Stresses the need for the incorporation of the following additional amendments in the National Pandemic Influenza Plan:
Develop guidelines about establishing work-relatedness of influenza cases, for use in workers’ compensation cases.
Provide governmental support for: essential employers who must hire or replace workers on MRP; laboratory surveillance; worker mental health services; emergency assistance to enable workers to stay at work while managing outside commitments; and extreme business expenses for worker protection.
Develop and maintain a list of key occupations and workplaces at risk, to aid in assuring workers are protected, including prioritization for distribution of limited vaccine or prophylaxis.
Require employers of first responders and healthcare workers (often local government) to stockpile respirators and other protective equipment.
Urges businesses to establish policies for employee compensation and sick leave that would be used during a pandemic that are not punitive and provide employees with adequate financial security to enable them to stay home from work when they or a family member are sick;
Affirms that businesses need to be intimately involved in planning efforts for pandemic flu on the local and state level, in collaboration with state and local health departments, schools and government;
Stresses the need for businesses to conduct education programs related to pandemic influenza to ensure that employees are aware of how to prevent transmission of the flu, signs and symptoms of the virus, and the need to stay home from work when they are sick.
Public Health Education and Communications
The HHS Pandemic Influenza Plan stresses that the success of containment measures, ranging from isolation to hand washing, depends on the level of understanding of the community of the importance of such measures. Such education must begin before a pandemic influenza outbreak or other public health emergency. Ultimately, public information and key messages must work to garner public cooperation, help multiple populations understand federal, state and local response efforts, educate and motivate vigilant adherence to self-protective prevention behaviors, and prepare communities for lifestyle, mental, and emotional issues related to response and containment measures. To this end, the media must be included in creating national, state and local education campaigns to ensure that accurate messages get consistently communicated.
The field of risk communication focuses on how to communicate with the public during an emergency. Significant questions will be raised by the public with the arrival of both avian influenza (food safety, water safety, handling and disposal of dead birds, need for environmental safeguards, etc) as well as in response to the emergence of a pandemic (need for increased protective hygiene measures, use of gloves and masks, utilization of public health containment measures such as “snow days” and where and when the public can access vaccinations and/or antivirals). However, there is a need to communicate effective messages to the public before a pandemic occurs so that they are ready and have accurate expectations.
Communication challenges are frequently the greatest issue faced in any emergency response.48 Accurate, consistent information and language understood by all community members is the backbone of a coordinated effort with local, state and federal government and allied response partners. In the pre-pandemic, pandemic alert and pandemic states, there must be consistent messages from local, state and federal public health partners.
The HHS Pandemic Influenza Plan, in annex 10, provides guidance regarding public health communications and contains recommendations for communications during the interpandemic, pandemic alert and pandemic stages. For the interpandemic and pandemic alert phases, the report recommends that pandemic flu preparedness efforts should include: assessing communications capacity and needs; conducting collaborative planning; developing and testing standard procedures for disseminating information; and developing, testing, and disseminating locally tailored messages and materials. During a pandemic, the plan outlines steps that need to be taken to provide timely, accurate information; coordinate communications leadership across all tiers of jurisdiction and promptly address rumors, misperceptions, stigmatization, and any unrealistic expectations about public and private health provider response capacity.9
Urges that communication systems, such as the national Health Alert Network, must be put in place and regularly tested to build rapid response capability as well as participating in drills and exercises with other response partners;
Urges CDC and state and local governments to provide funding to immediately plan and disseminate public health education campaigns urging individual and community readiness for an outbreak. Such efforts should include organizing community coalitions including local public health agencies, schools, churches, businesses and other key community stakeholders in order to create and disseminate effective disease containment messages;
Urges CDC and state and local health departments, in partnership with the media, schools, business and faith- and community-based organizations conduct a public education campaign addressing the utilization of containment measures ranging from restriction of public events to isolation to quarantine before a pandemic occurs so the public is aware of their use and importance;
Calls for HHS to develop templates for ads, fliers, radio ads and speeches that focus on different disease containment measures that local public health agencies, community leaders and multimedia outlets can use in order to ensure that public health education and communications are consistent across community and state lines;
Urges the development of public education campaigns for those on continuing medication to stockpile medication and medical supplies in case of an emergency;
Urges further research on the role of stockpiling other supplies;
Urges the development of public education campaigns in access to vaccines and other countermeasures, their administration and risks and benefits.
