The Canadian Pandemic Influenza Plan for the Health Sector

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Annex P -
Pandemic Influenza Psychosocial Annex

Table of Contents

• 1.0 INTRODUCTION
  • 1.1 Rationale: The Importance of Pandemic Influenza Psychosocial Planning
  • 1.2 Pandemic Influenza Psychosocial Planning Assumptions
  • 1.3 Goals of Pandemic Influenza Psychosocial Planning
  • 1.4 Psychosocial Planning Principles
• 2.0 PSYCHOSOCIAL PLANNING
  • 2.1 Key Planning Steps
  • 2.2Phase-Specific Planning Steps
  • 2.2.1 Phases 1-3. Goal: Develop, Test and Update Psychosocial Preparedness and Response Plans, Build Capacity/Resilience, Establish Communication with Partners, and Assess and Monitor
  • 2.2.2 Phase 4. Goal: Continue Preparedness Planning, Ensure Communication with Partners, and Assess and Monitor
  • 2.2.3 Phase 5. Goal: Communicate with Partners, Activate Resiliency and Preparedness Strategies, Assess and Monitor
  • 2.2.4 Phase 6. Goal: Mitigate Acute Stress, Disseminate Information and Implement Workforce and Social Resiliency Plans
  • 2.2.5 Post Peak (Second or Subsequent Waves). Goal: Monitor and Conduct Ongoing Assessment, Mitigate Chronic Stress and Complicated Grief Response, Redesign Strategies as Needed
  • 2.2.6 Post Pandemic Period. Goal: Support Short- and Long-Term Recovery, Assessment and Evaluation (Lessons Learned)
• 3.0 PSYCHOSOCIAL INTERVENTIONS
  • 3.1 Mental and Behavioural Health Implications
  • 3.2 Diversity and Dimensions of Vulnerability
  • 3.2.1 Sex
  • 3.2.2 Economic Marginalization
  • 3.2.3 Social Marginalization
  • 3.2.4 Physical and Mental Disabilities, Medical and Mental Health/Psychiatric Needs
  • 3.2.5 Special Language or Communication Needs
  • 3.2.6 Age
  • 3.2.7 Caregivers
  • 3.2.8 Occupational Groups
  • 3.2.9 Sole Health Care or Social Service Providers
  • 3.3 Coordination and Meeting Basic Needs
  • 3.4 Public Awareness, Education and Media Relations
  • 3.5 Normalizing Daily Living
  • 3.6 Staff Education and Training
  • 3.7 Stress Management Programs
  • 3.8 Links Between Communication, Information and Stress
  • 3.9 Psychological First Aid
  • 3.10 Workforce Resiliency Programs
  • 3.10.1 Key Components of Workforce Resiliency Programs
  • 3.10.2 Workforce Support Suggestions
  • 3.11 Support to Families and Communities
  • 3.11.1 Community Psychosocial Support Strategies
  • 3.11.2 Community-Based Strategies for Maximizing Resiliency
  • 3.12 Bereavement and Grief Support
  • 3.13 Assessment, Triage and Referral
  • 3.13.1 Psychosocial Assessment Goals
  • 3.13.2 Psychosocial Assessment Strategies
  • 3.13.3 Psychosocial Triage, Screening and Referral
• REFERENCES
• APPENDIX A: PSYCHOSOCIAL IMPLICATIONS AND PANDEMIC PLANNING
• APPENDIX B: PSYCHOSOCIAL ISSUES FOR ESSENTIAL SERVICE WORKERS
• APPENDIX C: PSYCHOSOCIAL COMMUNICATION PLANNING TIPS
• APPENDIX D: WEB-BASED PLANNING RESOURCES
• APPENDIX E: TIPS FOR LINKING PSYCHOSOCIAL PLANNING WITH EMERGENCY MANAGEMENT
• APPENDIX F: PSYCHOSOCIAL PLANNING CHECKLIST

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1.0 Introduction

This document outlines a suggested planning framework for addressing the psychosocial implications of a pandemic influenza or any large-scale public health emergency and is intended for, but not limited to, planners at all levels of government and non-governmental organizations.

