Past Epidemics, Natural Disasters, COVID19, and Mental Health: Learning from History as we Deal with the Present and Prepare for the Future.

As cases of the coronavirus disease (COVID-19) continue to rise, psychological endurance is a challenge many people will face. For mental health, heightened stress responses to the pandemic, is likely to manifest in three ways: 1) development of a new episode of a disorder in those with a predisposition to a major psychiatric disorder or an acute exacerbation in those who already have such a disorder, 2) development of a trauma or stressor related disorder, such as acute stress disorder, Post Traumatic Stress Disorder (PTSD), or adjustment disorders, and 3) development of a symptomatic stress response that does not meet the diagnostic criteria of a psychiatric disorder. The authors reviewed existing literature on past epidemics, natural disasters, and COVID-19 with a focus on psychiatry and mental health. Psychological effects of past epidemics (Severe Acute Respiratory Syndrome CoV-1, Ebola, Middle East Respiratory Syndrome, the Anthrax threat), past natural disasters, and current COVID-19 data suggest numerous psychological effects following the pandemic. Alcohol use, PTSD, anxiety, anger, fear of contagion, perceived risk, uncertainty, and distrust are a few of the immediate and long-term effects that are likely to result from the COVID-19 pandemic. Identifying people in need of mental health care and determining the appropriate psychiatric services and therapy needed will be important. Increasing the use and availability of telehealth, group meetings, and online resources are some ways that health care workers can prepare for the increasing demand of psychiatric services during and following the pandemic.

Efficacy of combining interview techniques in detecting deception related to bio-threat issues.

The purpose of this project was to assess the detecting deception efficacy of three well-validated "detecting deception" methods - i.e., forced choice testing (FCT), modified cognitive interviewing (MCI) and autobiographical implicit association testing (aIAT) - when applied to the issue of bio-threat. The detecting deception accuracies of FCT and MCI were 81% and 75%, respectively. Although the aIAT mean response times in block 5 differed significantly between deceptive and truthful persons, the classification accuracy was low. FCT alone reduced the group of 64 persons to 11 and detected 50% of the liars; the false positive rate was 9%. MCI alone reduced the group of 64 to 24 and detected 92% of the liars; the false positive rate was 54%. When FCT was paired with MCI, 75% of liars were detected and the false positive rate was 13%. Forced choice testing and MCI show promise as methods for detecting deception related to bio-threat under low-base-rate conditions. These methods took little time, enhanced the odds of detecting deceptive individuals and exhibited high positive likelihood ratios, suggesting that they have merit as screening tools. The aIAT required more time and was less accurate but may still serve as a useful screening tool.

Determinants of emergency response willingness in the local public health workforce by jurisdictional and scenario patterns: a cross-sectional survey.

BACKGROUND: The all-hazards willingness to respond (WTR) of local public health personnel is critical to emergency preparedness. This study applied a threat-and efficacy-centered framework to characterize these workers' scenario and jurisdictional response willingness patterns toward a range of naturally-occurring and terrorism-related emergency scenarios. METHODS: Eight geographically diverse local health department (LHD) clusters (four urban and four rural) across the U.S. were recruited and administered an online survey about response willingness and related attitudes/beliefs toward four different public health emergency scenarios between April 2009 and June 2010 (66% response rate). Responses were dichotomized and analyzed using generalized linear multilevel mixed model analyses that also account for within-cluster and within-LHD correlations. RESULTS: Comparisons of rural to urban LHD workers showed statistically significant odds ratios (ORs) for WTR context across scenarios ranging from 1.5 to 2.4. When employees over 40 years old were compared to their younger counterparts, the ORs of WTR ranged from 1.27 to 1.58, and when females were compared to males, the ORs of WTR ranged from 0.57 to 0.61. Across the eight clusters, the percentage of workers indicating they would be unwilling to respond regardless of severity ranged from 14-28% for a weather event; 9-27% for pandemic influenza; 30-56% for a radiological 'dirty' bomb event; and 22-48% for an inhalational anthrax bioterrorism event. Efficacy was consistently identified as an important independent predictor of WTR. CONCLUSIONS: Response willingness deficits in the local public health workforce pose a threat to all-hazards response capacity and health security. Local public health agencies and their stakeholders may incorporate key findings, including identified scenario-based willingness gaps and the importance of efficacy, as targets of preparedness curriculum development efforts and policies for enhancing response willingness. Reasons for an increased willingness in rural cohorts compared to urban cohorts should be further investigated in order to understand and develop methods for improving their overall response.

