Guidance

How to recover from flooding

Updated 19 December 2023

Flooding recovery

The Flood and Water Management Act 2010 places a statutory duty on the Environment Agency to develop a National Flood and Coastal Erosion Risk Management (FCERM) Strategy for England. This strategy describes what needs to be done by all risk management authorities (RMAs) who are involved in flood and coastal erosion risk management for the benefit of people and places. This strategy requires all responsible bodies to plan, prepare and respond to future flood events, ensuring appropriate recovery activities are executed in a timely manner. These activities are for local and national government agencies, as well as for individuals, communities, industry and charity organisations.

The ‘recovery phase’ following a flood event includes cleaning and drying of homes and properties to ensure and check for any health risks as a result of the flood. This section explains the different aspects of flood recovery and the recommended ways to clean up, to minimise potential risks to public health, covering advice for frontline responders and important messages that they can provide to residents affected by flooding.

Cleaning up after a flood

Residents should be advised to check their insurance by contacting their insurance company and following their advice – for those unsure of their insurance status, the National Flood Forum on 01299 403055, or the Association of British Insurers can both be contacted for support.

They should speak to the local flood action group or flood warden – if there has been a serious flood in the area, the local authority may have chosen a place like the town hall as a ‘flood hub’ from which to organise recovery efforts. There may also be a nearby flood warden or flood action group. For more information, contact the National Flood Forum for help in finding local support.

People affected by flooding can contact their local authority for questions about recovering from a flood, such as disposing of used sandbags or damaged furniture. If they are unable to help with collecting large flood-damaged items, they will be able to advise on where and how to discard these items or when they may be collected.

Residents should wear protective clothing while cleaning up after a flood – floodwater can contain sewage, harmful pollutants or contaminants to humans and animals. When cleaning up a home affected by floodwater, the use of rubber boots, protective overalls or waterproof apron, and waterproof gloves are important to avoid exposure to floodwater.

Scrubbing, hosing or pressure-washing may cause a lot of splashing, so it’s recommended to wear a standard face mask, such as those sold by DIY stores.

Eye protection such as goggles offer added protection and can be reused after thorough washing.

Hands should be washed thoroughly with soap and warm water after each clean-up session.

Clothes used for cleaning should be washed on a separate cycle from other clothes.

Electrical equipment checks

Residents should be advised to:

• switch off the electricity supply if it is safe to do so and a flood alert has been issued in the local area
• avoid turning on devices that use gas or electricity as there is a possibility they may have got wet – a registered electrician should be called to assess the condition and damage to electrical wiring, equipment and appliances that have been affected by the flood
• contact their insurance company and landlord if applicable for advice and to get approval to carry out any repairs – residents should take photos of the damage and keep records where possible

Drying out process

Dehumidifiers

Once floodwater has receded, dehumidifiers can be used to collect moisture from the air and can aid in drying out a property. Water is collected in the dehumidifier and can be disposed of down regular water drains and sinks.

Safety precautions: this method should not be used to remove floodwater from the home. Electrical equipment should not be plugged in until it has been dried thoroughly and inspected by a qualified electrician. Where possible, face masks and eye protection should be worn when emptying the water collection tank.

Natural weathering

Natural weathering (and drying out) means to leave wet items out to dry naturally. This is a recommended way to reduce contamination levels, under dry weather conditions. This option may be the most appropriate approach for open areas such as gardens and parks, as sunlight and natural UV radiation are effective at killing micro-organisms.

Cleaning measures

HEPA vacuum

High efficiency particulate arresting (HEPA) vacuum cleaners contain a very fine filter (HEPA filter), which makes it useful when vacuuming as it filters out biological contaminants effectively. Please note that this can only be used on dry material.

Safety precautions: it’s advisable to wear face masks as vacuums may produce dust particles. Electrical equipment should not be plugged in until it has been dried thoroughly and inspected by a qualified electrician.

Wet vacuum

Wet vacuum cleaners are designed to collect residual water from both hard floor surfaces and some soft furnishings such as carpets. Water is collected in the vacuum and can be disposed of down foul water drains and sinks.

Safety precautions: a normal vacuum should not be used when cleaning a wet surface. Where possible, face masks and eye protection such as goggles should be worn as vacuums can produce water droplets. Electrical equipment should not be plugged in until it has been dried thoroughly and inspected by a qualified electrician.

Normal vacuuming should not be used as a method to remove floodwater from the home.

Liquid detergents for cleaning

Floodwater can contain a mixture of harmful contaminants such as sewage, pathogens and pollutants, therefore, it is important to use effective cleaning solutions that will kill any of the above and avoid any harm to health.

Reactive liquids such as household bleach and detergents can be used effectively to remove and kill micro-organisms that may be present following floodwater contamination of surfaces in buildings (such as homes, schools or offices).

Household cleaning products and domestic detergents are widely available and can be found in most supermarkets and hardware stores. Diluted bleach can be used to mop hard floors or can be sprayed onto surfaces and then wiped off. Bleach should be left on surfaces for the contact time stated on the manufacturer’s instructions to ensure disinfection is effective. Bleach residues should be wiped off surfaces.

Safety precautions: appropriate personal protective equipment (gloves, disposable plastic apron such as those available from DIY stores) should be worn when using these products and care should be taken to ensure that manufacturer’s instructions are followed correctly. Cleaning activities should be carried out in ventilated spaces (for example with open windows) and bleach should not be mixed with other cleaning products as this could result in the release of harmful fumes.

Pressure hosing

Pressure hosing involves the use of high-powered water spray to remove surface contamination. Where possible wastewater should be collected for disposal or directed down water drains. Pressure hoses should be connected to a clean water supply.

Safety precautions: pressure hosing should only be carried out in outdoor environments, and appropriate personal protective equipment (gloves, disposable plastic apron, face mask and rubber boots) should be worn throughout.

Steam cleaning and hot washing

Steam cleaning and hot washing are 2 effective ways to clean upholstered objects (such as carpets, couches and sofas) around the house as a way to sterilise and deodorise damaged items. Steam cleaning uses machines that use steam and detergent solutions onto upholstered surfaces, carpets, tapestries and so on, which is then vacuumed before the fabric becomes saturated in the solution.

