1

Coping with the Emotional Challenges of Pandemic

Influenza

An Online Guide for Individuals and Families

division of mental health services

disaster & terrorism branch

2

Welcome

This Online program was developed to help individuals and families predict and prepare for the many emotional challenges associated with a potential pandemic influenza.

Emotional and physical preparedness are some of the most effective ways of addressing the anxiety and stress that may accompany such a serious worldwide disease outbreak.

3

Strategies for Coping

The two primary strategies for coping with the emotional impact of a pandemic influenza are:

• Education: Factual information about pandemic influenza and its impact;

• Preparation: Personal and family readiness for health emergencies.

4

Program Overview

This program will provide individuals and families with:

1. Factual information about avian influenza and the potential for a pandemic;

2. The emotional challenges that may accompany a pandemic;

3. Strategies and resources for managing the emotional consequences of pandemic influenza.

5

Understanding Avian Influenza and the Potential Pandemic

6

How Real is the Risk?• The World Health Organization and U.S. Centers

for Disease Control & Prevention (CDC) see a potential influenza as the single greatest global risk today.

• At the World Economic Forum recently held in Davos, Switzerland, pandemic influenza topped the list of concerns of almost every world leader.

• Leading experts have assessed the likelihood of a pandemic as “moderate”, but the severity as “very high.”

• A pandemic may disrupt global society in an unprecedented way and claim millions of lives.

7

How Real is the Risk?

• Leading healthcare experts are in agreement that the current H5N1 avian flu poses a real risk of mutating into the next pandemic.

• It is uncertain when and where the next global pandemic will begin, but…

• Experts agree that another catastrophic pandemic is imminent and that we may now be on the brink.

8

Pandemic Facts Definition: According to the World Health

Organization (WHO), viruses must meet three prerequisites to be called pandemics:

1. A novel virus subtype must emerge to which the general population has little or no immunity.

2. The new virus must be able to replicate in humans.

3. The new virus must be efficiently transmitted from one human to another; efficient human-to-human transmission is expressed as sustained chains of transmission causing community-wide outbreaks.

9

The Historical Perspective • Influenza pandemics are rare but recurrent

events.

• There have been at least 10 pandemics recorded over the past 300 years (i.e., approximately every 30 years).

• The last pandemic occurred in 1968 resulting in 1 to 4 million deaths worldwide.

• Each pandemic is unique, so predictive models can have great variation in estimates of fatalities.

10

The Historic Perspective: The Great Influenza (Continued) • The “Spanish Flu” of 1918 is often

called the “Great Flu”- The H1N1 strain infected between 200 million and 1 billion people around the world.

• The Bulletin of Medical History estimates that between 50 and 100 million people died.

• From 1918 to 1920, nearly half of the world’s population was infected during

three separate waves of disease.

11

An Important Note

While many scientists believe the current avian influenza outbreak has the potential to transform into a pandemic strain:

• Avian influenza and pandemic influenza are two different diseases.

• Bird flu primarily kills birds. It can also sicken and kill other mammals and humans.

• Pandemic influenza is transmitted person- to-person and primarily sickens and kills human.

12

On the Brink?

• The current bird flu, H5N1, first identified in Asia in 1997, has now reached epidemic levels in poultry and migratory birds.

• Cases of bird-to-bird and bird-to-human transmission initially seen only in Vietnam, Cambodia, Thailand and Indonesia, have now been found throughout Europe, Asia and Africa.

• Both bird-to-bird, and bird-to-human infections have been diagnosed in several countries, as well.

13

On the Brink? (Continued)

• There have been more than 160 confirmed human cases of H5N1 so far, with half resulting in death.

• So far, the H5N1 virus is following a similar evolutionary path as the 1918 virus.

• The WHO conservatively estimates that between 2 million to 7.4 million may die during the next pandemic.

• The WHO’s worst case scenario predicts between 40 and 50 million deaths worldwide.

14

The H5N1 Avian Influenza(Continued)

• So far, hundreds of millions of birds have died or been culled.

• Poultry production and trade have suffered serious disruptions, resulting in extreme financial hardship for millions.

• The H5N1 virus has recently been detected in mammals, such as pigs, tigers and domestics cats, all of which serve as “reservoirs” for the virus.

15

The H5N1 Avian Influenza(Continued))

• As the virus infects more people and animals it continues to mutate, increasing the chances of developing into a “human-to-human” disease.

• “Current ongoing epidemic of H5N1 avian influenza in Asia is unprecedented in its scale, its spread, and in the economic losses it has caused” –National Academy of Science, Institute of Medicine, 2005.

• H5N1 is a “novel virus”, to which there is no human immunity.

