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DEEP Center Disaster Behavioral Health Awareness Training for Health Care Professionals Copyright © 2004: All Rights Reserved Disaster Behavioral Health Awareness Training for Health Care Professionals James M. Shultz MS, PhD Zelde Espinel MD, MA, MPH Raquel E. Cohen MD, MPH Jorge R. Insignares MD Lisa Rosenfeld MPH DEEP Center University of Miami School of Medicine Brian W. Flynn EdD Rear Admiral, USPHS (Ret) Assistant Surgeon General (Ret) Jon A. Shaw MD, MS Department of Psychiatry University of Miami School of Medicine Robert J. Ursano MD Director, Center for the Study of Traumatic Stress Uniformed Services University of the Health Sciences Joseph A. Barbera MD Director Institute for Crisis, Disaster, and Risk Management The George Washington University Mauricio Lynn MD Abdul Memon MD S. Shai Gold Jackson Memorial Medical Center University of Miami School of Medicine DISASTER BEHAVIORAL HEALTH AWARENESS TRAINING FOR HEALTH CARE PROFESSIONALS CASE EXAMPLES Supplement: Case Examples Case 1: Chemical Weapons Site: Israel, Gulf War, 1991 Perpetrator: Iraq Agent: Scud missiles with possible poison gas payload Scud Missile Attack, Israel, 1991 Case 1 January 18 - February 28, 1991 23 missiles attack alerts 5 false alarms 1,059 ER visits 234 direct casualties (22%) 825 behavioral and psychological casualties (78%) Psychological:Medical = 3.5:1 Source: Karsenty et al. 1991 Scud Missile Attack, Israel, 1991 Case 1 Suffered acute anxiety: 544 Auto-injected atropine without exposure to the agent: 230 Died: 11 7 suffocated in their gas masks 4 fatal heart attacks Injured while running to sealed rooms: 40 Source: Karsenty et al. 1991 Case 1 Scud Missile Attack, Israel, 1991 Lessons learned More fatalities were from fear behaviors than from missile impact. More hospitalizations were for psychological responses than for medical injury. psychological “footprint” medical “footprint” Case 2: Chemical Weapons Site: Toyko Subway, 1995 Perpetrator: Aum Shinrikyo cult Agent: Sarin Gas Sarin Attack, Tokyo, 1995 Case 2 May 20, 1995: Monday morning rush hour Simultaneous, multipoint attack Sarin placed on 5 trains converging on central Tokyo 15 stations affected Major focal point: Kasumagaseki station Source: Olson, 1999 Sarin Attack, Tokyo, 1995 5,510 treated in 280 medical facilities 1,046 admitted to 98 facilities 134 responders among the injured 12 deaths >4,000 had no medical signs of injury or exposure Psychological:medical = >4:1 Case 2 Sarin Attack in Tokyo Subway Case 2 Examined and discharged: 4023 Hospitalized: 984 Severely injured: 62 Killed 12 Source: Norwood, 2002 Sarin Attack, Tokyo, 1995 Lesson learned Case 2 Psychological casualties outnumbered medical casualties. psychological “footprint” medical “footprint” Case 3: Radiological Contamination Site: Goiania, Brazil, 1987 Perpetrator: None (non-terrorist) Agent: Cesium 137 from abandoned radiotherapy device—1,600 Curies released Radiological Contamination, 1987 112,000 people sought medical examinations Many had vomiting and diarrhea although they were not contaminated Reports of fainting from fear at monitoring stations Lesson learned: Individuals can exhibit symptoms without exposure. Case 3 Case 43: Surat Plague Outbreak Site: Surat, India 1994 Perpetrator: none (non-terrorist) Agent: Yersinia pestis Surat Plague Outbreak 1994 September 1993 earthquake in the state of Maharashtra Decline in public health measures Increase in rat population Case 4 Surat Plague Outbreak 1994 150 cases/28 fatalities Physicians and pharmacists fled the city with antibiotics Hoarding of antibiotics Within 4 days, one quarter of population left the city Rumors of bioterrorism Case 4 Lesson learned: Lack of risk communication leads to widespread fear behaviors among the public and professionals. Case 5: Biological Weapons Site: US Mail System, 2001 Perpetrator: Domestic terrorist ? Agent: Modified anthrax Bioterrorism Fall 2001 Anthrax Outbreak via the U.S. Mail Release of several grams of anthrax spores in 7 mailed envelopes Case 5 Bioterrorism Fall 2001 Anthrax Outbreak 5 deaths 18 nonfatal infections 30,000 employees treated with antibiotics Hoarding of Ciprofloxacin Case 5 Bioterrorism Case 5 Fall 2001 Anthrax Outbreak Shutdown of: Brentwood mail processing center US House of Representatives Hart Senate Office Building Supreme Court HHS Building Bioterrorism Case 5 Fall 2001 Anthrax Outbreak HAZMAT calls: 60,000 excess calls nationwide in first 2 weeks In this outbreak, fear was “contagious” “Anthrax anxiety” was common “Contagious somatization”: anxious search for physical symptoms suggesting contagion Bioterrorism Case 5 Fall 2001 Anthrax Outbreak Accusations of differential, discriminatory treatment of postal workers relative to government office workers Lessons learned: 1.Even a small-scale event has cascading effects. Source: Ursano, 2003 2.Terrorism cuts along the fault lines of society Case 6: Severe Acute Respiratory Syndrome (SARS) Site: Asia, North America, and Europe Perpetrator: None (non-terrorist) Agent: Corona virus SARS Walking off the job Absenteeism Stigmatization of patients, their doctors and neighbors Discrimination Loss of jobs 45% of a group of 150 patients who have recovered from SARS had psychiatric problems Source: New York Times, 2003 Case 6 “Virtual visits” to the hospital Lesson learned: Epidemic infectious disease can generate fear behaviors among health care providers. Case 7: Flu season 2003-2004 Site: North America Perpetrator: None (non-terrorist) Agent: Influenza virus Flu Fears Case 7 Virulent strain of the influenza virus created widespread outbreaks in several states. Deaths of young children prompted fear. Citizens rushed to be vaccinated. Vaccine shortages occurred nationwide. * Typical annual death toll from flu: 36,000 Orange County, Florida: Thousands line up for free flu shots Flu Fears Case 7 In January 2004, CDC announced that the influenza vaccine did not offer protection against the outbreak strain of influenza Lessons learned: 1. Epidemic disease produces widespread fear among the general population. 2. Deaths of children exacerbate fears.