VI. Medical Countermeasures
Vaccine Manufacturing, Distribution, Tracking and Administration
Improving the nation’s readiness for pandemic influenza must be led by an effort to prevent transmission of the virus. As such, our national strategy must not be dominated by or solely rely on antivirals. Vaccine development, research and purchase should be priority activities in planning for pandemic influenza on the federal level, as pandemic viruses might be resistant to antivirals or develop drug resistance due to widespread use.49,50 The goal of developing and utilizing a pandemic influenza vaccine will differ from the seasonal flu vaccine, as mild illness will likely not be prevented. Ultimately, vaccine use should prevent mortality and severe morbidity associated with pandemic influenza.51 Vaccine administration may also be different if two doses of vaccine are required to achieve a protective level of immunity. If two doses of vaccine are required, then the education of the public will be a key component, as they are accustomed to the one-dose seasonal influenza vaccine.9
Scientists face several challenges in developing a pandemic flu vaccine especially since the exact viral strain that will result in an outbreak will be unknown until the incident begins unfolding. If the pandemic influenza strain is avian, mechanisms other than requiring two doses of vaccine may need to be developed to enhance the immunogenicity of the avian hemagglutinin (HA) to achieve a protective level of immunity. Also, researchers will not know what level of cross-protection a vaccine matched to an earlier virus strain would provide to the pandemic strain in circulation. Finally, considering there will not be enough vaccine supply in the early months to vaccinate the population at risk, researchers will have to explore different ways to maximize the number of doses available. This would include reducing the amount of HA antigen required to reach a protective level of immunity; alternative means to administer the vaccine; and use of known and novel adjuvants to enhance immunogenicity.51
Widespread vaccination of the population against the pandemic virus depends on the capacity to manufacture vaccines in an expedited and effective manner. As the process of preparing high growth reassortant influenza viruses by infecting an embryonated hen’s egg does not yield an efficient vaccine production, APHA supports efforts to utilize plasmid-based reverse genetics or other techniques to generate pandemic influenza vaccine candidates.
The HHS Pandemic Influenza Plan and the National Strategy for Pandemic Influenza outline the role of the federal government in investing in cell-based vaccine technology, and to purchase 20 million doses of the current avian A/H5 N1 vaccine. The plan also states that “at the onset of an influenza pandemic, HHS, in concert with federal partners, will work with the pharmaceutical industry to procure vaccine directed against the pandemic strain and to distribute vaccine to state and local public health departments for pre-determined priority groups based on pre-approved state plans.9
APHA supports the significant investment in cell-based vaccine technology, which will not only facilitate mass, expedited manufacturing of millions of doses of influenza vaccine, but has the potential to create vaccines for other diseases and to make current vaccines more effective. However, APHA is concerned that the HHS plan did not clearly outline whether federal purchase of influenza vaccine and centralized distribution will continue beyond the onset of a pandemic. Our current system of private purchase, reliant on supply and demand, will not give vaccine manufacturers ample incentive to produce all the necessary pandemic influenza vaccine, as there is no guarantee that they will be left with leftover vaccine due to insufficient purchasing levels. Also of concern is that the distribution of pandemic vaccine to health departments and providers may occur through private-sector vaccine distributors or directly from the manufacturer(s), without adequate federal oversight, and state and local public health input. Thus, the vaccine may not be available to those at highest risk.