It begins by providing the rationale for applying a psychosocial lens in pandemic influenza planning and goes on to describe the major components of psychosocial health emergency planning assessment, identification of vulnerable individuals/populations, development and delivery of support services, program evaluation and modification, as well as the need for comprehensive and timely communication and information sharing within all levels of government, non-governmental organizations, the public and the media.

A suggested planning framework is outlined detailing pandemic phase-specific activities. These are based on current research on the psychosocial dimensions of disasters, including lessons learned from the severe acute respiratory syndrome (SARS) outbreak in 2003, the public health response to the anthrax incidents in 2001 and professional consensus regarding best practice in psychosocial disaster response.

The scope and nature of the specific plans developed using this framework will vary and reflect the wide range of planning roles, responsibilities and resources that exist among pandemic planning partners at all levels of government.

The range of issues associated with psychosocial planning is broad (e.g. workforce resiliency, mental health and illness, social cohesion, public trust) involving all levels of government and multiple planning partners. Effective psychosocial pandemic planning will need to be coordinated and be collaborative across multiple systems if it is to result in plans that truly enhance Canada’s pandemic response capacity. As a result, this process is likely to place substantial and additional demands on planners in health, mental health and other social service systems. It will be particularly challenging for organizations or communities in which the availability of or access to planning resources (human, financial, material) is limited (e.g. rural, geographically remote or dispersed). Not addressing the psychosocial dimensions of pandemic planning, however, could have a cascading effect, derailing the country’s overall response capacity, exacerbating other pandemic-related issues (e.g. economic downturns, workforce shortages), and undermining business and community viability and continuity in the short and long term.

Anticipated impact on the Canadian health care system using U.S. CDC FluAid software & attack rates (according to the Public Health Agency of Canada):

• 4.5-10.6 million Canadians would become clinically ill and unable to attend work or other activities for at least 0.5 days;
• 2.1-5.0 million would require outpatient care; and
• 34,000-138,000 would require hospitalization and would recover, and there would be 11,000-58,000 deaths, with hospitalizations and deaths occurring in a relatively short (6-8 month) period – pandemic waves.

Estimates range anywhere from 10% to 25% of the population who will lose working days because of illness or caregiving responsibilities (US Department of Health and Human Services, 2005, Public Health Agency of Canada and Canadian Federal Department of Finance). A predicted economic impact of direct/indirect health outcomes was estimated to be between CAN $10 and $24 billion in 1999 and does not include other societal impacts (e.g. tourism, trade). Comparative health care usage rates between an interpandemic and pandemic year using Canadian data (Alberta):

• 3.7 times as many outpatient visits;
• 3.9 times as many hospitalizations; and
• 8.2 times as many deaths.¹

1.1 Rationale: The Importance of Pandemic Influenza Psychosocial Planning

The consequences of an influenza pandemic may far exceed those associated with any disaster we have yet encountered. In addition to posing a physical health threat, the secondary consequences of an influenza pandemic will be substantial. Illness, death, caregiving responsibilities and fear of infection will place extreme demands on the health care system and contribute to sudden and significant shortages of personnel and resources in all sectors. High rates of absenteeism, public health measures and fears of infection may result in the disruption of many normal business activities, contributing significant economic downturns particularly in tourism and other service-related industries. There may be extended and multiple periods of time when community members will not be able to engage in the routines of school, work and many leisure activities while simultaneously coping with the ongoing uncertainty of the threat and the grief of losing friends, family and colleagues.

Although disasters can often have positive secondary consequences, particularly during the response and the immediate recovery periods (e.g. increase in altruism, volunteerism, enhanced sense of social cohesion), public health measures (e.g. social isolation strategies) and the prolonged and extensive nature of an influenza pandemic may diminish some of this potential and exacerbate the social cleavages and breakdowns also common in the aftermath of disasters.² The multiple secondary consequences of the pandemic, along with the primary (medical) consequences, have significant implications for the psychological, emotional, behavioural or psychosocial well-being of individuals and communities.

