Center for the Study of Traumatic Stress
CSTS | Department of Psychiatry | Uniformed Services University | 4301 Jones Bridge Road, Bethesda, MD 20814-4799 | www.CSTSonline.org

Mental Health and Behavioral
Guidelines for Response toa Pandemic Flu Outbreak
Background on the Mental Health Impactof Natural Disasters, including Epidemics
It is only relatively recently that
pandemic outbreak situation.
There is almost no data on
attention has been focused on the mental
Data from the SARS outbreaks
health impact of disasters. Previously,indicatedthat upwards of 40% of thethe mental health impacts ofconcerns related to immediate physicalcommunity population experienced
outbreaks of disease.
health and community infrastructure
increased stress in family and work
risks in the aftermath of disasters suchsettings during the outbreak; 16%
as storms, earthquakes, or floods had
showed signs of traumatic stress levels;
overwhelmed considerations of the short and long-termand high percentages of the population felt helpless,mental health consequences of disasters, or the extent
apprehensive, and horrified by the outbreak (6). In anotherto which mental health played a role in the impact of acommunity survey 30% of those surveyed thought theydisaster (1).
would contract SARS, while only a quarter believed theyIn the arena of the health impact of natural disasters,
would survive if they contracted the disease, despite an
the majority of data available relate to weather or geologic
actual survival rate of 80% or more, indicating a fairly highevents (1). For example, there is some data on the longrate of perceived risk that might have preceded widespreadterm mental health impacts of disasters such as the Gujurat
panic had the outbreak been either more widespread or
and Turkey earthquakes (2); the 2004 Asian tsunami (3);more lethal (7). Community residents were diligent about
a number of large impact disasters in South America
adopting appropriate person-to-person transmission
and Asia; and published reports on Hurricanes Katrinaprecautions; however, precautions were adopted
and Rita (4-5). We know that severe stress reactions aredifferentially based upon anxiety levels and perceived risk
common; that front-line health and human servicesof contracting the disease, indicating the importance ofworkers are at high risk for PTSD; and that in general, evenstress and anxiety levels, as well as baseline mental health,in relatively developed countries, there is very little existing
on a public response to taking necessary precautions (7).
infrastructure in place that can adequately address theWe also know from the SARS outbreak that front-line
mental health needs of victims (5).
health workers may be particularly vulnerable to negative
In contrast, there is almost no data on the mental healthmental health sequelae of treating outbreak victims. Studies
impacts of outbreaks of disease. This is largely because there of the nurses who treated SARS patients indicated highhave been few pandemic health threats in the last century.
levels of stress and about 11% rates of traumatic stress
Since the highly lethal pandemic outbreak of influenza inreactions, including depression, anxiety, hostility and1918, there have been few global threats from infectious
somatization symptoms (8).
agents. SARS outbreaks in Asia and Canada, which caused
While there have been relatively few large outbreaks toglobal concern but fortunately did not result in large-scale
inform an appropriate response to a potential pandemic flu,outbreaks nor a global pandemic, gives us the most recent
the existing data on infectious disease outbreaks, data fromdata on the mental health concerns that are relevant in anatural disasters, and public mental health principles canContinued

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, andpsychiatric disease. In anticipation of significant disruption
and loss, promoting health protective behaviors and healthresponse 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 surveillanceand early detection efforts; (4) psychological responses tocommunity containment strategies (quarantine, movement
restrictions, school/work/other community closures); (5)health care service surge and continuity; and (6) responses
to mass prophylaxis strategies using vaccines and antiviral
medication.
The first step in preventing undesirable psychological,
emotional, and behavioral response is an effective publichealth program of risk assessment and communication,
public health prevention, and consequence management.
These are necessarily premised on having effective
political and community leadership, appropriate pre-event
organization, and staffing and funding.
Being alert to the interrelationship between
psychological, emotional, and behavioral responses andtheir effect on other elements of the response plan mustalso be emphasized. While planning can be based onassumptions that public health efforts to stop an outbreak
will be successful, the importance of managing theconsequences of failure and the subsequent behavioral
response to failure is crucial. This can extend from failure
to deliver support and services, to failure of a vaccine toprevent illness, to failure of therapies to work.
Recommended steps in response to a pandemic flu
outbreak are divided into four phases: preparedness, earlyoutbreak response, later response and recovery, and mental
health intervention planning.