The HHS plan also calls for the creation of a vaccine database by CDC, which should build on existing systems and be able to import relevant information from state immunization registries to help us more efficiently track the immunization of priority populations — including children, pregnant women, health care workers and the elderly — in an equitable fashion. However, without federally led vaccine distribution efforts, this database will not provide timely information regarding vaccine distribution, as manufacturers and private vaccine distributors will be relied on to provide the necessary information. This potential information gap on vaccine distribution and tracking of vaccines could be a significant obstacle in ensuring that priority individuals receive pandemic vaccine in proper order. In addition, such tracking will assist in ensuring equitable vaccine use across racial and ethnic populations. Existing immunization information systems (IIS, immunization registries) can be of great assistance in this tracking. Also, the HHS plan does not outline a process for how the priority vaccination guidelines may be altered or reviewed at the time of the pandemic to adapt to the epidemiology of the disease.
However, regardless of the epidemiology of disease, it is imperative that health care workers and first responders, as priority populations, get vaccinated in the event of a flu pandemic. Vaccination of such populations will not only protect their colleagues, but their patients and communities as well.
Calls for a guaranteed, substantial, if not complete, federal purchase of pandemic influenza vaccine, with some buyback provision included, so there are a number of vaccine manufacturers committed to produce adequate amounts of the vaccine most effective against the pandemic influenza strain;
Supports congressional efforts to appropriate additional resources to research activities targeted at manufacturing and utilizing cell-culture influenza vaccines;
Stresses the need for additional research targeted at pandemic vaccine development, including reducing the amount of HA antigen required to reach a protective level of immunity; alternative means to administer the vaccine; and use of known and novel adjuvants to enhance immunogenicity;
Urges that additional funds be made available to the CDC for developing and testing vaccine distribution and tracking systems;
Stresses the need for HHS to formulate a process to amend and review priority vaccination guidelines to adapt to the epidemiology of the pandemic influenza virus;
Strongly encourages the use of a pandemic influenza vaccine among all health care personnel and first responders as early on as possible in a pandemic.
Antiviral Drug Distribution, Tracking and Use
Antiviral medications such as oseltamivir and zanamivir have been shown to reduce the severity and duration of seasonal influenza, typically reducing the duration of illness by one or two days.5,52 However, their efficacy in effectively treating many individuals during an influenza pandemic is uncertain at best.5 The problem is that influenza strains can become resistant to antivirals, antivirals need to be administered within the first two days of the onset of symptoms to be effective, and the supply will likely be dramatically less than the projected need.52
The HHS plan, considering that an effective pandemic vaccine will not be in general circulation during the first months of an influenza pandemic, calls for the purchase of enough antivirals — oseltamivir and zanamivir — to treat 25 percent of the population. Efforts center on the federal purchase of 44 million courses of antiviral drugs for treatment, with another 6 million courses for containment. However, the federal plan contains a strategy to leverage state tax dollars to purchase the remaining 31 million courses of antiviral drugs with a 25 percent federal subsidy. Public health officials must have the flexibility to provide the medication where outbreaks are most severe, as certain states and communities will likely be affected more than others. Reliance on states to pay for a substantial portion of the cost of purchasing enough antiviral medication to cover their populations amounts to an unfunded mandate of approximately $510 million over a very short time. If this holds, states will likely either raise taxes or find offsets from already under-funded health programs to address this mandate. Also, the plan does not account for the fact that with current antiviral production capacity, there will likely be a shortage of antivirals at the advent of a flu pandemic as well.
The HHS plan again does not outline a process for how the priority guidelines for the distribution of antivirals may be altered or reviewed at the time of the pandemic to adapt to the epidemiology of the disease. The plan’s guidance for the use of antivirals for post-exposure prophylaxis is not clear. The HHS plan’s antivirals annex states that “When a vaccine becomes available, post-exposure prophylaxis may also be used to protect key personnel during the period between vaccination and the development of immunity. Strategies for antiviral prophylaxis may be revised as the pandemic progresses, depending on supplies, on what is learned about the pandemic strain and on when a vaccine becomes available.” However, the plan does not define a process for the identification of these key groups; moreover, strategies and priority groups for both treatment and prophylaxis will need to be developed. Once these key groups are identified, there is a need for accurate distribution and tracking systems to ensure that antivirals reach priority populations.