In a study of how people in the U.S. might respond to an outbreak of smallpox, approximately 40% of those
surveyed indicated that they would not get vaccinated even if vaccinations were made compulsory. Compliance with public health measures during a public health emergency cannot be assumed. Understanding the behavioural consequences of a pandemic is therefore not only a critical aspect of supporting social and individual resilience but
also has implications for the ability of governments to enact public health and emergency response strategies.
From the Redefining Readiness Study (available at: http://www.redefiningreadiness.net/ )

One has only to look at the literature emerging from the research on the SARS outbreak in 2003 to understand the critical importance of psychosocial planning. Analysis of the long-term psychosocial impact of SARS on health care workers (HCWs) indicates significantly higher levels of burnout, psychological distress, post-traumatic stress and behavioural consequences (e.g. reduced patient contact and work hours) in HCWs who worked in hospitals that treated SARS patients compared with those in hospitals that did not.³

SARS also caused disproportionate economic and social disruption given the relatively limited rates of infection (approximately 10,000 globally) and mortality (approximately 1,000 globally).⁴ The global macroeconomic impact, for instance, is estimated to have been between 30 and 100 billion dollars.⁵ Similarly, reviews of the anthrax incidents in the United States (U.S.) in 2001 suggest that the response capacity of the US public health network (e.g. US Centers for Disease Control and Prevention [CDC], public health departments) was “frail” and “highly stressed” by events that resulted in only 22 actual cases⁶ and in which the number of those prescribed antibiotics outnumbered the actual cases by a factor of more than 1,300.⁷ The psychosocial footprint of a pandemic is likewise anticipated to far outweigh the medical footprint, which will itself be substantial. Some of the psychosocial implications for individuals and families include the following:

• Emotional and financial strain associated with short and possibly long-term economic downturns and employment issues (e.g. job loss, underemployment, worker shortages);
• Increased incidence of mental health problems (e.g. stress, fear, anxiety, depression, complex grief);
• Increased role/emotional strain for particular family members (e.g. increased caregiving for children and the elderly, difficulty accessing health care and material goods, loss of income);
• Increased family violence, substance abuse, and other antisocial behaviours as a result of increased stress and decreased supports and resources;
• Occupational issues, including role and/or work overload, stress associated with non-routine roles, responsibilities, and worksites;
• Social challenges, including increased and mutually reinforced levels of uncertainty and fear, increased disputes associated with intra-community tensions;
• As a result of fear of infection and social distancing measures, breakdown of social support networks, social customs and community support mechanisms (e.g. volunteering, sporting and cultural groups) associated with individual and community belonging and resiliency;
• Increased stress, fear and anxiety associated with stigma and social exclusion;
• Emotional and behavioural health issues associated with disruption of routine activities; and
• Increased stress and distress resulting from real or perceived differences in access to and availability of psychosocial support and other health resources based on geographic location; social, economic and other forms of arginalization; and various individual factors (e.g. ability, sex, pre-existing health conditions).

Although governments and health systems around the world have been applying significant resources to pandemic influenza planning activity, very little of this activity has focused on the management and mitigation of or response to the psychosocial dimensions. Although psychosocial pandemic planning may place additional demands on planning processes that are already stretched for resources, not addressing these concerns could have a cascading effect that derails existing plans. If left unaddressed, the psychosocial responses of individuals and families to the pervasive and prolonged emotional and psychological demands of a pandemic may undermine Canada’s entire pandemic response capacity. Those who feel unsupported or overwhelmed by stress or grief may be less willing to comply with public health measures. Unaddressed psychological and emotional issues may result in behavioural responses (e.g. surges on health care facilities, unwillingness to work) that exacerbate other pandemic-related issues (e.g. economic downturns,
workforce shortages) and undermine business and community viability and continuity in the short and long term.