16

Pandemic Timeline

• Based on patterns of past pandemics, it is expected that a new strain would circle the globe in three waves.

• Each wave could last several months, separated by as long as a season.

• For multinational organizations it is important to note that different countries and continents may be in different phases at any one time.

17

A Global Health Crisis• Once a pandemic emerges, its global

spread is inevitable.

• Due to air travel, the pandemic can potentially reach all continents within three months.

• Countries will attempt to prevent its spread by closing borders and restricting travel.

18

Pharmaceutical Options in Public Health Response

• Vaccination would be possible only after several months of the onset of the pandemic.

• It is unclear if currently used antiviral medication, such as Tamiflu® (oseltamir) and Relenza ® (zanamivir), would be effective.

• There would not be enough vaccine or antiviral medication to treat the majority of the world population.

19

Non-Pharmaceutical Options in Public Health Response

• For most countries, pharmaceutical interventions will not be an option.

• Non-pharmaceutical interventions can include:

– Social distancing– Closing schools– Bans on mass gatherings: business,

cultural and religious – Bans on travel– Isolation– Quarantine

20

Demand on the Healthcare Systems

• Overwhelming.• Models suggest a substantial

percentage of the world population will require medical care;– Not enough beds,– Not enough staff,– Not enough equipment,– Not enough medicines.

• All countries will have these deficiencies at the onset and for several months into the pandemic. Many developing countries will lack these resources for the entire duration.

The Emotional Challenges of Pandemic Influenza

22

Emotional Challenges There are many emotional challenges that may

face individuals and families during a pandemic. These challenges are not limited to the medical impact of a disease outbreak, but include reactions to:

• Organizational and governmental response.• The impact on society.• Personal and social economic disruption.• Pre-existing medical or mental health issues.• Separation from natural sources of support.• Grief and loss of friends or family members.

23

Governmental ResponsesGovernmental Responses

Governments worldwide may operate in a “wartime” mode. This will involve:

• A focus on maintaining infrastructure operations.

• Priority will be given to power, sewage, water, emergency services and food distribution.

• Food and other supplies may be rationed.

• Distribution of most non-essential goods will be discontinued.

• Most retail businesses will close.

• Quarantines may be forced and violators arrested.

24

Impact on Society

There are a multitude of ways in which a pandemic would affect society. These include the:

• Loss of workforce.

• Loss of social capital.

• Many stranded when borders close and travel is restricted.

• Loss of personal connections during a heightened need for attachment.

Like other disasters and acts of terrorism, the pandemic will magnify preexisting social fractures related to cultural, religious, and economic differences.

25

Impact on Individuals and Communities

Many social responses revolve around loss. These losses may include the loss of:

• Control.• Income.• Privacy.• Autonomy.• Valued civil liberties.• Trust (i.e., in government, in humankind, etc.)• Beliefs or faith (i.e., patriotism, religious beliefs,

etc.)

26

Economic Disruption

• High rates of illness and prolonged absenteeism in workplaces.

• Significant reduction in work productivity.• Drastic decline in retail, tourism,

entertainment, travel and many economic sectors.

• Escalating unemployment.• Impairment of essential services such as

utilities, transportation and communications.

• Disruption or closure of financial markets and banking.

27

Economics and Potential Panic

Economics is not just about the financial markets, it is about how rare assets are allocated.

• Vaccines, antiviral medications, hospital beds, and later perhaps basic necessities will be in tremendous demand.

• Other important goods, such as food, water, and power will be in short supply, as will critical medicines like insulin, heart drugs, and other prescription medications.

• Masks, gloves, antibacterial soaps, and other protective equipment will also be in high demand and low supply.

• There is a likelihood of price gouging and the development of a “black market” for essential goods.

28

Personal Finances Due to closures of businesses, lost work time

related to illness or caring for others, and many other factors, individuals and households may suffer great financial difficulties, such as:

• Little or no personal or household income.

• Depletion of any available savings.

• Increased dependence on credit to replace income or cover large medical costs.

• Price gouging and elevated costs for many basic consumer goods.

• Risk of default on loans or mortgages.

• Potential for crisis-related financial exploitation.

29

Impact on Individuals’ Impact on Individuals’ Medical or Mental Health Medical or Mental Health ProblemsProblems

Individuals with pre-existing medical or mental health issues may encounter increased levels of stress and anxiety, along with disruptions of the health care delivery system. This may impact:

• The ability to travel to receive medications or treatment services.

• The ability of field workers to travel to deliver medications or treatment services.

• Expedited triage and discharge from hospitals to make way for acute medical patients.

• Separation from natural care givers and community support systems.

