Helping to Heal: Behavioral Health Planning

This collage displayed newspaper headlines related to food poisoning stories. It was created by the Minnesota Department of Health in the 1930s, and its message was part of a campaign admonishing citizens to be aware that safe food cannot be taken for granted. CDC/ Minnesota Department of Health, R.N. Barr Library; Librarians Melissa Rethlefsen and Marie Jones Cover Images: Photo Courtesy of the National Museum of Health and Medicine, Armed Forces Institute of Pathology, Washington, D.C., NCP 1603 - Emergency hospital during influenza epidemic, Camp Funston, Kansas Poster image: A Spanish Flu public notice from 1918, http://en.wikipedia.org/wiki/ Image:Spanish_flu_notice.jpg 2 November 2006 A manual for Community Services Boards and others who may provide behavioral health services during and after a public health emergency. This manual was produced through the Commonwealth of Virginia’s Department of Mental Health, Mental Retardation and Substance Abuse Services, under contract with Diana Nordboe and Amie Ware. 3 4 Module 1: Introduction…………………………………………………………………………………...6 Module 2: Overview of Public Health Emergencies…………………………………………...12 Module 3: Planning for a Public Health Emergency…………………………………………..44 Module 4: Funding for Behavioral Health after a Public Health Emergency………..80 Module 5: Characteristics and Disruptions of a Public Health Emergency…………..94 Module 6: Reactions to Public Health Emergencies………………………………………...112 Module 7: Interventions/Services…………………………………………………………………..142 Module 8: Promoting Behavioral Health During a Public Health Emergency…….198 Module 9: Managing Worker Stress in a Public Health Emergency…………………..236 Module 10: Lessons Learned and Best Practices……………………………………………..252 Note to Reader: Information throughout this manual has been extracted from a number of sources. To help the reader identify information from other sources, it will either be in quotation marks or indented. Sources are included after the quoted or indented sections, and reference lists are provided at the end of each module for additional information. 5 6 Public health emergencies may be caused by nature or by man. They may be the primary event, such as a pandemic, or the result of a disaster such as waterborne illnesses after a hurricane. There has been a great deal of attention in the United States and throughout the world on pandemic influenza, and therefore, much of this manual will concentrate on that specific public health threat. The Implementation Plan for the National Strategy for Pandemic Influenza states that a pandemic “will differ from most natural or manmade disasters in nearly every respect. Unlike events that are discretely bounded in space or time, a pandemic will spread across the globe over the course of months or over a year, possibly in waves, and will affect communities of all sizes and compositions. The impact of a severe pandemic may be more comparable to that of a widespread economic crisis than to a hurricane, earthquake, or act of terrorism. It may present as a particularly severe influenza season, or it may overwhelm the health and medical infrastructure of cities and have secondary and tertiary impacts on the stability of institutions and the economy. These consequences are impossible to predict before a pandemic emerges because the biological characteristics of the virus and the impact of our interventions cannot be known in advance (White House, Homeland Security Council, 2006, page 27).” Though the impact of a pandemic may differ from a natural disaster or act of terrorism, this manual assumes that a pandemic would be a traumatic event for those impacted, and therefore, like reactions to natural disasters and terrorism, the behavioral health reactions and interventions are expected to be similar. Much of the information in this manual about the impact and characteristics of a pandemic has been extracted from plans developed by state and Federal governments. Information about reactions has been adapted from existing knowledge and information about reactions to natural disasters or acts of terrorism, as well as information about the interventions that have been effective in helping people recognize and cope with those reactions. This manual adapts existing information and knowledge to form a basic understanding of what behavioral health workers may experience after a public health emergency, and encourages them to document their own experiences to help them better prepare and plan for future events. Without a doubt, there will be differences in the scope and impact of a public health emergency, such as a pandemic, to those of a natural disaster or an act of terrorism, and these differences are acknowledged throughout the manual. However, without recent experience and knowledge of all the consequences of a pandemic, it is not possible to cover all potential impacts, reactions, challenges, and characteristics. This is recognized in the Implementation Plan for the National Strategy for Pandemic Influenza in the introduction to the federal planning assumptions: “Pandemics are unpredictable. While history offers useful benchmarks, there is no way to know the characteristics of a pandemic virus before it emerges (Ibid, page 25).” While public health emergencies may be naturally occurring or human-caused, the Implementation Plan for the National Strategy for Pandemic Influenza encourages that preparedness for both natural and deliberate threats be merged. It states that “while Module 1 7 the initial events leading to a deliberate or natural outbreak of infectious disease are dramatically different, the actions necessary to prepare, provide early warning, and respond are nearly identical. We should make this principle explicit in our planning for outbreaks and ensure, to the extent possible, that the mechanisms that we put in place are mutually supportive (Ibid, page 20-21).” To help behavioral health workers understand the potential scope of a pandemic, and help them start planning now, the planning assumptions from the Implementation Plan for the National Strategy for Pandemic Influenza are provided below in their entirety. Federal planning efforts assume the following: 1. Susceptibility to the pandemic influenza virus will be universal. 2. Efficient and sustained person-to-person transmission signals an imminent pandemic. 3. The clinical disease attack rate will be 30 percent in the overall population during the pandemic. Illness rates will be highest among school-aged children (about 40 percent) and decline with age. Among working adults, an average of 20 percent will become ill during a community outbreak. 4. Some persons will become infected but not develop clinically significant symp- toms. Asymptomatic or minimally symptomatic individuals can transmit infection and develop immunity to subsequent infection. 5. While the number of patients seeking medical care cannot be predicted with certainty, in previous pandemics about half of those who became ill sought care. With the availability of effective antiviral medications for treatment, this pro- portion may be higher in the next pandemic. 6. Rates of serious illness, hospitalization, and deaths will depend on the virulence of the pandemic virus and differ by an order of magnitude between more and less severe scenarios. Risk groups for severe and fatal infection cannot be predicted with certainty but are likely to include infants, the elderly, pregnant women, and persons with chronic or immunosuppressive medical conditions. 7. Rates of absenteeism will depend on the severity of the pandemic. In a severe pandemic, absenteeism attributable to illness, the need to care for ill family members, and fear of infection may reach 40 percent during the peak weeks of a community outbreak, with lower rates of absenteeism during the weeks before and after the peak. Certain public health measures (closing schools, quarantin- ing household contacts of infected individuals, “snow days”) are likely to in- crease rates of absenteeism. 8. The typical incubation period (interval between infection and onset of symp- toms) for influenza is approximately 2 days. 9. Persons who become ill may shed virus and can transmit infection for one-half to one day before the onset of illness. Viral shedding and the risk of transmission will be greatest during the first 2 days of illness. Children will play a major role in transmission of infection as their illness rates are likely to be higher, they shed more virus over a longer period of time, and they control their secretions less well. Module 1 8 10. On average, infected persons will transmit infection to approximately two other people. 11. Epidemics will last 6 to 8 weeks in affected communities. Multiple waves (periods during which community outbreaks occur across the country) of illness are likely to occur with each wave lasting 2 to 3 months. Historically, the largest waves have occurred in the fall and winter, but the seasonality of a pandemic cannot be predicted with certainty. (Source: Ibid, page 25) The importance of behavioral health in a pandemic or other public health emergency cannot be understated. Behavioral health workers will be in a unique position to support the public health efforts in providing information to the public within effected communities about steps they can take to protect themselves, which will help them cope more effectively with their reactions. It will also help people who are suffering from a wide range of reactions that may hinder response and recovery efforts. Behavioral health

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