Calls upon Congress to require the federal government to protect Americans by purchasing all of antiviral treatment courses deemed necessary, as the level of protection Americans receive should not be determined by where they live and the current fiscal position of their states;
Opposes the provision of the HHS Pandemic Influenza Plan which would require states to purchase antivirals with a federal subsidy, as such action would divert needed resources from core public health and preparedness programs;
Urges the U.S. government to examine the effects of and consider increasing incentives for pharmaceutical companies to invest in the research concerning new drug development, efficacy assessments, and production capacity of antivirals to determine the most effective drugs, doses, timing for administration, the best methods of administration, and its integration into plans for vaccination;
Encourages Congress to appropriate additional resources to bolster U.S. production capacity of antivirals to ensure that the supply of antivirals in the event of a flu pandemic is sufficient to meet national demand;
Urges Congress to appropriate additional funds to CDC to develop and test antiviral drug distribution and tracking systems;
Urges HHS to formulate guidelines that outline strategies and priority groups for both treatment and prophylaxis.
Medical and Lab Supply Stockpiling and Use
APHA is aware of the Strategic National Stockpile’s work in amassing medical material, but is concerned that there are still inadequate funds for critical medicines and supplies, such as ventilators, syringes, gloves and intravenous antibiotics that will be in high demand during a pandemic. Equal priority should be given to assuring such material is available to permit a comprehensive response to a pandemic. Without it, manufacturers of key medical and lab supplies will not have the incentive necessary, or be able to invest in increasing their capacity, to produce such a high quantity of goods. Lessons learned from the Hurricane Katrina response include the need to stockpile response-related equipment and medication as well.11 Such stockpiling needs to include durable medical equipment and assistive devices and medications for children with special health needs, immunizations, and equipment and medication needed to maintain the health status of those with chronic illness, HIV/AIDS and other health problems.
Urges Congress to appropriate new, additional and sufficient resources towards the stockpiling of critical medicines and supplies, such as ventilators, syringes, gloves, intravenous antibiotics, reagents and N95 respirators;
Stresses the need for funds to be dedicated towards the stockpiling of equipment and medication needed to maintain the health status of those with chronic illness, HIV/AIDS and other health problems during a pandemic, including insulin, dialysis machines and oxygen;
Encourages HHS to work in cooperation and coordination with state and local health departments to create guidelines for the public use of certain stockpiled supplies, such as surgical masks, which may be necessary to transport patients from one location to another;
Urges the Food and Drug Administration to review its guidelines that limit the supply of prescription medication to be dispensed per prescription, so that individuals with serious health problems can access the prescriptions they need in the event of isolation or quarantine orders during a pandemic.
VII. Liability/Compensation Issues
Medical countermeasures administered in advance of or in response to an influenza pandemic may pose health risks to individuals receiving prophylaxis or treatment. Vaccines, antiviral medications, and other medical countermeasures are necessary tools to slow or halt the spread of the pandemic and to treat affected, or infected, individuals. However, all medical countermeasures carry some risk of adverse effects. Individuals who experience illness, disability, or death as a result of the administration of a medical countermeasure to combat pandemic influenza should have some method to receive compensation for their losses.
Since some adverse events are statistically inevitable, a compensation program should be set up prior to the pandemic, include clear criteria for qualifying for compensation, incorporate a claims system that provides for due process and equal protection, provide adequate resources to compensate affected parties, and appoint an independent adjudicatory body to administer the claims.