PREPAREDNESS
1. Education. Public education must begin immediately,
before a pandemic occurs, and be embed into existingdisaster public education campaigns, resources, andinitiatives (e.g. HLS’s www.ready.gov, Red Cross, CDC
public education and preparedness https://www.cdc.
gov/flu/pandemic-resources/planning-preparedness/
national-strategy-planning.html, and HHS https://www.cdc.gov/flu/pandemic-resources/index.htm). Thisshould focus on facts, to include what is known, what
is not known, and how individuals, communities, andorganizations can prepare for a potential outbreak.		
As we know from the SARS outbreak, public
education impacts threat awareness, threat assessment,
and preparedness behaviors in every phase of an event.
Public education in advance of an outbreak should be

inclusive of the varying degree of threats, to include
those of reasonably low threat potential to those withthe highest potential.
2. Leadership preparation. Leadership preparation
includes ensuring that public officials understand which
members of the population will be most vulnerable
and who will need the highest level of health services,
including mental health services. This includes
identification of those groups who may be at greatest
risk for problems related to contagion, such as thosewith psychiatric illness, children, elderly, homeless,and those with losses. Ongoing negative life events also
increase one’s risk for mental health problems, and mayplace certain people at higher risk for negative mental
health impact of an outbreak. In addition, health risk
behaviors such as smoking, drug use, and alcohol use
may increase in times of stress, putting some people atincreased risk.
3. Sustaining preparedness measures. Maintenance ofmotivation, capital assets, equipment, and funding tocontinue preparedness efforts over the long term must
be considered, not just to focus on immediate needs.
It is also important to remember that if responses
are under-supported and fail, the community anger
and lowered morale may complicate the ability of acommunity to respond to an outbreak, as well as therecovery process once an outbreak has ended.
4. Leadership functions. Leadership functions require
identification of community leaders, spokespersons,and natural emergent leaders who can affectcommunity and individual behaviors and who canendorse and model protective health behaviors. Special
attention to the workplace is imperative as corporations
have public education resources to potentially reachlarge populations. The media and celebrity groups
constitute important leaders in most modern societies
and have a critical role in providing leadership incommunication.

EARLY PANDEMIC RESPONSE
1. Communication. Wide dissemination of uncomplicated, empathically informed information on normal
stress reactions can serve to normalize reactions andemphasize hope, resilience, and natural recovery.		
Recommendations to prevent exposure, infection,or halt disease transmission will be met withskepticism, hope, and fear. These responses will vary
based on the individuals’ and the local community’s
past experiences with government agencies. In
addition, compliance with recommendations for
vaccination or medication treatment or prophylaxis willvary greatly and will not be complete. The media caneither amplify skepticism or promote a collaborative

approach. Interactions with the media will be bothchallenging and critical.		
The public must clearly and repeatedly be informed
about the rationale and mechanism for distribution oflimited supplies (e.g., Tamiflu). Leadership must adhere
to policies regarding such distribution, as abuses ofpolicy will undercut public safety and public adherence
to other government risk reduction recommendations.
2. Tipping points. Certain events, known as ‘tippingpoints’, will occur that can dramatically increase or
decrease fear and helpful or health risk behaviors.
Deaths of important or particularly vulnerable
individuals (e.g., children), new unexpected andunknown risk factors, and shortages of treatments are
typical tipping points. The behavioral importance ofcommunity rituals (e.g. speeches, memorial services,funerals, collection campaigns, television specials) are
important tools for managing the community wide
distress and loss.
3. Surges in demands for health care. Those who believe
they have exposed (but have not actually been) may
outnumber those exposed and may quickly overwhelm
a community’s medical response capacity. Planningfor the psychological and behavioral responses of thehealth demand surge, the community responses toshortages, and the early behavioral interventions after
identification of the pandemic and prior to availabilityof vaccines are important public health preparedness
activities.

LATER RESPONSE AND RECOVERY
1. Community structure. Maintenance of community
is important. Community social supports — formal
and informal — will remain important. In-personsocial supports may be hampered by the need to limit
movement or contact due to concerns of contagion.
Virtual contact — via web, telephone, television, andradio — will be particularly important at these times.
At other times local gathering places — places ofworship, schools, post offices, and grocery stores —could be points of access for education, training anddistribution. In as much as allowed, instilling a senseof normalcy could be effective in fostering resiliency.
In addition, observing rituals and engaging in regularactivities (such as school and work) might manage
community and organizational distress and untoward
behaviors. Providing tasks for community action
can supplement needed work resources, decrease
helplessness and instill optimism. Maintenance andorganization in order to keep families and members ofa community together is important (especially in eventof relocation).
2. Stigma and discrimination. Under conditions ofcontinuing threat, the management of ongoing racialand social conflicts in the immediate response period
and during recovery takes on added significance.
Stigma and discrimination may marginalize and isolate
certain groups, thereby impeding recovery.
3. Management of fatalities. Mass fatality andmanagement of bodies, as well as community
responses to this, must be planned for. Containment
measures related to bodies may also be in conflictwith religious beliefs, rituals of burial, and the usual
process of grieving. Local officials should be aware of
the potential negative impact of disrupting normal
funeral rituals and processes of grieving in order totake safety precautions. Public health announcements
should include (if known) how long the virus
remains in the corpse and what should be done withthe bodies. In a pandemic, funeral resources will
be overwhelmed and mortuaries may not want tohandle contaminated bodies. Careful identification ofbodies must be insured and appropriate, and accurate
records maintained.