Steam cleaning physically extracts contaminants from materials and surfaces. The steam is applied by hand-held wands or automated systems, and the contaminated wastewater is collected for disposal and should be directed down water drains and sinks. Steam cleaners that use hot water are not suitable for silk, viscose or cotton velvet fabrics. Steam cleaning should be used on dry items.

Hot washing involves the washing of fabrics at temperatures above 60°C in a washing machine. This is not suitable for delicate items of clothing or for certain fibres, so washing instructions should be checked before using this method.

Safety precautions: safety face masks should be worn where possible as steam cleaning may produce water droplets. Electrical equipment should not be plugged in until it has been dried thoroughly and inspected by a qualified electrician. Clothing should not be hand washed at high temperatures; it should be done as per manufacturer’s instructions, and appropriate protection should be used to prevent burns from hot water.

Specialist cleaning

Gentle or specialist cleaning can remove contamination from smaller objects (for example dry cleaning of a wedding dress or gentle cleaning of jewellery). This can be done after relevant items have dried out properly. Specialist cleaners should be advised that the item has been exposed to floodwater and possible harmful contaminants such as sewage.

Safety precautions: appropriate personal protective equipment (gloves, disposable plastic apron) should be worn throughout specialist cleaning processes.

Removal of contaminated material and debris

It is important to assess whether items that have come into contact of floodwater can be appropriately cleaned for reuse. If they are beyond repair or disinfection, they should be removed from the property and placed in appropriate disposal bins (such as council collection bins and skips). This is because these items can be harmful to health if not effectively cleaned or repaired and in some cases attract pests. 

Objects or furnishings that need to be checked for contamination, and considered for disposal:

• small materials removed from the building (such as books, papers, pictures, wall hangings)
• small equipment and office items (such as staplers, telephones, hand tools)
• large durable materials removed from the building (such as furniture, computers, copiers, fax machines, printers)
• building and decorating materials, such as carpeting, draperies, window blinds,   window air conditioners, ceiling panels, wallboard, and panelling
• refuse, food, and other unwanted materials present at the site at the time of     contamination

Similarly, garden debris, grass and vegetation removal involves removing residual contamination by cutting the grass or collecting leaves in gardens, allotments, and other recreational areas.

Safety precautions: care should be taken when lifting heavy objects. Electrical equipment (such as leaf blowers) should not be plugged in until it has been dried thoroughly and inspected by a qualified electrician. Appropriate personal protective equipment should be worn when handling contaminated material for disposal. Contaminated items should be double bagged for disposal where possible, and bags containing contaminated food should not be left out in open areas as they will attract pests.

Cleaning surfaces

Recovery and decontamination of residential areas (such as homes, gardens, schools and playing fields) will be required once the floodwaters have receded. There are a range of different surface types that may need to be cleaned after a flood. The best approach to cleaning will depend on the surface or type of material involved (such as wall or carpet). For example, natural weathering (and drying out) may be the most appropriate approach for recreational areas as sunlight and natural UV radiation are effective at killing micro-organisms.

The following table details the different types of surfaces and the best and safest way to clean them.

Types of surfaces and how they can be cleaned in a safe manner

Surface types	Examples	How they can be cleaned
External building surfaces	Walls, roofs, windows, garages and paved areas	External building surfaces are usually quite robust, so active cleaning (household detergents or bleach) or pressure hosing are efficient and effective methods for cleaning.
Internal hard building surfaces	Walls, ceilings, hard floors	Internal hard building surfaces are also quite robust, so active cleaning (household detergents or bleach) are efficient and effective methods for cleaning.
Soft furnishings	Carpets, curtains, sofas, bedding	Soft furnishings are porous and absorbent and can be extensively damaged by floodwater. People will need to decide whether to throw them away or clean them (steam cleaning or a hot 60°C machine wash), and should remember to ask their insurer before discarding items if they cannot be cleaned (such as mattresses and carpets).
Personal (precious objects)	Photos, jewellery, books, CDs and so on	Personal (precious objects) can be gently cleaned once they have dried out.
Vehicles	Cars, motorcycles, bicycles	The outside of vehicles is quite robust, so active cleaning (household detergents or bleach) and pressure hosing are efficient and effective methods for cleaning. However, the inside of vehicles should be considered in the same way as soft furnishings.
Recreational areas	Parks and open spaces, gardens, allotments and playing fields	The cleaning of potentially contaminated soil and vegetation will depend on what it is used for. Removing obvious signs of contamination should be prioritised once the floodwater has receded. Natural weathering (and drying out) may be the most appropriate approach for recreational areas as sunlight and natural UV radiation are effective at killing micro-organisms.

Mould

Flooding and heavy rainfall may also affect indoor environmental quality, including increased exposure of households to mould. Changes in the absolute moisture content of the outdoor air may mean that increased ventilation may be required to remove moisture from the indoor environment. Heavy rainfall events increase the risk of rainwater ingress into buildings. The key to controlling mould is to control the moisture levels in the environment. After flooding, residents should be advised that:

• mould can grow on damp walls – if this does not stop as their home dries, they should contact a specialist
• heating, dehumidifiers and good ventilation can help dry out their home
• small areas of mould can be removed easily with proprietary mould removal solutions available in hardware stores – if the mould persists or is extensive it may be advisable to contact a specialist cleaner who has experience in the field of fungal remediation and follow current guidance

Most people will not encounter any health problems from short-term exposure to mould and fungal spores. It is important to note, however, that there is medical evidence linking prolonged exposure to high levels of mould with exacerbation of asthma and eye and nose irritation in some individuals. If there is extensive fungal growth within a property and residents believe that their health might be affected, they should be advised to consult their GP.