30

Grief and Loss

Several aspects of the pandemic and public health response may complicate grief and loss reactions. These include the:

• Inability to see loved ones or say “good-bye” to those who may die in the hospital or while separated from family.

• Inability to retrieve the body for timely burial or funeral rituals.

• Shortage of caskets, burial sites or crematoriums.

• Mass stockpiling of corpses until burial or cremation can be facilitated.

31

Unique Challenges for Expatriate Employees and Students Abroad

For those individuals working or studying away from their home nations, there may be additional emotional stress associated with:

• Not being able to return home due to travel restrictions, even if loved ones are sick or have died.

• Disruptions in communications systems that prevent contact with loved ones.

• Coping with one’s own illness without the care and comfort of loved ones.

32

Ethical IssuesEthical Issues Political leaders must consider the

emotional consequences of such unavoidable ethical issues as:

• Which groups to prioritize for vaccine or antiviral medications?

• How to ration medicines, healthcare services, equipment and basic supplies?

• Should the limited supply of antiviral medications be given to healthy people to reduce the risk of becoming ill, or to ill people to reduce their risk of dying?

Coping with the Emotional Challenges of Pandemic

Influenza

34

Normal Emotional Reactions

• It is normal and understandable to feel anxious and worried about a spreading disease, especially if there is not an available cure or enough medicine.

• Anxiety is related to the fear of the unknown, and all of us are vulnerable to this type of reaction at different times and in the face of different threats.

35

Using Natural Supports

• Natural supports, as available, are essential in dealing with threats that do not pass quickly.

• Support from family, friends, clergy and others to whom people naturally turn should be encouraged.

• Schools, faith-based and civic/volunteer organizations also are part of this primary support system.

• It would be helpful to find support systems—people who are thinking about the same issues you are thinking about and to share ideas.

36

Tips for Coping

The following are some useful suggestions for coping with the emotional challenges stemming from pandemic influenza and other health emergencies:

• Limit your exposure to graphic news stories or images.

• Get accurate, timely information about the disease from credible sources.

• Seek out and follow the advice of experts.

• Maintain as much of a normal daily routine as possible.

37

• Stay busy, both mentally and physically.• Communicate when possible with friends, family

and supporters.• Draw upon your spirituality or personal beliefs for

comfort.• Express yourself through writing, poetry, drawing

and other arts. • Talk and share your thoughts and feelings with

others.

Tips for Coping Tips for Coping (Continued)(Continued)

38

Staying Healthy

Pre-pandemic, practicing good health habits is another way of reducing the risk of all types of influenza in your home or family. To stay as healthy as possible:

• Eat a balanced diet. Be sure to eat a variety of foods, including plenty of vegetables, fruits, and whole grain products. Also include low-fat dairy products, lean meats, poultry, fish, and beans.

• Drink lots of water and go easy on salt, sugar, alcohol, and saturated fat.

• Exercise on a regular basis and get plenty of rest.

39

Staying Healthy (Continued)

Take common-sense steps to limit the spread of germs. Make good hygiene a habit:

• Wash hands frequently with soap and water.

• Cover your mouth and nose with a tissue when you cough or sneeze.

• Properly dispose of used tissues.

• Cough or sneeze into your upper sleeve if you don’t have a tissue.

• Clean your hands after coughing or sneezing. Use soap and water or an alcohol-based hand cleaner.

• Stay at home if you are sick.

40

Limit the Spread of InfectionLimit the Spread of Infection

To limit the spread of germs and prevent infection:

• Teach your children to wash hands frequently with soap and water, and model the correct behavior.

• Teach your children to cover coughs and sneezes with tissues, and be sure to model that behavior.

• Teach your children to stay away from others as much as possible if they are sick. Keep children home from school if sick.

41

Preparedness Facilitates Resilience

• Some of the emotional and behavioral consequences of a pandemic may be mitigated by preparedness efforts.

• Sources of useful preparedness for individuals, families and communities can be found at:

http://www.pandemicflu.gov http://www.who.int/csr/disease/influenza/en/

42

Family Preparedness

To plan for a pandemic:

• Talk with family members and loved ones about how they would be cared for if they got sick, or what will be needed to care for them.

• Store a supply of water and food. During a pandemic, if you cannot get to a store, or if stores are out of supplies, it will be important for you to have extra supplies on hand. This can be useful in other types of emergencies, such as power outages and disasters.

43

• Have nonprescription drugs and other health supplies on hand, including pain relievers, stomach remedies, cough and cold medicines, fluids with electrolytes, and vitamins.

• Encourage family members to volunteer with local groups to prepare and assist with emergency response.

• Encourage family members to get involved in your community as it works to prepare for an influenza pandemic.

