2) the role of safety communication through public/private collaboration; (3) psychological, emotional, and behavioral responses to public education, public health surveillance and early detection efforts; (4) psychological responses to community containment strategies (quarantine, movement restrictions, school/work/other community closures); (5) health care service surge and continuity; and (6) responses to mass prophylaxis strategies using vaccines and antiviral medication.

Recommended steps in response to a pandemic flu outbreak are divided into four phases: preparedness, early outbreak response, later response and recovery, and mental health intervention planning.

1. Education. Public education must begin immediately, before a pandemic occurs, and be embedded into existing disaster public education campaigns, resources, and initiatives.
2. Leadership preparation. Leadership preparation includes ensuring that public officials understand which members of the population will be most vulnerable and who will need the highest level of health services, including mental health services.
3. Sustaining Preparedness Measures. Maintenance of motivation, capital assets, equipment, and funding to continue preparedness efforts over the long term must be considered, not just to focus on immediate needs.
4. Leadership Functions. Leadership functions require identification of community leaders, spokespersons, and natural emergent leaders who can affect community and individual behaviors and who can endorse and model protective health behaviors.

Early Pandemic Response
1. Communication. Wide dissemination of uncomplicated, empathically informed information on normal stress reactions can serve to normalize reactions and emphasize hope, resilience, and natural recovery. Recommendations to prevent exposure, infection, or halt disease transmission will be met with skepticism, hope, and fear. In addition, compliance with recommendations for vaccination or medication treatment or prophylaxis will vary greatly and will not be complete. Interactions with the media will be both challenging and critical. The public must clearly and repeatedly be informed about the rationale and mechanism for distribution of limited supplies (e.g., Tamiflu). Leadership must adhere to policies regarding such distribution, as abuses of policy will undercut public safety and adherence to other risk reduction recommendations.
2. Tipping points. Certain events, known as ‘tipping points’, will occur that can dramatically increase or decrease fear and helpful or health risk behaviors. Deaths of important or particularly vulnerable individuals (e.g., children), new unexpected and unknown risk factors, and shortages of treatments are typical tipping points. The behavioral importance of community rituals (e.g. speeches, memorial services, funerals) are important tools for managing the community-wide distress and loss.
3. Surges in demands for health care. Those who believe they have been exposed (but have not actually been) may outnumber those exposed and may quickly overwhelm a community’s medical response capacity. Planning for the psychological and behavioral responses of the health demand surge, the community responses to shortages, and the early behavioral interventions after identification of the pandemic and prior to availability of vaccines are important public health preparedness activities.

Later Response and Recovery
1. Community structure. Maintenance of community is important. In-person social supports may be hampered by the need to limit movement or contact due to concerns of contagion. Virtual contact will be particularly important at these times. At other times local gathering places could be points of access for education, training and distribution. In as much as allowed, instilling a sense of normalcy could be effective in fostering resiliency. In addition, observing rituals and engaging in regular activities (such as school and work) might manage community and organizational distress and untoward behaviors. Providing tasks for community action can supplement needed work resources, decrease helplessness and instill optimism. Maintenance and organization in order to keep families and members of a community together is important (especially in event of relocation).
2. Stigma and discrimination. Under conditions of continuing threat, the management of ongoing racial and social conflicts in the immediate response period and during recovery takes on added significance.
3. Management of fatalities. Mass fatality and management of bodies, as well as community responses to this, must be planned for. Containment measures related to bodies may also be in conflict with religious rituals of burial, and the usual process of grieving. Local officials should be aware of the potential negative impact of disrupting normal funeral rituals and processes of grieving in order to take safety precautions.

Mental Health Intervention Planning
1. Efforts to increase health protective behaviors and response behaviors. Individuals under stress will need reminders to take care of their own health and limit potentially harmful behaviors.
2. Good risk communication following risk communication principles.
3. Good safety communication. Promoting clear, simple, and easy-to-do measures can be effective in helping individuals protect themselves and their families.
4. Public education. Educating the public not only informs and prepares, it enlists them as partners in the process and plan. Education and communications will need to address fears of contagion, danger to family and pets and mistrust of authority and government.
5. Facilitating community directed efforts. By organizing communal needs and directing action toward tangible goals, this will help foster the inherent community resiliency toward recovery.
6. Utilizing evidence-informed principles of psychological first aid. These basic principles include:
- Establish safety; identify safe areas and behaviors.
- Maximize individuals’ ability to care for self and family and provide measures that allow individuals and families to be successful in their efforts.
- Teach calming skills and maintenance of natural body rhythms (e.g., nutrition, sleep, rest, exercise).
- Maximize and facilitate connectedness to family and other social supports to the extent possible (this may require electronic rather than physical presence).
- Foster hope and optimism while not denying risk.
7. Care for first responders to maintain their function and workplace presence.
8. Mental Health Surveillance. Ongoing population level estimates of mental health problems in order to direct services and funding. Surveillance should address PTSD, depression and altered substance use as well as pscyhosocial needs (eg housing, transportation, schools, employment) and loss of critical infrastructure necessary to sustaining community function.