Managing the physical health impacts of flooding

Flooding has extensive and significant impacts on health. Aside from direct effects due to – for example – death and injury, floodwater can contain a range of items that can be hazardous to health, such as:

• human and livestock waste
• sewage
• household, medical and industrial hazardous waste (chemical, biological, and radiological)
• physical objects (for example wood, vehicle debris, rubbish)
• wild or stray animals (for example rodents, birds)
• petrol or oil spillages

Many of these can increase the risk of spread of infection, although disease outbreaks linked to flooding remain rare in England. Hand washing is the most important way to get rid of harmful bugs. Using warm, clean water and soap, rinsing and drying hands after going to the toilet, before eating or preparing food, after being in contact with floodwater, sewage or with items that have been in the water is the most effective way of preventing infection. Cold water can be used if warm is not available. If there is no clean water, then disposable soapy, wet wipes or sanitising gel can be used to carefully clean all parts of the hands and dry them.

This section outlines approaches to management of food, water and chemical hazards arising following flooding, with the aim of minimising risks to public health. Advice spans recommendations for frontline responders and advice that should be provided to residents to manage potential hazards to their health and those of others.  

Food and food safety

Microbes and waterborne infectious diseases can be transmitted in floodwater and contaminate food, food storage and preparation areas. Flooding can disrupt power supply that can spoil perishable foods stored in fridges and freezers as a result of flooding. The kitchen or cooking space may have also been in contact with floodwater and will require a thorough cleaning before this space can be used for any food preparation.

General advice on food safety

The Food Standards Agency advises not to eat any food that has been touched or covered by floodwater or sewage. Residents should be advised that they should not:

• salvage food that has come into contact with floodwater including tins as they may be damaged or contaminated and pose significant issues to health
• eat any produce grown on an allotment or garden that has been flooded unless it has been cooked

Produce that might be ‘ready to eat’ such as lettuce or strawberries that were in the allotment or garden when it flooded should be thrown away. It is safe to eat produce that is to be cooked, even if it has been contaminated by floodwater, because cooking will kill any harmful germs that might be present. It is also safe to eat produce that is growing above the water and not contaminated with floodwater, such as fruit on trees.

Considering refrigeration, residents should be advised that:

• if power has been cut off and their fridge has not been working for up to 4 hours but the door has remained closed, the food inside will be safe – if their fridge has not been working for more than 4 hours, it is advisable to throw away the food inside
• if their freezer has not been working for more than 4 hours, they should throw away the food inside – they should throw away any ice cream that has gone soft; however, meat and fish that are still below 8°C can be refrozen or cooked and eaten

Residents should ask for advice from the environmental health service at their local authority if they have a catering business and have been affected by flooding.

Preparing food safely after a flood

Residents should be advised that they should always wash their hands with clean water (preferably warm water, but if that is not available, then cold water can be used) and soap and dry them, before eating or preparing food. This is especially important after going to the toilet and after being in contact with floodwater (including sewage or other items that have been in floodwater).

If there is no clean water, they should use disposable wet wipes or sanitiser gel to carefully clean all parts of their hands and dry them.

If there is a possibility that gas or electrical appliances have got wet, they should only be turned on once they have been checked by a qualified gas engineer or electrician.

Residents should clean and disinfect all work surfaces and all items to be used before food preparation such as plates, pans, cutlery and plastic or ceramic chopping boards, but wooden chopping boards and wooden spoons should be discarded if contaminated by floodwater. If they have a working dishwasher and mains water supply, this is a more efficient way to clean and sanitise smaller items.

They should also thoroughly clean the inside of their fridge and food cupboards if they have been touched by floodwater using a hot detergent solution or any other disinfectant.

Preparing baby formula

If residents think there are issues with the tap water supply in their property (for example an odour or discoloration of water) then they should not use this water to prepare baby formula. Residents should instead be advised to ensure they use bottled water that has been boiled and cooled for at least 30 minutes in a clean, covered container, and then follow the instructions on making the feed. They can also use ready-made formula milk as an alternative.

If they do not have gas or electricity to boil water, they can use unboiled bottled water but must then give the feed to the baby immediately. They should not, under any circumstance, give unboiled tap or tank water as these sources might be contaminated.

If giving a baby bottled water, residents should be advised to check the label for sodium or ‘Na’ and that it is not higher than 200mg per litre as a high concentration can be harmful to babies.

Discarding flood contaminated food

Residents should be advised to:

• put flood-damaged food and kitchen items in black plastic refuse sacks, double bagged if possible, seal them and put them out when the next refuse collection is due
• remember to check with insurers before disposal because food may be insured; damaged food – including tins – should not be salvaged as they may be damaged or contaminated
• ask for advice from the environmental health service at their local authority if they have a catering business and have been affected by flooding

Water supplies and water safety

Mains water supply and distribution network might not always be affected by flooding; however, it is important to check before using mains water. Private water supplies such as a well or spring can become affected.

General advice on water safety

Water companies have a duty to take all necessary steps to protect public health. For example, should water treatment works become flooded, alternative supplies will be made available, such as bottled water or water bowser, but in the meantime, consumers may be advised to boil water before drinking or temporarily stop using water for domestic purposes.

Residents should be advised not to use tap water if they think there are issues with the supply, such as an odour or discolouration of the water. Water that may be contaminated should not be used for any of the following:

• to wash dishes
• to wash food or during food preparation
• to wash hands
• to make ice
• in baby formula

Water from the hot tap is not suitable for drinking, whether in flood circumstances or not.

Mains testing

Residents who notice a change in water quality, such as water discolouration, change in taste or smell should be advised to contact their local water company. While waiting for an answer, and if water is urgently required, they should boil all water intended for drinking or use bottled water.

The quality of tap water is the responsibility of the local water company, supervised by the Drinking Water Inspectorate.

If there is evidence that the tap water may be contaminated, the water company will issue advice to boil water.

Boiling water

Boiling water is one of the most effective ways of sanitising and killing waterborne microbes and is recommended in situations where microbial contamination of drinking water could threaten public health. Water suppliers will send 3 kinds of water notices for different circumstances:

1. ‘Boil tap water before use’: this will be for drinking and food preparation. All water for these purposes should be brought to a boil and then allowed to cool before using.
2. ‘Do not drink your tap water’.
3. ‘Do not use your tap water’.