A comprehensive and multi-pronged psychosocial response to people’s emotional, psychological and behavioural reactions to an influenza pandemic can mitigate or prevent some of these adverse outcomes and enhance not only the nation’s response capacity but also its long-term recovery process. The focus in psychosocial pandemic planning is to maximize personal and social resilience, occupational performance and the likelihood of people’s compliance with public
health measures. This will require a multisectoral, collaborative and holistic planning process that supports and enhances alliances within health (e.g. medical, public, mental and Aboriginal health) and across other systems (e.g. social services), and integrates the expertise of those already providing psychosocial support and engaged in psychosocial disaster planning. As with all disaster and emergency planning, the process of planning is at least as significant as if not more significant than the plan it produces. Effective emergency response capacity rests on the quality of relationships (i.e. sense of trust, cooperation and collaboration) and the contributions of those who are directly and indirectly affected by and are the subject of plans.

Addressing the psychosocial impacts of a pandemic is closely aligned with the practice of risk communications. Risk communications is the development, exchange and dissemination of appropriate information to enable authorities responsible for managing risk situations and stakeholders (those affected by the risk or those who perceive themselves at risk) to make wellinformed decisions. It focuses on facilitating dialogue and exchanging essential information between stakeholders and the authorities. It can be a vital public health intervention because it advocates the preparation of communications and risk mitigation strategies that are grounded in the social, cultural and political realities of the situation. The mitigation of the psychosocial impacts of a public health emergency is therefore a key outcome of effective risk communications.

1.2 Pandemic Influenza Psychosocial Planning Assumptions

The Canadian Pandemic Influenza Plan (CPIP) is based on a set of planning assumptions outlined earlier in the body of the CPIP. Although best planning practices in emergency management tend to focus on an all-hazards approach, there has been an acknowledgement that planning for an influenza pandemic and other large-scale public health disasters (e.g. terrorist attack involving chemical, biological, nuclear, radiological or explosive agents) presents some unique challenges (e.g. intact infrastructure but high rates of absenteeism and a prolonged duration). The planning assumptions guiding this framework flow from current professional consensus regarding the human response to extreme stress and large-scale emergencies. They also acknowledge that effective psychosocial response requires a contextualized response* addressing the influence of social, cultural, economic and personal factors,⁸ and an analysis of the psychosocial implications of the planning assumptions guiding the CPIP framework. For example, the CPIP is
based on an assumption that a standard dose of antiviral medication will be available to all who need early treatment. The psychosocial implication of this assumption is a general sense of reassurance and trust in the equity and efficacy of the government’s response to the early threats of an influenza pandemic.

However, should the required dose need to be increased, it is unclear whether this kind of universal availability will be possible in the early stages of an outbreak. How decisions are made about who is prioritized in this scenario and how this is communicated to health care staff and the public will prompt other psychosocial responses. Similarly, there is an assumption that the demand on health care resources and facilities will outstrip their availability, requiring the prioritization of treatment strategies. There may be several responses to either of these scenarios:

• Fear and fear-based behaviours (e.g. surge on hospital facilities, anger at those who have received medication);
• An increase in moral stress and anxiety for those responsible for making and implementing decisions regarding treatment prioritization;
• The potential stigmatization of these decision-makers or those who are perceived to have differential access to health treatment and/or medication;
• Increased fear, anxiety, anger and possibly grief for those who perceive inequities and/or who lose loved ones as a result of such treatment decisions; and
• A decrease in the public trust that undermines compliance with other public health or emergency measures. (See Appendix A for an overview of other psychosocial implications of major pandemic planning assumptions.)
  

Effective psychosocial planning would anticipate and plan for these possible responses through:

• Public education and staff training;
• Consideration not only of the content of public communication but also the process (the how and the who of communication); and
• The development and implementation of strategies to support workers and the public more generally and to more effectively manage their stress and fear, and the emotional and behavioural responses of others.