Immunity from tort liability for industry and fair compensation for patients offers a sound dual approach to vaccine policy. The national Vaccine Injury Compensation Program (VICP) has created a no-fault system that pays for injuries caused by specific immunizations.53 To recover compensation from the VICP, claimants must show that a listed vaccine caused their injury. Compensation comes from a Compensation Trust Fund financed by a tax on each administered dose.53 Congress added influenza to VICP in 2004.53 However, the VICP only covers trivalent (annual) influenza vaccine. Experimental influenza vaccines currently are not covered under VICP, so these new types of vaccine would need to be added. Patients can opt-out of VICP and bring a lawsuit in court, which has led to the critique that legal liability represents a major disincentive for the industry. Nevertheless, influenza vaccine litigation has been rare, with only 10 reported cases during the past 20 years and most with small verdicts.54
Mass use of an untried vaccine during a public health emergency would temporally coincide with the occurrence of numerous conditions. There is some likelihood that the vaccine might be causally associated with adverse events, some severe. Health care workers and patients would be less likely to volunteer without a fair compensation system, as the failed smallpox vaccination campaign demonstrated.55 A no-fault system, like VICP, would provide relief for injured patients and greater certainty for industry. A reformed VICP system would have to take account of important issues: an overwhelmed program, resulting in delays; assuring there is sufficient money in the compensation trust fund; and injustices caused by excessive burdens placed on patients injured by a new vaccine. In return, the industry should be spared lawsuits based on strict liability, but should answer to claims of recklessness or gross negligence.
Recommends that a federally funded compensation program be established for those who become ill or are injured, disabled or die as a result of receiving the pandemic or experimental influenza vaccine.
VIII. Ensuring access to preventive care and treatment for pandemic influenza
Preventing the transmission of and limiting morbidity and mortality related to pandemic influenza will ultimately depend on the access of Americans to the vaccine, and care and treatment should they become ill. The health care utilization patterns of the uninsured need to be factored into pandemic influenza preparedness and response efforts. In general, studies have shown that being uninsured or underinsured leads to a decreased utilization of preventive care, as affected individuals only seek necessary health care in urgent situations. This is shown in the reality that the uninsured tend to have diagnoses of malignancies at more advanced stages,56 and have higher mortality rates resulting from hospitalizations when compared to insured individuals.57 This is especially troubling in the event of pandemic influenza, as the uninsured would be less likely to seek health care quickly if they developed symptoms of influenza. And, when they seek care in later stages, it will be uncompensated care provided in hospitals.
Calls for the federal purchase of vaccines and antivirals at least for uninsured individuals and children eligible for the Vaccines for Children (VFC) program;
Calls upon Congress and HHS to establish an emergency Medicaid designation for uninsured individuals during an influenza pandemic that would require states to provide medical assistance to these individuals under state Medicaid plans, but increase the federal medical assistance percentage for providing medical assistance to these individuals.
IX. Surge capacity
Surge capacity is defined as “the number of critical casualties arriving per unit of time that can be managed without compromising the level of care.58 The core components to increasing surge capacity during an influenza pandemic are the availability of: 1) skilled health professionals to supplement the existing health work force, 2) sufficient space and resources within health care and public health facilities to coordinate and handle the influx of patients, 3) adequate stockpiles of consumable and durable medical goods, including vaccines, antiviral medications, ventilators, and other necessary supplies, and 4) appropriate laws and policies to allow for the effective continuation of essential medical and public health services.
The ability of the public health system to handle an influenza pandemic will require an unprecedented allocation of resources to both treat the victims and stem the tide of the pandemic. The current health care work force cannot be depended on in event of a flu pandemic, due to expected high absentee rates due to illness or fear of becoming ill. It is important to recognize that local providers in many cases do not have the resources to provide basic primary health care under normal circumstances, much less to provide surge capacity. Volunteers during Hurricane Katrina observed that chronic health conditions were as significant a concern as acute problems in the affected populations.59 Populations that are already vulnerable will become much more so in a pandemic situation.79 Hospital bed capacity is lacking in many areas, even those that are not under-served, due to cost cutting initiatives that reduce the availability of inpatient beds. Therefore, the availability of adequate resources to provide surge capacity is imperative. Distribution of resources equitably to areas of the country based on need must be guaranteed. Public health professionals should help to gauge the needs of each community. Resource allocation should be determined based upon need rather than other priorities.