Boiling water can carry a risk of scalding accidents. It is advisable to use a kettle rather than pots and pans. If open containers such as pots and pans must be used, then special care should be taken when young children or vulnerable people are nearby. Pan handles should be turned inwards when boiling water in pans so that children cannot reach them. Once boiled water begins to cool it is vulnerable to recontamination from kitchen utensils, so it is important that boiled water is used as soon as possible.

Mains water for showering and bathing

If the water company has advised that the domestic supply is unsafe for drinking, then it is also inadvisable to use this for bathing infants as they may ingest some during bathing. In this situation, bottled water is a safe alternative. Baby wipes can also be used for hand cleansing and washing infants.

For anyone using contact lenses, it is advised to use saline solution as the only method to clean contacts. Tap water or boiled water should not be used to wash them. Hands should be washed using warm water and soap. Contact lenses should not be touched with hands that may have been in contact with contaminated water as this could spread infection. If in doubt, residents should be advised to consult their opticians.

Private water systems

Residents whose water comes from a private supply such as a well or spring should check that it has not been affected by the floodwater. If it has been covered by floodwater, they should proceed with caution and ring their local authority for advice. While waiting for an answer or if in doubt, they should assume that the water is unsafe to drink and source an alternative supply. This is because boiling water kills pathogenic bacteria, viruses and parasites, but does not remove harmful chemicals.

Floodwater health and safety

Pets

Infections in pets during and after periods of flooding in the UK are very rare as harmful bacteria in floodwater are usually diluted and so present a low risk. However, swallowing floodwater or mud that has been brought into the garden by the floodwaters can cause stomach upsets or diarrhoea.

Residents should be made aware of the following advice to help reduce the risk of infection to pets:

• avoid direct contact with floodwater and prevent pets from drinking floodwater (running or standing water)
• if there is still a significant amount of water in the environment, keep pets and animals on a lead or limit access to the garden and public land as much as possible until the water has receded
• keep pets out of the affected area until clean-up has been completed – make sure to remove all obvious signs of contamination and any accumulated rubbish once the floodwater has receded before allowing pets access to the garden
• clean away mud and dry pets well after outdoor access, remember to wash hands thoroughly and frequently when handling pets that have been outdoors
• ensure pet vaccinations and deworming are up to date

Residents should contact their local vet if they need advice and more information.

Safe play areas

Residents should be advised not to let young children play on affected grassed or paved areas until they have been cleaned down and restored to their normal condition. Sunlight and natural processes in soil help destroy harmful bacteria and any excess risk to health should disappear within a number of weeks. In the meantime, residents should be advised to wash their hands with warm water and soap as it is the best way of protecting health during the recovery phase.

Sports and recreational fields

In the course of flooding in the UK, sports playing fields and pitches can become inundated with floodwater that may be contaminated with sewage and chemicals (normally at low concentrations). Many affected sports fields have been subject to flooding regularly over recent years and as a result have deliberately been sited on land in floodplains that cannot be used for development. During the recovery phase it is important to assess whether there may be any public health implications from contamination on these pitches after the floodwater has receded and drained away.

Normal soil on playing fields and pitches will contain bacteria and fungi, some of which are usually associated with sewage. Testing the soil for contamination will not add any useful information when assessing the risk to public health. Risks cannot be completely eliminated and some pathogens may survive in low numbers in soil for some weeks. The risk of infection therefore remains low, and people using these pitches are routinely advised to take basic hygiene precautions (including washing hands after playing, before eating or drinking, thoroughly washing cuts incurred on the field with clean water, covering cuts before playing and keeping their tetanus immunisation up to date). Any additional micro-organisms deposited by the floods could be expected to decay rapidly as the pitch dries out in sunlight.

Where sports fields and pitches have been flooded, gross contamination (litter carried in by the flood) should be removed. Protective clothing such as waterproof boots, plastic aprons and gloves should be worn while cleaning up, and any open cuts should be covered with waterproof plasters. Hands should be cleaned with soap and warm water after being in contact with floodwater or items that have been contaminated and particularly before eating or preparing food. Following this, the appropriate action to return the pitch to a good playing condition should be carried out according to the local council’s advice.

If a playing field has been subject to specific contamination, for example due to an overflowing septic tank or floodwater coming directly from an obvious specific chemical source, residents should be advised to contact their local council, health protection team or the Environment Agency to report an environmental incident. Appropriate remedial action (if any) will be determined on the basis of a risk assessment with professional advice from the UK Health Security Agency (UKHSA), the local authority and Environment Agency.

Chemical hazards

Flooding mobilises chemicals in the environment and may lead to increased contact between persons and industrial or agricultural chemicals (such as pesticides). For questions or concerns about any chemical hazards or pollution in homes or properties, residents should be advised to contact their local council, their local health protection team or the Environment Agency (helpline: 0800 80 70 60).

Toilets and septic tank cleaning

Infectious disease outbreaks arising from floods in the UK are rare. Despite the rarity of such events, it’s important to be aware of the small risk. Contaminants can enter floodwater due to groundwater, surface water and the overtopping of rivers, which cause sewage systems to overflow and get mixed with the floodwater. This causes the floodwater to become contaminated and be harmful if exposed.

Raw or partially treated sewage may attract domestic animals, vermin and pests, which can create an unpleasant environment (odour and sight), but also could be one of the risks to public health.

The Environment Agency and UKHSA work together to reduce the risk of pollution leaks into floodwater to protect public health. This may include risk assessment of whether significant pollution has been produced by industry or from sewage treatment works and additional monitoring of watercourses.  

Toilet blockage – how to flush

The following options may be available to residents whose toilets cannot be used.

It may be possible and practicable to use the facilities of unaffected family, friends, neighbours, public toilets, rest centres, local shops, supermarkets and hotels. Chemical toilets may be provided in the area.

Portable bag-in-a-bag products (for example, ‘brief relief’, ‘wag bag’) designed for solid and urine waste may be provided in your area. Once used according to manufacturers’ instructions, the waste bag should be placed inside another bag, such as a bin liner, and disposed of in the usual way.