MENTAL HEALTH INTERVENTION
PLANNING
1. Efforts to increase health protective behaviors andresponse behaviors. Individuals under stress will needreminders to take care of their own health and limit
potentially harmful behaviors. This will include taking
medication, giving medications to elderly and children,
and when to go for vaccination.
2. Good risk communication following risk
communication principles. The media can either
amplify skepticism or promote a collaborative
approach. Interactions with the media will be bothcritical and challenging.
3. Good safety communication. Promoting clear, simple,and easy-to-do measures can be effective in helping
individuals protect themselves and their families.
4. Public education. Educating the public not only
informs and prepares, it enlists them as partners in theprocess and plan. Education and communications willneed to address fears of contagion, danger to family andpets and mistrust of authority and government. The
tendency to expect or act as if these are not present candelay community wide health protective behaviors.
5. Facilitating community directed efforts. By
organizing communal needs and directing action
toward tangible goals, this will help foster the inherent
community resiliency toward recovery.
6. Utilizing evidence-informed principles ofpsychological first aid. These basic principles include:xx Establish safety; identify safe areas and behaviors

xx Maximize individuals’ ability to care for self andfamily and provide measures that allow individuals
and families to be successful in their efforts
xx Teach calming skills and maintenance of natural
body rhythms (e.g., nutrition, sleep, rest, exercise)xx Maximize and facilitate connectedness to family
and other social supports to the extent possible(this may require electronic rather than physicalpresence)xx Foster hope and optimism while not denying risk.
7. Care for first responders to maintain their function
and workplace presence. This will require assistanceto ensure the safety and care of their families. First
responders will be comprised of a diverse population,
to include medically trained personnel to bystanders
with no experience.
8. Mental health surveillance. Ongoing population level
estimates of mental health problems in order to direct
services and funding. Surveillance should address
PTSD, depression and altered substance use as well
as psychosocial needs (e.g., housing, transportation,schools, employment) and loss of critical infrastructurenecessary to sustaining community function.

3. Chakrabhan ML, Chandra V, Levav I, Pengjuntr W,
Bhugra D, Mendis N, Na A, van Ommeren M. Panel
2.6: mental and psychosocial effects of the Tsunami on
the affected populations. Prehospital Disaster Medicine
2005 Nov-Dec;20(6):414-9.
4. Centers for Disease Control. Assessment of healthrelated needs after Hurricanes Katrina and Rita—
Orleans and Jefferson Parishes, New Orleans area,Louisiana, October 17-22, 2005. MMWR Morb Mortal
Wkly Rep. 2006 Jan 20;55(2):38-41.
5. Voelker, R. Post-katrina mental health needs prompt
group to compile disaster medicine guide. JAMA. 2006
Jan 18;295(3):259-60.
6. McAlonan GM, Lee AM, Cheung V, Wong JW, Chua
SE. Psychological morbidity related to the SARS
outbreak in Hong Kong. Psychological Medicine. 2005
Mar;35(3)459-60.
7. LauJT, Yang X, Pang E, Tsui HY, Wong E, Wing YK.
SARS-related perceptions in Hong Kong. Emerging
Infectious Diseases. 2005 Mar;11(3):417-424.
8. Chen CS, Wu HY, Yang P, Yen CF. Psychological distressof nurses in Taiwan who worked during the outbreak ofSARS. Psychiatric Services. 2005 Jan;56(1): 76-9.

References
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Bioterrorism, stress and pain: the importance of an
anticipatory communirt preparaedness intervention.
Journal of Psychosomatic Research . 2005 Apr;
58(4):311-6.
2. Altindag A, Ozen S, Sir A. One-year follow-up studyof posttraumatic stress disorder among earthquake
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Prepared by the Center for the Study of Traumatic Stressin collaboration with the Mental Health Section of theAmerican Public Health Association.
Disaster Response Education and Training Project,
Center for the Study of Traumatic Stress.
For more information see www.CSTSonline.org.

Center for the Study of Traumatic Stress
Department of Psychiatry
Uniformed Services University
4301 Jones Bridge Road, Bethesda, MD 20814-4799
www.CSTSonline.org