Family Preparedness (Continued)

44

Changes in the Workplace • Think about what information the people in your

workplace will need if you are a manager. This may include information about insurance, leave policies, working from home, possible loss of income, and when not to come to work if sick.

• Meet with your colleagues and make lists of things that you will need to know and what actions can be taken.

• Find volunteers who want to help people in need, such as elderly neighbors, single parents of small children, or people without the resources to get the medical help they will need.

• Identify other information resources in your community, such as mental health hotlines, public health hotlines, or electronic bulletin boards.

45

Anticipate Transportation Problems

Think about how you can rely less on public transportation during a pandemic. For example, store food and other essential supplies so you can make fewer trips to the store.

• Prepare backup plans for taking care of loved ones who are far away.

• Consider other ways to get to work, or, if you can, work at home.

46

Childcare Needs Schools and childcare centers may be closed to slow the

spread of disease or because a significant number of staff members are unable to come to work. It is advisable to consider alternative means of childcare and schooling during the pandemic period. You may wish to:

• Help schools plan for pandemic influenza. Talk to the school nurse or the health center. Talk to your teachers, administrators, and parent-teacher organizations.

• Plan home learning activities and exercises. Have materials, such as books, on hand. Also, plan recreational activities that your children can do at home.

• Identify alternative care providers and make arrangements prior to the onset of the pandemic.

47

Be Prepared

Build up a supply of water and food. During a pandemic you may not be able to get to a store. Even if you can get to a store, it may be out of supplies. Public waterworks services may also be interrupted. Stocking supplies can be useful in other types of emergencies, such as power outages and disasters. Store foods that:

• Are non-perishable (will keep for a long time) and don’t require refrigeration.

• Are easy to prepare in case you are unable to cook.

• Require little or no water, so you can conserve water for drinking

48

Food Items to Have On Hand

During a possible prolonged health emergency, it is recommended that you have the following items on hand:

• Ready-to-eat canned meats, fruits, vegetables, and soups.

• Protein or fruit bars; dried fruits and nuts.• Canned juices, bottled water.• Canned or jarred baby food and formula.

• Pet foods, if necessary.

49

Medical, Health & Emergency Supplies

If possible, it is also recommended to have:

• Prescribed medical supplies or equipment, such as glucose or blood pressure monitoring equipment

• Soap and water; alcohol-based hand wash

• Medicines for fever, such as acetaminophen or ibuprofen.

• Thermometer• Anti-diarrheal medication

50

Medical, Health & Emergency Supplies (Continued)

• Vitamins• Fluids with electrolytes• Cleansing agents/soaps• Flashlight and batteries• Portable radio• Manual can opener• Garbage bags• Tissues, toilet paper, disposal diapers if

necessary

51

Take common-sense steps to limit the spread of germs. Make good hygiene a habit.

• Wash hands frequently with soap and water.

• Cover your mouth and nose with a tissue when you cough or sneeze.

• Dispose of used tissues.

• Cough or sneeze into your upper sleeve if you don’t have a tissue.

• Clean your hands after coughing or sneezing. Use soap and water or an alcohol-based hand cleaner.

Staying Healthy (continued)

52

In Conclusion

• At present the risk of pandemic influenza cannot be eliminated, only managed or reduced by the behavior of governments, communities and individuals.

• The risks to our physical and emotional health may be very serious, but they too can be managed.

• Management of these risks and the impact of a pandemic is a shared responsibility between governments and individuals, families and communities…

and attempts to manage the physical and emotional consequences must begin today.

53

For More InformationFor More Information

Please contact the New Jersey Department of Human

ServicesDivision of Mental Health Services

Disaster & Terrorism Branch

Tel 609-984-2767E-mail mhsttag@dhs.state.nj.us

Website www.disastermentalhealthnj.com

54

Online ResourcesOnline Resources

• New Jersey Department of Health & Senior Services: http://www.state.nj.us/health

• Centers for Disease Control and Prevention, Pandemic Influenza Worldwide Preparedness: www.cdc.gov/flu/pandemic

• World Health Organization Epidemic and Pandemic Alert and Response: http://www.who.int/csr/en/

• The U.S. government Web site for information on pandemic flu and avian influenza: www.pandemicflu.gov

• Center for Infectious Disease Research & Policy (CIDRAP) Academic Health Center -- University of Minnesota: http://www.cidrap.umn.edu/cidrap/content/influenza/panflu/

55

ReferencesReferences

The information presented in this program has been adapted from three primary sources:

http://www.cdc.govhttp://www.pandemicflu.govhttp://www.who.int/csr/en/

Please visit these sites for more information and updates about the avian influenza and pandemic influenza.