 Septic tanks

If floodwaters have affected a property with a septic tank system (also known as an onsite wastewater system), the septic tank may also be affected.

Wastewater from homes and all buildings contains sewage from toilets and grey-water from bathrooms, kitchens and laundry. Wastewater can contain human disease-causing micro-organisms such as bacteria, viruses and parasites. Diseases can be transmitted to humans from wastewater if appropriate measures are not taken, although this is very rare if safe hygiene measures are followed. The safe disposal of wastewater is an essential part of protecting your health and the health of others. Ensure children and pets are kept away from wastewater affected areas.

The advice in the Environment Agency note, ‘Dealing with septic tanks during flooding’, sets out information for members of the public and operators responsible for dealing with septic tanks during flooding, with suggestions for immediate action to be taken if the septic tank is waterlogged and will not drain. In addition, it sets out other options for action in the short and longer term, and highlights sources of further information.

Septic tank systems typically comprise a concrete, plastic or fibreglass tank. In a functioning system, the solids in the wastewater settle in a primary tank. The wastewater is then discharged through pipes into soil in a designated area on the property, often called a soak away or drainage field.

Failed systems are not easy to identify; however, some simple indications may include:

• a pungent odour around the tank and land application area
• blocked fixtures and wastewater overflowing from the relief point
• high sludge levels within the primary tank
• sewage flowing up through the toilet and sinks

For septic tanks affected by floodwater, there are recommended actions to be taken immediately, and in the short and long term.

Immediate actions  – just as a warning or alert is issued

If the septic tank system becomes covered with water, residents should be advised:

• not to use the tank at all if possible and to avoid contact with any standing water that may contain sewage – they should continue to do this until the septic tank or drainage field is no longer covered in water and make arrangements to have their tank emptied if the situation allows (see above)
• to consider hiring temporary portable toilet services
• to report suspected signs of damage (such as waste blocking watercourse and damaged riverbanks) to the Environment Agency incident hotline on 0800 80 70 60 (Freephone, 24-hour service) so that a team can investigate and take the appropriate action
• to eliminate all non-essential water use and flush toilets as little as possible while a flood is in progress; they should continue to do this until the ground is no longer flooded (the Waterwise website has quick tips on reducing water use in the home)
• to arrange for the septic tank to be emptied and the contents removed by a contractor on a regular basis until the ground is no longer flooded following the event, though this is unsustainable in the long term
• to get advice from their drainage contractor before having the tank emptied, as in some circumstances emptying the tank can cause mud or silt to be drawn into the tank or, in extreme cases, result in it lifting out of the ground

Short-term actions – soon after the flood event

Residents should be advised to:

• check none of the pipes with clean water systems are connected to any affected water systems; if clean surface water needs to be disposed of, it is acceptable to do so via a drainage field or stream without treatment
• keep away from the septic tank drainage area as standing water, wet ground or ponded water may contain untreated sewage – they should avoid doing work until the ground conditions are suitable
• wear protective clothing, covering the eyes, skin and lungs from the fumes if caustic or toxic chemicals have been added to the septic tank in the past, and it is backing up into the cellar, basement or drainage field
• clean the area and disinfect the floor if sewage has backed up into the home – a household bleach-based detergent (according to manufacturer’s instructions) should be used to disinfect the area thoroughly, and the septic tank should be professionally inspected and serviced if any damage is suspected (only trained specialists should clean or repair septic tanks because tanks may contain dangerous gases)
• contact the manufacturer for specific advice on how flooding or power outages may affect composting toilets or other similar approved systems if these are in place in or around the property

Long-term actions – after recovery phase to ensure future flood preparedness and protection measures

Residents should be advised to:

• consider connecting to the public sewer if possible – the local sewage undertaker will be able to provide details on applications for this connection
• ensure this system is well maintained, so it is better able to cope in extreme weather
• consider more appropriate site of the septic tank and the soakaway, keeping it away from areas associated with flooding or waterlogging if possible
• consider an improved treatment option which can be discharged directly to surface water, removing the need for an infiltration system

For further information they can contact the Environment Agency National Customer Contact Centre (NCCC) on 03708 506 506, and visit the Environment Agency website for guidance on environmental permits.

After a flooding event, residents should:

• inspect the septic tank system for signs of damage and to determine if removal of silt or debris is required, then take any actions required – an appropriately qualified contractor may be needed to inspect and take action
• consult a local sewage undertaker who, under s101A of the Water Industry Act (1991), should provide a public sewer – this is especially the case if there are issues with surface and ground water flooding that has become polluted from a damaged septic tank that services several properties

CO poisoning

Carbon monoxide (CO) is produced when fossil fuels such as gas, petrol, diesel, coal, coke, oil and other fuels such as wood and charcoal burn without enough air. Incorrectly installed, poorly maintained or poorly ventilated heating and cooking devices are the main sources of CO. Exposure to high indoor levels can be fatal, while exposure to lower levels can result in symptoms that resemble flu, viral infections or food poisoning.

Headache, tiredness, difficulty in thinking clearly and feeling sick are the most common symptoms. Drowsiness, dizziness, shortness of breath and chest pains may also be experienced. Prolonged exposure to low levels of CO over a long period of time can cause harm to health, often leading to lasting neurological damage in victims.

In England, CO poisoning remains a significant cause of death after flooding. The risk of CO poisoning can occur during flooding and in the recovery phase afterwards and is often associated with inappropriate indoor use of portable generators. A literature review found that the infrequent use or improper maintenance of appliances can release CO into a room from a flood event or other disasters. For example, wood burners and rarely used chimney flues may become problematic following a flood.

To reduce the risk of CO poisoning, residents should be advised that they should not use outdoor equipment (such as petrol- or diesel-powered tools, camping stoves and generators) inside for drying, heating, cooking, and power supply.

Petrol or diesel generators and other fuel-driven equipment (including fuel-driven DIY equipment) should never be brought indoors or other enclosed spaces. Using these devices can be fatal.