In addition to considering the psychosocial implications of other pandemic planning assumptions, this framework is founded on specific psychosocial assumptions:

• The emotional, behavioural and social (psychosocial) consequences of an influenza pandemic will be widespread, given that the clinical attack rate is estimated to be between 15% and 35% of the population with predicted absenteeism rates of 10% to 25% during peak pandemic periods;
• As a new and “invisible” threat of sustained duration (i.e. multiple waves of infection over a period of 12-18 months), an influenza pandemic will generate a good deal of uncertainty, anxiety and stress resulting in prolonged exposure to extraordinary and chronic stress. The size of the psychosocial “footprint” of a disaster is often much larger than the “medical” footprint;⁷
• Exposure to extreme and/or prolonged stress is likely to significantly and adversely compromise immunity, healing and recovery, and overall health and/or illness states. Such stress is a risk factor for physical, mental and social health problems and is associated with a variety of physical ailments (e.g. heart disease), chronic conditions, and mental and social health disorders (e.g. post-traumatic stress, depression, anxiety, substance abuse, domestic violence);
• People are generally resilient and have developed individual mechanisms and skills to cope with stress that are more or less effective and reflect greater or lesser availability and access to resources (e.g. personal, emotional, cognitive resources; social support networks; economic and material resources). By their very definition, although disasters do not rob people of these they can overwhelm them. The novel and sustained nature of the challenges of a pandemic
  disaster will likely overwhelm some individuals’ and/or groups’ ability to cope effectively; and
• Sharing common experiences can enhance a sense of belonging, mutuality and support but can also exacerbate feelings of helplessness, disempowerment and other difficult emotions, and contribute to an emotional sense of being overwhelmed.
• Psychosocial consequences will vary across a spectrum of severity and duration (from brief to long-term) and may include the following:
  • An increase in the development of psychiatric disorders and/or the exacerbation of pre-existing psychiatric disorders (i.e. depression, anxiety and substance abuse);
  • Fear-driven behaviours and impaired decision making;
  • Impaired cognitive, social and family functioning; and
  • Decreased workplace and school performance.
• Any of these psychosocial consequences, including psychiatric/psychological disorders, may develop:
  • In individuals who are not physically/medically affected by influenza;
  • Concomitant with physical illness or injury, or in response to illness or injury in
    someone else; and
  • In response to social, economic and other secondary consequences of a pandemic.
• The development of comprehensive psychosocial support plans and workforce and social resiliency programs will mitigate the severity of the adverse psychosocial consequences of the pandemic;
• Absentee rates may affect psychosocial planning and response activities;
• Effective psychosocial support is based on an understanding that knowledge is empowering and a critical component of stress reduction. An effective risk communication approach considers stakeholders’ values in decision-making processes and tailors communications strategies (content and process) to their perceptions and understanding of risk. This approach is based on the principle that transparency will increase trust and empowerment and facilitate cooperation in carrying out pandemic response and recovery strategies; and
• Effective psychosocial support is based on an understanding that individuals and communities have unique capacities, needs and vulnerabilities requiring creativity and flexibility in the development and delivery of services. Effective psychosocial response is based as much as possible on evidence-informed practices and the engagement in planning and delivery of services of those with front-line psychosocial disaster planning and response experience.

* For a comprehensive articulation of operational guidelines for psychosocial support in mass and other emergencies see Seynaeve.⁸

1.3 Goals of Pandemic Influenza Psychosocial Planning

The primary objective of a psychosocial response to any disaster or public health emergency is to restore and increase individuals’ capacity to go on with their lives by addressing their social, emotional, psychological and physical needs. It includes supporting and strengthening social systems (e.g. social support networks) and helping individuls to regain a sense of control, diminish psychological arousal, effectively manage stress and improve adaptive coping strategies. There a number of specific goals:

• Protect and promote psychosocial well-being and resilience;
• Mitigate, prevent or treat the mental and/or behavioural health issues that arise for individuals in response to the disaster and/or the process of recovery from that disaster;
• Support or restore a sense of confidence, competence, efficacy and trust;
• Support or enhance individuals’ adaptation to the stress and distress and their capacity to respond to the adverse impacts of a disaster through a sense of empowerment and responsibility, and an action orientation;
• Support workers’ willingness and ability to continue to work;
• Improve support of and adherence to other public health measures;
• Support the development of plans that will include rapid assessment of psychosocial needs, mapping of resources and vulnerabilities, including the identification of those with specific vulnerabilities, and the ongoing evaluation of the effectiveness of support programs and strategies; and
• Augment Canada’s capacity to respond effectively over time to disasters and public health emergencies.

1.4 Psychosocial Planning Principles

The guidelines for planning and managing a psychosocial response to a pandemic reflect core humanitarian principles (e.g. valuing of human rights and equity). Psychosocial planning should maximize fairness in terms of the availability and accessibility of mental health, psychiatric and psychosocial support services in affected populations across workplaces, languages and various individual factors (e.g. sex, age, ethnicity, geographic location):

• Effective psychosocial support is based on the fundamental value of participation, and the need for different groups to have some control over decisions affecting their lives and to develop local ownership. Every effort should be made to include in the planning process representatives of people who experience specific dimensions of vulnerability (e.g. impaired mobility, impaired cognitive ability, dependency on dialysis or medical equipment/processes) or who experience specific barriers to accessing information and/or resources or acting on that information (e.g. sex, age, language issues, poverty, geography); The Canadian Pandemic Influenza P 10 lan for the Health Sector
• Programs and interventions should build on and mobilize the local capacities and resources of individuals, families and communities. They should support and enhance existing resources (e.g. social service agencies, family support resources, counselling and mental health programs) and sustainability;
• Psychosocial support and care for individuals and communities address highly sensitive issues, including cultural values and competencies, but lack the extensive scientific evidence available in some other disciplines. Because of this, psychosocial programming should draw on research evidence and lessons learned from other disasters and emphasize a coordinated, collaborative approach that minimizes gaps and the unnecessary duplication of services;
• By its very nature, psychosocial support is multidimensional and needs to integrate multiple strategies. As such, it requires a planning process that is collaborative, coordinated and inclusive. It should reflect both the variance in roles, responsibilities and access to resources across planning partners, and the simultaneous need for consistency of planning goals and access to psychosocial support and resources;
• The majority of affected people seeking help will look for social, practical and financial support, not mental health or counselling interventions, but the former actions can have positive or negative mental health consequences. Effective psychosocial response in disasters and public health emergencies requires a proactive, integrated approach in order to reach a wider range of people, minimize stigma associated with mental health services and maximize sustainability;
• Psychosocial support addresses different types of needs, including basic psychosocial care, specialized treatment of mental health problems and/or psychiatric/psychological disorders, family and community support, education and training in stress management, and specialized services for responders and the public (e.g. psychological first aid);
• Psychosocial programs should integrate continuous review of plans and services by assessing both direct health effects and indirect consequences, such as social and economic impacts, and should allow for plans to be updated as required to incorporate lessons learned and recommended improvements; and
• Effective psychosocial planning and response requires clearly designated leadership, roles and responsibilities for the guidance and provision of psychosocial support. Further, psychosocial support must be clearly linked to and included inother public health and medical emergency functions.