Efforts to increase surge capacity also need to include how to care for individuals who are in need of medical care not related to the prevention and treatment of pandemic influenza. For example, as pregnancy and childbirth account for almost one out of four hospital stays for women,60 measures must be taken to ensure that there are separate medical facilities to specifically cater to women in labor and delivery and pregnant women with complications. Persons with other health problems ranging from broken bones to heart conditions need to be able to access medical care in alternate facilities.
The HHS Pandemic Influenza Plan identifies multiple steps that may be taken to increase surge capacity during a pandemic, but most of these recommendations focus on the availability of clinical medical care. While this capacity is indeed vital to an effective pandemic response, pandemic planners should also consider and account for meeting surge capacity needs within the public health system. This can be accomplished by planning to expand the public health work force during an emergency, identifying and training public health professionals in disciplines relevant to pandemic response, and bolstering laboratory and epidemiological capacity to help track the disease. This planning should be done at all levels of government, but is particularly important for state and local health departments to have their own plans to meet surge capacity in case of a widespread pandemic.61
Urges public health officials to follow the steps recommended by the HHS Pandemic Influenza Plan to improve surge capacity during a pandemic in the areas of staffing, bed supply, consumable and durable goods, and continuation of essential medical services;
Stresses the need for populations in need of medical care not related to pandemic influenza, ranging from women in labor and delivery to individuals with severe heart conditions, to be able to access such care in separate facilities from those treating individuals infected with pandemic influenza;
Encourages public health officials to plan for improving surge capacity of the public health work force to engage in core public health activities during a pandemic. Advance registry systems should be developed to coordinate volunteer health professionals, as these are preferable to relying on ad hoc or spontaneous volunteers;
Encourages the utilization of already existing voluntary agencies such as the Medical Reserve Corps to facilitate health care workforce surge in the event of a flu pandemic;
Stresses the need for training programs to be developed for volunteers listed on registry systems;
Encourages public health officials to plan for increasing laboratory and epidemiological capacity to assist in efforts to track the spread of pandemic influenza;
Supports the enactment of federal and state legal protections for health professionals responding to meet surge capacity during a pandemic, including licensure reciprocity, protections from legal liability, workers’ compensation coverage, and employment protection;
Urges public health officials to develop pandemic response plans and systems that permit explicit cooperation between 1) different levels of government, 2) different government agencies, and 3) the public, private, and non-profit sectors. Fostering strong relationships and effective coordination among all of these entities and institutions is important to providing effective surge capacity during a pandemic;
Urges Congress to provide sufficient resources to state and local governments and health departments, hospitals and laboratories to prepare for influenza epidemics and pandemic. Resources should be targeted to areas most in need of assistance as determined by public health experts.
X. Mental health issues
Attention to mental and behavioral health issues should be part of the integrated response to a pandemic. While researchers have studied human behavior and human reaction following disasters for decades, it has only recently been recognized that mental health preparedness is central within every community. Previously, concerns related to immediate physical health and community infrastructure risks in the aftermath of disasters such as storms, earthquakes, or floods 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.62 Mental health needs in this section refer to the reactions of the public to the specter of pandemic influenza.