It is advisable to place equipment outdoors and at 20 feet to avoid air from entering the building, with the exhaust facing away from windows or doors to prevent exhaust gases from being drawn indoors. The exhaust gases contain carbon monoxide, which can quickly build up to poisonous levels without good ventilation – which involves keeping doors and windows open whenever possible.

It is important to have all appliances which use fossil fuels (and wood) installed and serviced at least annually by a qualified and registered engineer, where the appliances are operated according to the manufacturers’ instructions. Residents should not turn on appliances which use fossil fuels (and wood) if they may have got wet until checked by a qualified engineer.

CO monitors can be placed in the area where there are potential sources. These monitors should be equipped with audible alarms to warn people when CO concentrations are too high. However, these alarms should not be seen as an alternative to following the above guidance or the use of caution.

Car batteries

When handling car batteries, it is advisable to use rubber gloves. This is because car batteries are usually lead-acid batteries, containing 35% sulphuric acid. Old batteries can leak this acid and may be covered by floodwater. Car batteries need to be safely handled to avoid exposure to their dangerous chemicals and potential contaminants from floodwater. They can be disposed at local civic amenity sites. Residents should be advised to let the site operator know if the batteries are leaking or contaminated from floodwater.

Household chemicals

Wear rubber gloves when handling household chemicals. Floodwater may have displaced containers of hazardous chemicals such as cleaning products, garden pesticides and domestic heating oil from their normal storage places in the home. Further information on storing domestic heating oil is available on GOV.UK and information on its safe handling is available from the Oil Firing Technical Association (OFTEC).

Oil and petrol leakages

Oil in floodwater

There may be visible oil films floating on floodwaters both inside buildings and surrounding areas. It is recommended that these films should not be disturbed and exposure to them should be avoided as skin exposure may cause a variety of skin conditions.

Once floodwaters recede, and following an initial clean, if there is any remaining oil contamination in accessible areas in the home, this can be removed with a detergent solution and washing the surface down. In inaccessible areas such as under floorboards, it may leave an odour problem but it will not cause a health issue. Further advice should be sought from environmental health staff if the odour persists or if you are particularly concerned about it being present in your home. Oil pollution and other contaminants can also be reported to the Environment Agency pollution incident freephone number 0800 80 70 60 (24 hour service).

Petrol in floodwater

There may be visible petrol films floating on the floodwaters both inside buildings and surrounding areas. It is recommended that these films should not be disturbed and exposure to them should be avoided as skin exposure may cause a variety of skin conditions and the vapour may be irritating to eyes and lungs.

Once floodwaters recede, the ground can be washed with detergent solution to remove the petrol. Additionally, smoking or fire sources such as matches in the area with petrol films should be avoided at all costs.

Gas and electrical systems

Residents should not turn on gas or electrics if there is a chance they have become wet and should only do so once they have been checked by a qualified gas engineer or electrician, respectively.

Sandbags

Sandbags are a cheap flood protection measure; they help to keep water out for short periods of time and can be made more effective if used with plastic sheeting. They can filter out some muddy sediments found in floodwaters. Local councils should have access to sandbags that can be deployed during floods – residents can check with them in advance.

However, sandbags tend to retain contaminants from the floodwater they come into contact with and the floodwater can seep out. Gloves should be worn when handling them and thorough washing of hands is recommended after doing so. If sandbags are contaminated by floodwater, these should be taken to the local household waste recycling centre and the staff informed of their contamination. If this is not possible, residents should seek advice from their local council on how best to dispose of them.

In particular, residents should be advised that they should not:

• place any used sandbags or their components (sand or sack) in their household waste
• allow children or pets to come into contact with the sand as it may be contaminated and hazardous to health

If sandbags need to be stored temporarily while awaiting disposal it is best to lay them out so they can dry rather than stacking them. It is highly unlikely there is any risk of microbial infection during the drying out process, but it is best to choose an area away from pets and children, preferably in direct sunlight to hasten the weathering process. If handing contaminated sandbags, gloves and protective clothing should be worn to avoid exposure.

If in doubt, residents can contact their local health protection team for advice as well as the local household waste recycling centre.

Damaged outbuildings and asbestos

Flood clean-up may involve renovation, removal, demolition or salvage of flood damaged structures and materials. Such materials may contain asbestos – residents can check with their local council on how to check for asbestos and its safe removal.

Residents can contact their local council as they will be able to advise on the best method for disposal, as materials such as sprayed asbestos coatings, asbestos insulation, asbestos lagging and asbestos insulating board should only be removed and disposed of by a licensed contractor.

Specialised licensed asbestos removal companies will be able to undertake specialist removal – check the Health and Safety Executive (HSE) for licensed asbestos contractors.

Ventilation

Enclosed areas such as garages and cellars can leave a build-up of fumes once the floodwater has receded; if possible, avoid entering these spaces. Before entering, a protective face mask should be worn, covering skin and eyes so as to not expose them to potential hazardous fumes.

On entry to the area, windows and doors should be opened, and residents should then exit the area to allow for this space to be ventilated out. They can return in around an hour; it is best to avoid allowing children and pets in these spaces until it is safe to do so.

Local health services

Anyone with concerns for their health or mental health should contact their GP for advice, or NHS 111. To check whether scheduled appointments are affected (such as GP, outpatient or inpatient at a local hospital), residents can use the usual local telephone numbers for their health services. In more severe circumstances, local NHS services may be issuing updates.

Assessment and management of mental health

The immediate dangers to physical health from flooding events are highly visible; however, the majority of impacts on health in England are associated with mental rather than physical health. This section of the guide covers the preventative measures that are needed to reduce the mental health effects caused by flooding on affected people and communities. It should be used by healthcare professionals, local authorities, government bodies and relevant agencies before, during and after a flood event.

The guidance below provides insight into the adverse psychosocial impacts on flood-affected communities and how relevant agencies can develop plans to mitigate their effects. It particularly focuses on groups who may be at increased risk of impacts on mental health and wellbeing following a flood event.

