1. Coping with the Emotional Challenges of Pandemic Influenza An Online Guide for Individuals and Families

2. Welcome This Online program was developed to help individuals and families predict and prepare for the many emotional challenges associated with an influenza pandemic. Emotional and physical preparedness are some of the most effective ways of addressing the anxiety and stress that may accompany a worldwide disease outbreak. 2 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

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. 3 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

4. Program Overview This program will provide individuals and families with: 1.Factual information about influenza and pandemics; 2.The emotional challenges that may accompany a pandemic; 3.Strategies and resources for managing the emotional consequences of an influenza pandemic. 4 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

5. Understanding Influenza and Pandemics 5 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

6. Working Definitions Epidemic: From Greek epi (upon) and demos (people) Pandemic: From Greek pan (all) and demos (people) A worldwide crisis with universal vulnerability across all boundaries Note: The term pandemic refers to the geographic distribution of the disease, not the severity of the illness or virulence of the strain New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

7. 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 effectively. 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. 7 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

8. How Real is the Risk? On June 11, 2009, the World Health Organization (WHO) declared that a H1N1 (a.k.a. swine flu) pandemic had begun. 8 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

9. New Strains Develop by Reassortment Like all influenza viruses, avian and swine flu viruses change constantly Pigs can be infected by avian influenza and human influenza viruses as well as swine influenza viruses When influenza viruses from different species infect pigs, the viruses can reassort (i.e. swap genes) and new viruses that are a mix of swine, human and/or avian influenza viruses can emerge New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

10. 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 1 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 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

11. The Historic Perspective: The Great Influenza (Continued) The Spanish Flu of 1918 is often called the Great Flu- The flu 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 worlds population was infected during three separate waves of disease. 11 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

12. 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. It is important to note that different countries and continents may be in different phases at any one time. 12 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

13. 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. Some countries may attempt to prevent its spread by closing borders and restricting travel. 13 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

14. Pharmaceutical Options in Public Health Response Vaccination would be possible only after 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 much of the worlds population. 14 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

15. Non-Pharmaceutical Options in Public Health Response For many 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 15 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

16. The Emotional Challenges of Pandemic Influenza New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

17. Potential Emotional Responses Foreseeable emotional responses to a devastating pandemic would likely involve serious mental health problems such as: Fear and anxiety Sadness and depression Increased rates of suicide Traumatic stress reactions Complicated grief and bereavement Any and all of these mental health problems may occur in both the diagnostic and sub- diagnostic range. New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

18. 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. 18 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

19. Impact on Society There are a multitude of ways in which a pandemic could affect society. These include the: Loss of workforce. Loss of social capital. Some people 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. 19 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

20. 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.) 20 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

21. Possible 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. 21 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

22. Economics and Potential Panic Economics is not just about the financial markets, it is by definition about how scarce assets are allocated. Vaccines, antiviral medications, hospital beds, and later perhaps basic necessities will be in tremendous demand. If supply chains are disrupted, other important goods, such as food, water, and power may 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. 22 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

23. Panic is related to the perception that there is a limited opportunity for escape, a high-risk of being injured or killed, or that help will only be available to the very first people who seek it. Panic in Emergencies Panic is unlikely in most emergencies 23 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

24. Denial Denial is more likely than panic in most emergencies It appears that the major problem in an emergency is getting people to move, rather than preventing wild panic or disorderly flight (Quarantelli, 1972) 24 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

25. Personal Finances Due to the possible closures of businesses, lost work time related to illness or caring for others, and many other factors, individuals and households may suffer increased 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. 25 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

26. Impact on Individuals with Pre-existing Conditions Individuals with pre-existing medical or mental health issues may encounter increased levels of stress and anxiety related to disruptions of the health care delivery system. The pandemic may impact: The ability of consumers to travel to receive medications or treatment. The ability of community-based 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. 26 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

27. 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. 27 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

28. 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 ones own illness without the care and comfort of loved ones. 28 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

29. Ethical 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 Whether to distribute the limited supply of antiviral medications to healthy people to reduce the risk of becoming ill, or to ill people to reduce their risk of dying? 29 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

30. Coping with the Emotional Challenges of Pandemic Influenza New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

31. Normal Emotional Reactions It is normal and understandable to feel anxious and worried about a spreading disease, especially if there is not a readily 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. 31 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

32. Everyone has different ways of reacting to emergencies or threatening events. It is quite normal and natural for people to experience stress reactions in many different ways, including being: Preoccupied with thoughts or interest in health-related news stories Unable to concentrate at work or school Becoming irritable or tense with people Having difficulty sleeping Feeling hopeless or depressed Feeling more distrustful Worrying about personal and family safety Emotional Reactions Are Phase-specific: Pre-pandemic Alert Phase New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