Predicting psychological ripple effects: the role of cultural identity, in-group/out-group identification, and attributions of blame in crisis communication.

Incidents of intentional food contamination can produce ripple effects in consumers such as reduced trust and increased anxiety. In their postcrisis communication, food companies often direct the blame at the perpetrator in an effort to mitigate potential losses and regain consumer trust. The attempt to placate consumers may, in itself, potentially create psychological ripple effects in message readers. This study examined the interacting influence of two message characteristics: identity of the perpetrator of the crime (in-group/out-group membership), and the attribution of blame (reason why the perpetrator committed the crime), with message receiver characteristic (cultural identity) on psychological ripple effects such as blame, trust, anxiety, and future purchase intention. Results indicated that although group membership of the perpetrator was not significant in predicting outcomes for the organization, the attribution communicated in the message was. American message receivers blamed the organization more and trusted it less when personal dispositional attributions were made about the perpetrator. Asian message receivers blamed the organization more and trusted it less when situational attributions were made about the perpetrator. Lowered trust in the company and increased anxiety correlated with lower purchase intent for both American and Asian message receivers. Implications for crisis message design are discussed.

Flu, risks, and videotape: escalating fear and avoidance.

While extensive risk perception research has focused on emotions, cognitions, and behavior at static points in time, less attention has been paid to how these variables might change over time. This study assesses how negative affect, threat beliefs, perceived risk, and intended avoidance behavior change over the course of an escalating biological disaster. A scenario simulation methodology was used that presents respondents with a video simulation of a 15-day series of local news reports to immerse respondents in the developing details of the disaster. Systemic manipulation of the virus's causal origin (terrorist attack, medical lab accident, unknown) and the respondent's proximity to the virus (local vs. opposite coast) allowed us to investigate the dynamics of public response. The unfolding scenario was presented in discrete episodes, allowing responses to be tracked over the episodes. The sample includes 600 respondents equally split by sex and by location, with half in the Washington, DC area, and half in the Los Angeles area. The results showed respondents' reactions to the flu epidemic increased as the disaster escalated. More importantly, there was considerable consistency across respondents' emotional, cognitive, and behavioral responses to the epidemic over the episodes. In addition, the reactions of respondents proximally closer to the epidemic increased more rapidly and with greater intensity than their distant counterparts. Finally, as the flu epidemic escalated, both terrorist and accidental flu releases were perceived as being less risky and were less likely to lead to avoidance behavior compared to the unknown flu release.

An assessment of nurses' knowledge of botulism.

OBJECTIVE: To assess nurses' knowledge of botulism, a Centers for Disease Control Category A bioterrorism agent, one case of which constitutes an emergency. DESIGN: The study utilized survey research. SAMPLE: The cluster sample included 1,414 registered nurses. MEASURE: The survey gathered demographic data and nurses' knowledge of the background, manifestation and management of botulism. RESULTS: The mean percentage of correct answers for the sample was 25.95%, with a standard deviation (SD) of ±19.89%. Only 90 (6.3%) achieved 60% or more correct. Educational preparation, experience, specialty/area of practice and whether nurses had a class in disaster medicine were also examined and although differences were noted, none of these factors accounted for a score of 60% or above. CONCLUSIONS: The results of this study indicate the need for an assessment of the current education nurses receive about botulism.

The public health disaster trust scale: validation of a brief measure.