Risks to mental health from flooding

The English National Cohort Study of Flooding and Health was established by Public Health England (PHE) in 2014 to investigate the long-term impacts of flooding on mental health. This study found that people who had experienced flooding were more likely to have symptoms of post-traumatic stress disorder (PTSD), depression and anxiety disorders (such as general anxiety disorder, panic disorder) between 6 months to 3 years following the event.

In the first survey, people whose homes had been flooded were up to 6 times more likely to report probable PTSD, depression and/or anxiety than people who had not been flooded. Significant mental health impacts were experienced by those with floodwater in the home. The extent of these impacts was affected by the amount of time the floodwater stayed in the home as well as the levels of the floodwater present. Psychological morbidity was still prevalent 2 years after the event, especially for rates of anxiety disorders. The study also found symptoms suggestive of a mental health disorder in those who lived in the vicinity of flooded homes or in a community affected by a flood event, but who otherwise were not directly flooded (that is, did not experience floodwater within the home).

Experiencing disruption as a consequence of flooding can have mental health impacts even in the absence of being flooded. Loss of gas, water and electricity services, loss of access to health and social care services and health concerns are significant stressors associated with flood-related mental health burden. Primary and secondary stressors are factors that are either directly or indirectly associated with flooding which may be amenable to action in order to reduce their public health impact.

Primary and secondary stressors that are associated with poorer mental health include:

• loss of sentimental items
• loss of domestic utilities such as electricity, water, gas
• concerns about health and health of others
• financial concerns, including concerns about house repairs and value
• difficulties with home repairs
• health-related stressors, such as lack of access to healthcare, new or continuing health concerns or conditions, and lack of access to prescription medications can place people at greater risk of psychological effects of flooding – this could be particularly acute for those with learning disabilities, autism or dementia due to a change in routine and surroundings
• family and relationship stressors, such as interruption of normal routines, separation from friends and family, and difficulties with neighbours
• stress relating to education and schooling, such as loss of education facilities and loss of socialisation associated with attending school
• feelings of loss of control and fear of recurrence of another extreme event, and heightened anxiety, especially those with existing anxiety or past trauma
• economic stressors such as problems with insurance claims and compensation, recovery of and rebuilding homes, loss of employment and/or income, and loss of physical possessions and resources
• stress arising from exposure to media reporting
• being evacuated or displaced

For the majority of affected people, distress caused by flooding will be temporary and they will be able to cope with the psychological effects, often helped by adequate sources of practical, social and even emotional support. However, an important minority of people who are affected by flooding may subsequently develop more severe psychological problems such as depression or PTSD in the short to long term. Others may experience an exacerbation of pre-existing mental health conditions.

Often people with symptoms of mental ill health do not seek help from formal sources. It is likely there is a significant unrecognised burden of mental ill health after flooding within communities. With improved identification, individuals who would benefit from access to specialist psychological healthcare can be supported to access the right support to meet their personal needs and circumstances.

A phased approach to care

It is important to provide the right help at the right time when a flood occurs and during the recovery phase. A response should begin by attending to basic needs, such as safety, security, food shelter and acute medical problems. It should then proceed through interventions and support delivered by professionals, volunteers, communities and non-specialist support providers as appropriate. Lastly, where needed, specialist mental health care services should be considered. This type of sequenced response will help to provide co­ordinated, accessible information and evidence-informed support to all those affected during flooding.

A phased approach is based on the principle that support may be required over an extended period and the level of support required may change during that period, as illustrated in the 4-tiered pyramid. Most distress is usually temporary, with the majority of people able to cope with the psychological effects of being flooded by accessing their existing resources. However, an important minority of people who are affected by flooding may go on to develop more severe psychological problems. Others may experience an exacerbation of pre-existing mental health conditions. A small proportion of individuals may therefore require access to specialist psychological healthcare, with some requiring care over extended periods. This range of psychological distress means that the support each person needs will be different depending on their circumstances. The required support may increase or decrease over time.

Finally, the impacts of a flood on local mental health needs may not be apparent from routine surveillance data if the proportion directly affected in the population served is small, or if some of those who experience mental health impacts are displaced and accessing services in other areas. Local joint strategic needs assessments between all the agencies involved should take account of this possible underestimate when planning support services. The actions described in this guide are not prescriptive and tiers 1 to 4 are intended to be flexible.

Four-tiered pyramid for flood response

The response to a flood can be illustrated as a phased approach where the first 2 response activities encompass the actions needed for the majority of the population. This is followed by more focused and targeted care for those at higher risk.

The sections below outline suggested actions under each of these tiers in more detail.

Tier 1 intervention: immediate response

At the bottom of the pyramid is the support that should be universally available to people affected by flooding and which is protective against developing symptoms of mental health disorders. These include addressing the immediate practical needs of people directly or indirectly affected, such as encouraging people to leave dangerous areas, restoring utilities, ensuring continuity of care for those accessing health and care services, or supporting the flood recovery process. This also includes the mental health needs of formal and volunteer responders. Being flooded or disrupted by flooding is associated with poorer mental health outcomes, so minimising the impact of flooding at the time of the event is likely to be protective.

At the general level, public mental health messages should focus on normalising the distress caused by flooding and destigmatising its possible effects on mental health. Recommendations for responders in this tier focus on:

• addressing immediate physical needs
• communicating important public health messages

Address immediate dangers and offer practical support

In the immediate response to a flood, the priority is crisis management, addressing the risk to life and the immediate physical needs of affected households and individuals. Ensuring help reaches people at this stage supports psychological resilience at the point when people are most vulnerable.

In the immediate aftermath of a flood, individuals, households and communities are likely to need different levels of support to manage the secondary stressors associated with poorer mental health following flooding.

Most people’s need for support is met by people close to them. However, assumptions should not be made that everyone naturally understands how to deliver effective and safe support. Family members may not be suitable to deliver practical support during the highly stressful period after a flood. Consequently, help with transportation, evacuation and other practical needs should ideally be provided by trained responders or volunteers.

Suggestions for flood responders

In the event of a flood and in the immediate aftermath, responders should focus on minimising the risk to life and addressing the immediate physical needs of affected households and individuals, including basic needs of food, accommodation and sleep.