In the arena of the health impact of natural disasters, the majority of data available relate to weather or geologic events.62 For example, there are some data on the long-term mental health impacts of such disasters as the Gujurat and Turkey earthquakes;63 the 2004 Asian tsunami;64 a number of large impact disasters in South America and Asia; and Hurricanes Katrina and Rita.65,66 We know that severe stress reactions are common; that front-line health and human services workers are at high risk for Post-Traumatic Stress Disorder; and that in general, even in relatively developed countries, there is very little existing infrastructure in place that can adequately address the mental health needs of victims.66
Furthermore, as a pandemic unfolds, emotional reactions can color the response to the factual situation. Distrust of information can further foster extreme responses. At the societal or community level, group reactions can occur, such as panic. Panic and crisis reactions may become disproportionate to the actual threat, compromising effective action. Enlisting cooperation with directives may prove problematic, further straining multiple institutional structures beyond the health and mental care institutions such as the police, and so on. Some limited lessons may be learned from the study of populations under siege or at war. Monitoring for the development of panic-like reactions may provide an opportunity for earlier intervention; plans for these contingencies need to be developed that integrally involve health and public health professionals. The failure to plan may have adverse sequelae; for example, driven by panic, the urge to contain the infected can lead to bizarre quarantine practices.70, 71, 72 It is hoped that honesty in information flowing to the public about outbreaks may help limit panic.73 During recent SARS outbreaks, lack of adequate disclosure may have contributed to panic.74,75
There are almost no data on the mental health impacts of outbreaks of acute pandemic disease. This is largely because there have been few pandemic health threats in the last century. Since the highly lethal pandemic outbreak of influenza in 1918, there have been few global threats from infectious agents. The recent outbreaks of SARS in Asia and Canada, which caused global concern but fortunately did not result in large-scale outbreaks nor a global pandemic, provide the most recent data on the mental health concerns that are relevant to a pandemic flu outbreak situation.
The data from the SARS outbreaks indicated that upwards of 40 percent of the community population experienced increased stress in family and work settings during the outbreak; 16 percent showed signs of traumatic stress levels; and high percentages of the population felt helpless, apprehensive, and horrified by the outbreak.67 In another community survey, 30 percent of those surveyed thought they would contract SARS, while only a quarter believed they would survive if they contracted the disease, despite an actual survival rate of 80 percent or more, indicating a fairly high rate of perceived risk that might have preceded widespread panic had the outbreak been either more widespread or more lethal.68 Community residents were diligent about adopting appropriate person-to-person transmission precautions; however, precautions were adopted differentially based upon anxiety levels and perceived risk of contracting the disease, indicating the importance of stress and anxiety levels, as well as baseline mental health, on a public response to taking necessary precautions.
Decision-makers will be concerned with many issues beyond health per se, including feared and real economic impacts, and may feel pressured to take unduly hasty actions (such as relaxation of an imposed quarantine; for example, in Quebec data on the incubation period of SARS were ignored, and the lifting of quarantine was associated with a secondary outbreak). There is a likelihood that uncertainties in data will occur, further complicating decisions about whether and how to react.
We also know from the SARS outbreak that front-line health workers may be particularly vulnerable to negative mental health sequelae of treating outbreak victims. Studies of the nurses who treated SARS patients indicated high levels of stress and about 11 percent rates of traumatic stress reactions, including depression, anxiety, hostility and somatization symptoms.69
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. In anticipation of significant disruption and loss, promoting health protective behaviors and health response behaviors will be imperative. 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) preventing and responding to panic (5) psychological responses to community containment strategies (quarantine, movement restrictions, school/work/other community closures); (6) health care service surge and continuity; and (7) responses to mass prophylaxis strategies using vaccines and antiviral medication. Attention needs to be focused both on global-level and community issues, such as the possibility of panic and other crowd or mob mentalities and reactions, and personal health related issues that focus on individuals.