CONTEXT: Trust contributes to community resilience by the critical influence it has on the community's responses to public health recommendations before, during, and after disasters. However, trust in public health is a multifactorial concept that has rarely been defined and measured empirically in public health jurisdictional risk assessment surveys. Measuring trust helps public health departments identify and ameliorate a threat to effective risk communications and increase resilience. Such a measure should be brief to be incorporated into assessments conducted by public health departments. OBJECTIVE: We report on a brief scale of public health disaster-related trust, its psychometric properties, and its validity. DESIGN: On the basis of a literature review, our conceptual model of public health disaster-related trust and previously conducted focus groups, we postulated that public health disaster-related trust includes 4 major domains: competency, honesty, fairness, and confidentiality. SETTING: A random-digit-dialed telephone survey of the Los Angeles county population, conducted in 2004-2005 in 6 languages. PARTICIPANTS: Two thousand five hundred eighty-eight adults aged 18 years and older including oversamples of African Americans and Asian Americans. MAIN OUTCOME MEASURES: Trust was measured by 4 items scored on a 4-point Likert scale. A summary score from 4 to 16 was constructed. RESULTS: Scores ranged from 4 to 16 and were normally distributed with a mean of 8.5 (SD 2.7). Cronbach α = 0.79. As hypothesized, scores were lower among racial/ethnic minority populations than whites. Also, trust was associated with lower likelihood of following public health recommendations in a hypothetical disaster and lower likelihood of household disaster preparedness. CONCLUSIONS: The Public Health Disaster Trust scale may facilitate identifying communities where trust is low and prioritizing them for inclusion in community partnership building efforts under Function 2 of the Centers for Disease Control and Prevention's Public Health Preparedness Capability 1. The scale is brief, reliable, and validated in multiple ethnic populations and languages.

The public acceptance of smallpox vaccination to fight bioterrorism in Japan: results of a large-scale opinion survey in Japan.

OBJECTIVES: This study examines the public acceptance of smallpox vaccinations in the event of a terrorist attack using smallpox. The article also provides public health professionals with the information necessary for such smallpox management. METHODS: A questionnaire survey was conducted in a city in Japan asking about prospective action when smallpox vaccination is advised after a terrorist attack and factors that could influence individual decisions about such vaccination. RESULTS: Only a tiny fraction of people (0.12%) expressed their rejection of vaccination. Of the respondents, 63.6% showed their intent to be vaccinated promptly when such a measure was required; 28.6% wanted to decide for themselves, having some reservations. Those in the younger age group, those suffering from hypertension/cardiac diseases, and those who considered the threat of smallpox terrorism less seriously were likely to reserve their vaccination decisions until after examining information. CONCLUSIONS: Communication programs regarding smallpox vaccination should be well planned beforehand and should especially target those people who reserve their decisions at such times. Health professionals should also be well equipped with all information necessary for appropriate and effective smallpox management in the face of such a bioterrorism attack or the strong potential of one.

Perceptions and reactions with regard to pneumonic plague.

We assessed perceptions and likely reactions of 1,005 UK adults to a hypothetical terrorist attack involving pneumonic plague. Likely compliance with official recommendations ranged from good (98% would take antimicrobial drugs) to poor (76% would visit a treatment center). Perceptions about plague were associated with these intentions.

Demeter's Resilience: an International Food Defense exercise.

The National Center for Food Protection and Defense (NCFPD), which is led by the University of Minnesota, hosted an international food defense exercise on 27 to 29 May 2008. Established in 2004, NCFPD is a Department of Homeland Security Center of Excellence with the mission of defending the food system through research and education. Tabletop exercises are practice-based scenarios intended to mimic real life experiences. The objective of the exercise discussed in this article was to facilitate discussion to increase awareness among exercise participants of both the threat that would be posed by an intentional attack on the food supply and the international impact of such an attack. Through facilitated discussion, exercise participants agreed on the following themes: (i) recognition of a foodborne disease outbreak is driven by the characteristics of the illness rather than the actual number of ill individuals; (ii) during the course of a foodborne outbreak there are generally multiple levels of communication; (iii) a common case definition for a foodborne disease is difficult to develop on a global scale; and (iv) the safety and health of all individuals is the number one priority of all parties involved. Several challenges were faced during the development of the exercise, but these were overcome to produce a more robust exercise. The following discussion will provide an overview of the challenges and the strategies used to overcome them. The lessons learned provide insight into how to plan, prepare, and host an international food defense exercise.

Confidence in biopreparedness authorities among Finnish conscripts.

