6th International Disaster and Risk Conference IDRC 2016 Integrative Risk Management - Towards Resilient Cities. 28 August - 01 September 2016 in Davos, Switzerland

1. Trauma Signature Analysis of the
2013-2016 West Africa Ebola Virus Disease Outbreak:
The Prominent Role of Fear-Related Behaviors
James M. Shultz
Director, Center for Disaster &
Extreme Event Preparedness
(DEEP Center)
University of Miami Miller
School of Medicine, Miami,
Florida, USA
Janice L. Cooper
Florence Baingana
Maria A. Oquendo
Zelde Espinel
Benjamin M. Althouse
Louis Herns Marcelin
Sherry Towers
Maria Espinola
Clyde B. McCoy
Laurie Mazurik
Milton L. Wainberg
Yuval Neria
Andreas Rechkemmer
Presented at: 6th
International Disaster and Risk Conference (IDRC), Global Risk Forum, Davos, Switzerland, 29 August 2016

2. Geographic footprint: Historical outbreaks vs. the 2013-2016 outbreak
2013-2016 EVD Outbreak
“Intense transmission nations”
Guinea, Sierra Leone, Liberia
2013-2016
EVD Outbreak
6 African nations
Italy, Spain, UK –
1 case each
USA – 4 cases
24 previous
EVD outbreaks

3. Epidemiological indicators
• EVD cases: highest number of cases (28,652 cases through March 2016)
• EVD deaths: highest number of deaths (11,325 deaths through March 2016)
• EVD survivors: highest number of survivors (estimate: 17,300 survivors)
• Duration: Longest EVD outbreak in history (28 months: Dec 2013 – Mar 2016)
• Geographic footprint: Largest geographic range – only EVD pandemic
• Geographic footprint: New territory – the first outbreak for all 10 nations
• Urban spread: first EVD outbreak to spread intensively in urban centers
• International spread via air travel
Distinguishing Features of the 2013-2016 West Africa EVD Outbreak

4. TotalTotal
Sierra LeoneSierra Leone
LiberiaLiberia
GuineaGuinea
Epidemic Curve of EVD Cases: 2013-2016 West Africa EVD Outbreak

5. World Health Organization EVD Surveillance Maps: 10/29/14 and 10/28/15
October 29, 2014
October 28, 2015

6. Fear
A motivational state aroused by specific stimuli
that give rise to defensive behavior or escape.
“fight or flight response”
“freeze, flight, fight, fright, faint”
Fear and Fear-Related Behaviors (FRBs)
Fear-related behaviors
Fear-related behaviors (FRBs) are
individual or collective behaviors and actions
initiated in response to fear reactions that are
triggered by a perceived threat or actual exposure
to a potentially traumatizing event.
Importantly, FRBs modulate the future risk of harm.

7. Fear-arousing Elements: Virus, Symptoms, Care Environment, Restrictions

8. 1) Accelerating the spread of Ebola virus and EVD illness
2) Impeding the utilization of life-saving Ebola treatment units
3) Curtailing medical services for non-Ebola conditions
4) Increasing risks for psychological distress and psychiatric disorders
5) Amplifying the downstream cascades of social and societal issues
Fear-Related Behaviors (FRBs) and Consequences

9. 1) Accelerating the spread of Ebola virus and EVD illness
FRB1: Providing Ebola care in home settings
FRB2: Conducting unsafe body cleansing and burial practices
FRB3: Fleeing from home communities/migrating to new setting
2) Impeding the utilization of life-saving Ebola treatment units
3) Curtailing medical services for non-Ebola conditions
4) Increasing risks for psychological distress and psychiatric disorders
5) Amplifying the downstream cascades of social and societal issues
Fear-Related Behaviors (FRBs) and Consequences

10. 1) Accelerating the spread of Ebola virus and EVD illness
FRB1: Providing Ebola care in home settings
FRB2: Conducting unsafe body cleansing and burial practices
FRB3: Fleeing from home communities/migrating to new setting
2) Impeding the utilization of life-saving Ebola treatment units
FRB4: Avoiding or foregoing available, life-saving Ebola treatment
FRB5: Health care workers defecting from hazardous duty
3) Curtailing medical services for non-Ebola conditions
4) Increasing risks for psychological distress and psychiatric disorders
5) Amplifying the downstream cascades of social and societal issues
Fear-Related Behaviors (FRBs) and Consequences

11. 1) Accelerating the spread of Ebola virus and EVD illness
FRB1: Providing Ebola care in home settings
FRB2: Conducting unsafe body cleansing and burial practices
FRB3: Fleeing from home communities/migrating to new setting
2) Impeding the utilization of life-saving Ebola treatment units
FRB4: Avoiding or foregoing available, life-saving Ebola treatment
FRB5: Health care workers defecting from hazardous duty
3) Curtailing medical services for non-Ebola conditions
FRB6: Avoiding life-saving treatment for non-Ebola conditions
4) Increasing risks for psychological distress and psychiatric disorders
5) Amplifying the downstream cascades of social and societal issues
Fear-Related Behaviors (FRBs) and Consequences