Reiterates the need for leadership preparation, including 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;
- Calls for the 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;
Recommends the widespread dissemination of uncomplicated, empathically informed information on normal stress reactions, which can serve to normalize reactions and emphasize hope, resilience, and natural recovery;
Stresses the need to inform the public about the rationale and mechanism for distribution of limited supplies (e.g., Tamiflu);
Reiterates the importance of community rituals (e.g. speeches, memorial services, funerals, collection campaigns, television specials) as important tools for managing the community wide distress and loss and coping with such situations as deaths of important or particularly vulnerable individuals (e.g., children), new unexpected and unknown risk factors, and shortages of treatments;
Urges federal, state and local public health partners to plan at societal, local and individual levels 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 especially during the time frame prior to availability of vaccines;
Stresses the importance of the maintenance of community, to manage community and organizational distress and untoward behaviors, especially as in-person social supports may be hampered by the need to limit movement or contact due to concerns of contagion. Virtual contact — via web, telephone, television, and radio — will be particularly important at these times;
Declares that 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, as stigma and discrimination may marginalize and isolate certain groups, thereby impeding recovery;
Reiterates the need to plan for mass fatality and management of bodies, as well as the community responses to such situations and activities, including taking into consideration various religious rituals of burial and disseminating public health announcements addressing (if known) how long the virus remains in the corpse and what should be done with the bodies;
Supports efforts to increase health protective behaviors and response behaviors, including reminding individuals to take care of their own health and limit potentially harmful behaviors;
Encourages the dissemination of good safety communication, as promoting clear, simple, and easy-to-do measures can be effective in helping individuals protect themselves and their families;
Calls for the utilization of evidence-informed principles of psychological first aid;
Stresses the need to provide care for first responders to maintain their function and workplace presence, including providing assistance to ensure the safety and care of their families;
Urges that mental health surveillance, at both the societal and individual level, be conducted in tandem with disease surveillance. Such surveillance should address PTSD, depression and altered substance use, psychosocial needs (e.g. housing, transportation, schools, employment), and loss of critical infrastructure necessary to sustaining community function or which might foster panic.
1. American Public Health Association. Policy 2005-2: Developing a Comprehensive Public Health Approach to Influenza. December 14, 2005.
2. Harper SA, Fukuda K, Uyeki TM, Cox NJ, Bridges CB. Prevention and Control of Influenza: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR July 29, 2005 / 54(RR08);1-40
3. National Institute of Allergy and Infectious Diseases. Focus on the Flu — Research: Flu Primer. Available at: http://www3.niaid.nih.gov/news/focuson/flu/research/primer/default.htm. Last accessed: April 5, 2006
4. Public Health Service. Cross-Species Infectivity and Pathogenesis Conference transcript, July 21 and 22, 1997, Bethesda MD. Summaries of presentations and the discussions are accessible at http://worldaidsday.nih.gov/dait/cross-species/contents.htm. Last accessed: June 14, 2006.
5. Fauci AS. Emerging and Re-Emerging Infectious Diseases: Influenza as a Prototype of the Host-Pathogen Balancing Act. Cell February 24, 2006. Available at: http://www3.niaid.nih.gov/about/directors/pdf/2-23-06_Cell.pdf. Accessed: April 5, 2006.
6. Centers for Disease Control and Prevention. Fact Sheet: Key Facts about Influenza and Influenza Vaccine.
7. Centers for Disease Control and Prevention. Fact Sheet: Pandemic Influenza.
8. WHO global influenza preparedness plan. March 2005. Available at: http://www.who.int/csr/resources/publications/influenza/GIP_2005_5Eweb.pdf. Accessed: April 5, 2006.
9. United States Department of Health and Human Services. HHS Pandemic Influenza Plan. November 2005.
10. United States Department of Homeland Security. National Response Plan. December 2004.
11. White House. The Federal Response to Hurricane Katrina: Lessons Learned. February 2006. Available at: http://www.whitehouse.gov/reports/katrina-lessons-learned.pdf. Accessed May 30, 2006.
12. Trust for America’s Health. A Killer Flu? June 2005. Available at: http://healthyamericans.org/reports/flu/Flu2005.pdf. Accessed May 30, 2006.
13. NACCHO Press Release: Public Health Officials Urge More Federal Aid for Local Pandemic Influenza Response, November 2, 2005. http://www.naccho.org/documents/NACCHOPandemicFluPlanResponseNov2005.pdf. Accessed: April 5, 2006.
14. Centers for Disease Control and Prevention. Improvement in Local Public Health Preparedness and Response Capacity — Kansas, 2002—2003. MMWR May 13, 2005. 54(18);461-462.
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