A large sample of Finnish military conscripts of the armored brigade were questioned on the extent to which they trusted the information given biopreparedness authorities (such as the police, military, health care, and public health institutions) and how confident they were in the authority's ability to protect the public during a potential infectious disease outbreak, from either natural or deliberate causes. Participants answered a written questionnaire during their initial health inspection in July 2007. From a total of 1,000 conscripts, 953 male conscripts returned the questionnaire. The mean sum scores for confidence in the information given to biopreparedness authorities and the media on natural and bioterrorism-related outbreaks (range = 0-30) were 20.14 (SD = 7.79) and 20.12 (SD = 7.69), respectively. Mean sum scores for the respondents' confidence in the ability of the biopreparedness authorities to protect the public during natural and bioterrorism-related outbreaks (range 0-25) were 16.04 (SD = 5.78) and 16.17 (SD = 5.89). Most respondents indicated that during a natural outbreak, they would have confidence in information provided by a health care institution such as central hospitals and primary health care centers, whereas in the case of bioterrorism, the respondents indicated that they would have confidence in the defense forces and central hospitals.

Public Understanding, Perceptions, and Information Sources about Bioterrorism: Pilot Study from the Republic of Serbia.

Bioterrorism presents a complex national, international, and human security threat, which requires a multidisciplinary approach to preparation and planning. Although the public plays an integral part of every aspect of bioterrorism, their understanding of and attitudes toward bioterrorism have not been extensively researched in the past, but are important for efficient knowledge communication. This study examines the baseline public comprehension and perceptions of bioterrorism, as well as the underpinning, trusted information sources in the Republic of Serbia. Results demonstrate overall poor understanding of bioterrorism and a notable lack of distinction between bioterrorism and infectious agents in general. These findings represent the first such body of knowledge in Europe and are in agreement with previous data from North America and Australia. Interestingly, the idea that bioterrorism agents are an intentional laboratory product of genetic engineering and synthetic biology approaches is significantly present among the surveyed population, but with contradicting views on whether such actions would be malicious or well-intended. These ideas, coupled with substantial mistrust in government institutions and news media, could inflict serious consequences and, therefore, should be taken into consideration when designing prevention and preparedness strategies, as well as interventions through knowledge communication.

Chemical-Biological Terrorism and Its Impact on Children.

Chemical and biological events (including infectious disease outbreaks) may affect children disproportionately, and the threat of a chemical or biological attack remains in the United States and worldwide. Although federal programs and funding support a broad range of federal initiatives for public health preparedness and response, funding at the state and local levels has been flat or is decreasing, potentially leaving communities vulnerable. Consequently, pediatricians need to prepare and be ready to care for children in their communities before, during, and after a chemical or biological event, including during long-term recovery. Some medical countermeasures for particular chemical and biological agents have not been adequately studied or approved for children. The American Academy of Pediatrics provides resources and education on disaster preparedness and response, including information on the pediatrician's role in disasters, pediatric medical countermeasures, and mental health after an event as well as individual and family preparedness. This policy statement addresses the steps that clinicians and policy makers can take to protect children and mitigate the effects of a chemical or biological attack.

Chemical-Biological Terrorism and Its Impact on Children.

Children are potential victims of chemical or biological terrorism. In recent years, children have been victims of terrorist acts such as the chemical attacks (2017-2018) in Syria. Consequently, it is necessary to prepare for and respond to the needs of children after a chemical or biological attack. A broad range of public health initiatives have occurred since the terrorist attacks of September 11, 2001. However, in many cases, these initiatives have not ensured the protection of children. Since 2001, public health preparedness has broadened to an all-hazards approach, in which response plans for terrorism are blended with those for unintentional disasters or outbreaks (eg, natural events such as earthquakes or pandemic influenza or man-made catastrophes such as a hazardous-materials spill). In response to new principles and programs that have evolved over the last decade, this technical report supports the accompanying update of the American Academy of Pediatrics 2006 policy statement "Chemical-Biological Terrorism and its Impact on Children." The roles of the pediatrician and public health agencies continue to evolve, and only their coordinated readiness and response efforts will ensure that the medical and mental health needs of children will be met successfully. In this document, we will address chemical and biological incidents. Radiation disasters are addressed separately.

Anthrax Exposure, Belief in Exposure, and Postanthrax Symptoms Among Survivors of a Bioterrorist Attack on Capitol Hill.