33. As the disease changes, news coverage and the word on the street may increase fears and peoples anxieties. It is understandable that emotional reactions may become more intense as well. In addition to the reactions discussed earlier, people may experience more: Difficulty sleeping Difficulty communicating thoughts Headaches/stomach problems Feeling hopeless, depression or sadness Easily frustrated Poor work performance Increased use of alcohol/drugs Emotional Reactions Are Phase-specific: Prepandemic Phase New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

34. Emotional Reactions Are Phase-specific: Pandemic Phase Once a pandemic begins, the virus can spread around the world quickly. People in all nations are affected during the pandemic period. This phase of the disease can last for several months. Many individuals will also experience acute emotional reactions, as well as health risks during this time. These emotional reactions include: Physical aches and pain unrelated to the illness Extreme fear, panic and dread Inability to focus on work or school Helplessness and/or hopelessness Depression Acute grief and sadness Disorientation and confusion Overwhelmed with self-doubt and uncertainty New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

35. With each passing wave of illness, fewer and fewer people get sick or die, but the emotional impact of the earlier waves remains. During the months and years that follow in peak of the pandemic, there are also many emotional challenges. These include: Ongoing grief and bereavement for those who have died Financial and other daily life stressors created by the disruption of the pandemic Regaining a sense of trust and belief in the future Fear that another wave of illness may begin Restoring a sense of safety and security at home and work Adjusting to changing roles and responsibilities at home and work Managing residual traumatic stress and other lingering mental health issues Emotional Reactions Are Phase-specific: Recovery Phase New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

36. 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 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

37. 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 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

38. Tips for Coping (Continued) 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. 38 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

39. Helping Children Cope Provide only age-appropriate information to children Be honest, but dont vent your frustrations or overwhelm the child Provide children with opportunities to talk about what they are seeing or hearing in the news and the community Dont be afraid to admit that you cant answer all of their questions Allow children to discuss other fears and concerns about unrelated issues Monitor childrens television viewing. Limit your childs exposure to graphic or troubling scenes. Watch news reports with your child so that you are available to answer their questions and to monitor their reactions New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

40. Help children understand that there are no bad emotions and that a wide range of reactions is normal Encourage children to express their feelings to adults (including teachers and parents) who can help them understand their sometimes strong and troubling emotions In addition to the tragic things they are seeing or hearing, help children identify good things, such as heroic actions and the assistance offered by people throughout the country and the world Provide children with an opportunity to play and have fun. This is a healthy outlet for children coping with stress. To the degree possible while maintaining honesty, reassure children that you will be with them and it will be alright Helping Children Cope (Cont.) New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

41. Staying Healthy P racticing 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. 41 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

42. 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 dont 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. 42 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

43. Limit the Spread of Infection To limit the spread of germs and prevent infection: Teach children to wash hands frequently with soap and water, and model the correct behavior. Teach children to cover coughs and sneezes with tissues, and be sure to model that behavior. Teach children to stay away from others as much as possible if they are sick. Keep children home from school if sick. 43 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

44. 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: 44 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch http://www.pandemicflu.gov http://www.who.int/csr/disease/influenza/en/

45. 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. 45 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

46. Family Preparedness (Continued) 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. 46 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

47. 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. 47 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

48. 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. 48 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

49. 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. 49 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

50. 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 dont 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. 50 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

51. 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. 51 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

52. 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 52 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

53. 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 53 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

54. In Conclusion At present the risk of severe 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 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. 54 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

55. For More Information Please contact the New Jersey Department of Human Services Division of Mental Health Services Disaster & Terrorism Branch Tel 609-777-0728 E-mail mhsttag@dhs.state.nj.usmhsttag@dhs.state.nj.us Website www.disastermentalhealthnj.comwww.disastermentalhealthnj.com 55 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

56. Online Resources New Jersey Department of Health & Senior Services: http://www.state.nj.us/health http://www.state.nj.us/health New Jersey Department of Health & Senior Services Pandemic Influenza Awareness Program: http://www.state.nj.us/health/training/panflu/index.shtml Centers for Disease Control and Prevention, Pandemic Influenza Worldwide Preparedness: www.cdc.gov/flu/pandemicwww.cdc.gov/flu/pandemic World Health Organization Epidemic and Pandemic Alert and Response: http://www.who.int/csr/en/ http://www.who.int/csr/en/ The U.S. government Web site for information on pandemic influenza: www.pandemicflu.govwww.pandemicflu.gov Center for Infectious Disease Research & Policy (CIDRAP) Academic Health Center -- University of Minnesota: http://www.cidrap.umn.edu/cidrap/content/influenza/panflu/Academic Health CenterUniversity of Minnesota http://www.cidrap.umn.edu/cidrap/content/influenza/panflu/ 56 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch

57. References The information presented in this program has been adapted from three primary sources: http://www.cdc.gov http://www.pandemicflu.gov http://www.who.int/csr/en/ Please visit these sites for more information and updates about pandemic influenza. 57 New Jersey Division of Mental Health Services – Disaster & Terrorism Branch