1. Schopflocher DP, Russell ML, Svenson LW, Nguyen T, Mzaurenko I. Pandemic influenza planning: using the U.S. Centers for Disease Control FluAid Software for small area estimation in the Canadian context. Ann Epidemiol 2003;14:73-6.
2. Kaniasty K, Norris F. The experience of disaster: individuals and communities sharing trauma. In Gist R, Lubin B, eds. Response to Disaster: Psychosocial, Community and Ecological Approaches. London: Brunner/Mazel, 1999: 25-62.
3. Maunder RG, Lancee WJ, Balderson KE, et al. Long-term psychological and occupational effects of providing hospital healthcare during SARS outbreak. Emerg Infect Dis 2006;12:1942-9.
4. Smith RD. Responding to global infectious disease outbreaks: lessons learned from SARS on the role of risk perception, communication and management. Soc Sci Med 2006;63:3113-23.
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7. Schultz JM, Espinel Z, Flynn BW, Hoffman Y, Cohen RE. DEEP Prep: All Hazards Disaster Behavioral Health Training. Miami, FL: Center for Disaster and Extreme Event Preparedness, 2003.
8. Seynaeve GJR, ed. Psycho-social support in situations of mass emergency. A European policy paper concerning different aspects of psychological support and social accompaniment for people involved in major accidents and disasters. Brussels, Belgium: Ministry of Public Health, 2001.
9. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, IV-TR. Washington: APA, 2000.
10. World Health Organization. International Statistical Classification of Diseases and Related Health Problems. Geneva: World Health Organization, 1992.
11. Glaser R, Kiecolt-Glaser JK, Malarkey WB, Sheridan JF. The influence of psychological stress on the immune response to vaccines. Ann N Y Acad Sci 1998;840:649-55.
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13. Marsella AJ, Christopher MA. Ethnocultural considerations in disasters: an overview of research, issues, and directions. Psychiatr Clin North Am 2004;27:521-39.
14. Disaster Stress and Trauma Response Services Committee, British Columbia Ministry of Health Services. Psychosocial Response Workbook. Available at: http://www.health.gov.bc.ca/emergency/dstrs.html . 2007.
15. Schnurr PP, Green BL. Trauma and Health: Physical Health Consequences of Exposure to Extreme Stress. Washington, DC: American Psychological Association, 2003.
16. Amaratunga CA, Carter M, O’Sullivan TL, Phillips KP, Saunders R, Thille P. Caring for Nurses in Public Health Emergencies: Enhancing Capacity for Gender-based Support Mechanisms in Emergency Preparedness Planning. Ottawa, Canadian Policy Research Networks, 2008. Available from: http://www.cprn.org/doc.cfm?doc=1841&l=en. Accessed Sept. 12, 2008.
17. Canadian Tourism Commission. SARS: the potential impact on the domestic and selected international travel markets to Canada. 2003. Available at: http://ftp.canadatourism.com/ ctxUploads/en_publications/SARSPotential.pdf
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    Further Reading

Paul M. Darby. The Economic Impact of SARS. Special Briefing. Conference Board of Canada. 2003. Available at: http://www.conferenceboard.ca/documents.asp?rnext=539

Guberman N, Nicholas E, Nolan M, Rembicki D, Lundh U, Keefe J. Impacts on practitioners of using research-based carer assessment tools: experiences from the UK, Canada, and Sweden, with insights from Australia. Health and Social Care in the Community 2003;11(4):345-55.

Norris FH. Range, magnitude, and duration of the effects of disasters on mental health: review update, 2005. Hanover, NJ: Dartmouth College (Dartmouth Medical School and National Center for PTSD). Available from: http://redmh.org/. Accessed Jan. 22, 2008.

Norris FH, Friedman MJ, Watson PJ. 60,000 disaster victims speak: Part II. Summary and implications of the disaster mental health research. Psychiatry: Interpersonal & biological processes 2002;65:240-60.

Norris FH, Friedman MJ, Watson PJ, Byrne CM, Diaz E, Kaniasty K. 60,000 disaster victims speak: Part I. An empirical review of the empirical literature, 1981-2001. Psychiatry: Interpersonal & Biological Processes 2002;65:207-39.

World Health Organization (2003). The World Health Report 2003 – Shaping the Future. Chapter 5. SARS: lessons from a new disease. Available from: http://www.who.int/whr/2003/chapter5/en/index4.html . Accessed June 2, 2003 Appendix B

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