BACKGROUND: Following chemical, biological, radiological, and nuclear disasters, medically unexplained symptoms have been observed among unexposed persons. OBJECTIVES: This study examined belief in exposure in relation to postdisaster symptoms in a volunteer sample of 137 congressional workers after the 2001 anthrax attacks on Capitol Hill. METHODS: Postdisaster symptoms, belief in exposure, and actual exposure status were obtained through structured diagnostic interviews and self-reported presence in offices officially designated as exposed through environmental sampling. Multivariate models were tested for associations of number of postdisaster symptoms with exposure and belief in exposure, controlling for sex and use of antibiotics. RESULTS: The sample was divided into 3 main subgroups: exposed, 41%; unexposed but believed they were exposed, 17%; and unexposed and did not believe that they were exposed, 42%. Nearly two-thirds (64%) of the volunteers reported experiencing symptoms after the anthrax attacks. Belief in anthrax exposure was significantly associated with the number of ear/nose/throat, musculoskeletal, and all physical symptoms. No significant associations were found between anthrax exposure and the number of postdisaster symptoms. CONCLUSIONS: Given the high incidence of these symptoms, these data suggest that even in the absence of physical injury or illness, there may be surges in health care utilization. (Disaster Med Public Health Preparedness. 2019;13:555-560).

Misrepresentation of health risks by mass media.

BACKGROUND: Mass media are a leading source of health information for general public. We wished to examine the relationship between the intensity of media coverage for selected health topics and their actual risk to public health. METHODS: Mass media reports in the United States on emerging and chronic health hazards (severe acute respiratory syndrome (SARS), bioterrorism, West Nile Fever, AIDS, smoking and physical inactivity) were counted for the year 2003, using LexisNexis database. The number of media reports for each health risk was correlated with the corresponding death rate as reported by the Centers for Disease Control and Prevention. RESULTS: The number of media reports inversely correlated with the actual number of deaths for the health risks evaluated. SARS and bioterrorism killed less than a dozen people in 2003, but together generated over 100 000 media reports, far more than those covering smoking and physical inactivity, which killed nearly a million Americans. CONCLUSIONS: Emerging health hazards are over-reported in mass media by comparison to common threats to public health. Since premature mortality in industrialized societies is most often due to well-known risks such as smoking and physical inactivity, their under-representation on public agendas may cause suboptimal prioritization of public health resources.

Adherence to Emergency Public Health Measures for Bioevents: Review of US Studies.

The frequency of bioevents is increasing worldwide. In the United States, as elsewhere, control of contagion may require the cooperation of community members with emergency public health measures. The US general public is largely unfamiliar with these measures, and our understanding of factors that influence behaviors in this context is limited. The few previous reviews of research on this topic focused on non-US samples. For this review, we examined published research on the psychosocial influences of adherence in US sample populations. Of 153 articles identified, only 9 met the inclusion criteria. Adherence behaviors were categorized into 2 groups: self-protective behaviors (personal hygiene, social distancing, face mask use, seeking out health care advice, and vaccination) and protecting others (isolation, temperature screening, and quarantine). A lack of uniformity across studies regarding definitions and measures was noted. Only 5 of the 9 articles reported tests of association between adherence with emergency measures and psychosocial factors; perceived risk and perceived seriousness were found to be significantly associated with adherence or adherence intentions. Although it is well documented that psychosocial factors are important predictors of protective health behaviors in general, this has not been rigorously studied in the context of bioevents. (Disaster Med Public Health Preparedness. 2018;12:528-535).

Facilitation of risk communication during the anthrax attacks of 2001: the organizational backstory.

The anthrax attacks of 2001 created risk communication problems that cannot be fully understood without appreciating the dynamics among organizations. Case studies of communication in New Jersey, consisting of interviews with a range of participants, found that existing organizational and professional networks facilitated trust among decisionmakers. This interpersonal trust improved communication among agencies and thereby risk communication with the public. For example, "white powder scares" were a problem even in places without contamination. Professionals' trust in each other was vital for responding productively. Conversely, organizational challenges, including conflict among agencies, hindered communication with key audiences. Although centralization and increased control are often seen as the remedy for communicative confusion, they also can quash the improvisational responses needed during crises.