12. 1) Accelerating the spread of Ebola virus and EVD illness
FRB1: Providing Ebola care in home settings
FRB2: Conducting unsafe body cleansing and burial practices
FRB3: Fleeing from home communities/migrating to new setting
2) Impeding the utilization of life-saving Ebola treatment units
FRB4: Avoiding or foregoing available, life-saving Ebola treatment
FRB5: Health care workers defecting from hazardous duty
3) Curtailing medical services for non-Ebola conditions
FRB6: Avoiding life-saving treatment for non-Ebola conditions
4) Increasing risks for psychological distress and psychiatric disorders
FRB7: Stigmatizing Ebola survivors and EVD family members
FRB8: Blaming, attacking, and stigmatizing health workers
5) Amplifying the downstream cascades of social and societal issues
Fear-Related Behaviors (FRBs) and Consequences

13. 1) Accelerating the spread of Ebola virus and EVD illness
FRB1: Providing Ebola care in home settings
FRB2: Conducting unsafe body cleansing and burial practices
FRB3: Fleeing from home communities/migrating to new setting
2) Impeding the utilization of life-saving Ebola treatment units
FRB4: Avoiding or foregoing available, life-saving Ebola treatment
FRB5: Health care workers defecting from hazardous duty
3) Curtailing medical services for non-Ebola conditions
FRB6: Avoiding life-saving treatment for non-Ebola conditions
4) Increasing risks for psychological distress and psychiatric disorders
FRB7: Stigmatizing Ebola survivors and EVD family members
FRB8: Blaming, attacking, and stigmatizing health workers
5) Amplifying the downstream cascades of social and societal issues
FRB9: Stigmatizing/isolating the intensive transmission nations
Fear-Related Behaviors (FRBs) and Consequences

14. 1) Accelerating the spread of Ebola virus and EVD illness
FRB1: Providing Ebola care in home settings
FRB2: Conducting unsafe body cleansing and burial practices
FRB3: Fleeing from home communities/migrating to new setting
2) Impeding the utilization of life-saving Ebola treatment units
FRB4: Avoiding or foregoing available, life-saving Ebola treatment
FRB5: Health care workers defecting from hazardous duty
3) Curtailing medical services for non-Ebola conditions
FRB6: Avoiding life-saving treatment for non-Ebola conditions
4) Increasing risks for psychological distress and psychiatric disorders
FRB7: Stigmatizing Ebola survivors and EVD family members
FRB8: Blaming, attacking, and stigmatizing health workers
5) Amplifying the downstream cascades of social and societal issues
FRB9: Stigmatizing/isolating the intensive transmission nations
Fear-Related Behaviors (FRBs) and Consequences

15. 2013-2016 West Africa EVD Outbreak

16. RISK FACTORS FOR
PSYCHOLOGICAL DISTRESS
AND DISORDERS
EXPOSURE SEVERITY
N/A Low Moderate Severe Very
Severe
Extreme
H
A
Z
A
R
D
Severe exposure to infectious disease
risks
N/A <10,000 >10,000 >100,000 >1
million
>10
million
Strong fear/panic/ perceived life threat N/A <10,000 >10,000 >100,000 >1
million
>10
million
Pandemic infectious disease cases N/A <10,000 >28,600 >100,000 >1
million
>10
million
Witnessing death or life-threatening
disease
N/A <1,000 >1,000 >10,000 >100,000 >1
million
Witnessing grotesque symptoms
and dead bodies
N/A <1,000 >1,000 >10,000 >100,000 >1
million
Multiple cascading risks and
consequences
N/A Low Moderate Severe Very
Severe
Extreme
Human-generated contribution to
risks
N/A Low Moderate Severe Very
Severe
Extreme
2013-2016 West Africa EVD Outbreak: TSIG Summary Table

17. RISK FACTORS FOR
PSYCHOLOGICAL DISTRESS
AND DISORDERS
EXPOSURE SEVERITY
N/A Low Moderate Severe Very
Severe
Extreme
L
O
S
S
EVD mortality N/A <1,000 5,000 >11,300 300,000 >1
million
Bereaved survivors (loss of
immediate family members)
N/A <4,000 20,000 >45,000 1,200,000 >4
million
Severe household financial losses N/A <1,000 >1,000 >10,000 >100,000 >3
million
Severe national financial losses N/A < $100
million
> $10
million
> $100
million
> $1
billion
> $6
billion
RISK FACTORS FOR
PSYCHOLOGICAL DISTRESS
AND DISORDERS
EXPOSURE SEVERITY
N/A Low Moderate Severe Very
Severe
Extreme
CC
HH
AA
NN
GG
Total affected persons N/A <1004,000 >100,000 >1
million
>20
million
>100
million
Disruption of essential services N/A <10,000 >10,000 >100,000 >1
million
>10
million
Lack of food, clean water N/A <10,000 >10,000 >100,000 >5
million
>10
million
Stigma, discrimination N/A Low Moderate Severe Very
Severe
Extreme
2013-2016 West Africa EVD Outbreak: TSIG Summary Table

18. 2013-2016 West Africa EVD Outbreak