The response may involve signposting affected people to practical support available from appropriate sources such as the local authority, Environment Agency, National Flood Forum, or the British Red Cross.

At this stage in the flood response, members of the public should be advised against trying to evacuate people or clear homes themselves, so as not to put themselves in danger. However, examples of organised ‘spontaneous volunteers’ can provide great support to affected community, such as the Khalsa Aid during the 2015 floods who helped provide food and other assistance to affected areas. It is important to note the psychosocial needs of volunteers and volunteer groups should be appropriately supported as community responders.

Utilities companies should seek to reinstate domestic utilities as soon as possible, especially to those households previously identified as most at-risk, including but not limited to those on the Priority Services Register.

Promoting uptake of flood insurance

People whose homes are flooded and who do not have home or contents insurance, or who find insurance processes stressful, experience worse mental health symptoms. Insurance coverage is also uneven. According to the Association of British Insurers, as low as half of the poorest 10% of households have home contents insurance, compared to 75% of all households. Figures can be even lower in flood risk areas.

Flood Re is a joint government and insurance industry flood reinsurance scheme designed to help households at high risk of flooding to access affordable insurance and will run until 2039. It provides both buildings and contents cover. Flood Re does not deal directly with residents, but instead allows insurance companies to pass the flood risk element of home insurance policies over to Flood Re for a set premium based on council tax bands. Flood Re does not apply to homes built after 2009, larger leaseholds or small and medium-sized enterprises (SMEs). The BIBA insurance directory is very helpful in understanding potential covers available.

Households in rented accommodation are also less likely to have contents insurance and will be reliant on their landlord or housing association for building insurance.

Public mental health communications

Universal public mental health messaging in the event of a flood should focus on validating the feelings that people may have and normalising the stress and distress that flooding can cause.

The following messages can inform public communications via a range of media, and via local voluntary, community and social enterprises (VCSE) organisations and volunteers:

• having floodwater in your home or being evacuated can be very distressing
• distress is a common and understandable reaction to experiencing flooding – it is normal to notice changes in your thoughts and feelings
• having your life disrupted by flooding, even if you do not have floodwater in your home, for example through loss of gas, water or electricity supply or health and social care services, can be just as stressful as the house being flooded
• events that occur as a result of a flood can also be stressful – common sources of stress include concerns about your own health or the health of others, concerns for the welfare of pets, added financial burden or worries, repairing your home, insurance process and the loss of sentimental items
• it is normal to seek help from friends and family; however, you should seek professional support if your distress lasts for more than 2 weeks without change

Some support groups that can be accessed are:

• NHS talking therapies
• local flood wardens
• community support groups

Public health communications should be tailored to all communication needs, ensuring all materials and support are accessible for the whole population, taking into consideration language, literacy and disability-related needs.

‘How to prepare for flooding’ contains advice for people affected by flooding, which can also be used in public communications.

Tier 2 interventions

For the majority of individuals affected by flooding, psychosocial impacts can be managed through ‘light touch support’ by providing psychosocial support by appropriately trained responders. This involves a set of self-help actions, or actions which anyone in a position to help can provide, including first responders, volunteers, members of the family or community, if they have received appropriate training. It covers psychosocial support, which can include exploring coping mechanisms, signposting to support services that might help, or attending to basic needs, such as safety, security, food, shelter and acute medical help. This support is not in place of necessary professional support, but to identify the needs of people affected and linking them with appropriate support services.

Recommendations for responders in this tier focus on:

• delivering evidence-based psychosocial support such as psychological first aid involving suitably trained responders
• offering short-term one-to-one support where needed – developing an active monitoring support system, either face to face or by phone
• involving voluntary and community sector organisations
• continuing to offer practical measures to support flood recovery

Psychological first aid (PFA)

Evidence highlights that the recovery from a flood can often be more stressful and difficult than coping with the flood itself. Support provided in response to a flooding event should therefore focus on actions to reduce the immediate distress on mental health and wellbeing and avert future negative impacts from both the flood and recovery process. PFA is a world-wide implemented approach to helping individuals affected by an emergency, disaster, or humanitarian crisis, such as a flooding event.

PFA is a straightforward way of delivering psychosocial care to support others in the immediate aftermath of a range of psychological needs, as well as coping with the consequences on people’s lives, by providing humane, supportive and practical assistance for people who are distressed, in ways that respect their dignity, culture and abilities.

Anyone can be trained to deliver PFA. However, PFA is not, nor cannot, replace specialist care and people should be referred for further support as needed, for example people in need of immediate medical care or other specialist support such as safeguarding services. In such cases, people may need to be referred for further assessment or support.

Main suggestions for provision of PFA are to:

• ensure responders have received appropriate training
• provide access to psychosocial support for response staff and volunteers during and following their involvement in a flood response to ensure they are able to look after themselves while supporting others

People who have been affected by flooding can benefit from a PFA approach, but PFA cannot replace specialist care and people with acute distress, prolonged symptoms of distressed and other special needs may need to be referred for further support.

The main stages of PFA are:

• ‘prepare’ to deliver PFA
• ‘look’ to assess the situation and identify those in need
• ‘listen’ to understand their specific needs
• ‘link’ to provide further support

People involved in a flood event generally demonstrate high levels of resilience, and although some degree of distress is common, it is usually temporary. Therefore, most people do not require assistance from mental health services. For those who do require support, this does not necessarily need to be from mental health service professionals, as anyone can provide psychosocial support. Providing practical care and support as well as emotional support can be carried out by anyone. It consists of supportive responses for those who have experienced a crisis situation and may need support.

Main actions and principles for providing PFA are as follows:

• assess the situation and ensure that their circumstances are safe, and help them to contact recovery agencies if needed
• check that there are no immediate physical health needs, for example those that may require an ambulance or a hospital visit
• explore the individual’s needs and concerns, and identify if any basic needs are not met, such as access to food, water, shelter and medication
• help people to contact their loved ones and others who can provide familiar sources of support
• help to identify practical ways to address people’s needs and access to services
• listen, but do not pressure people to talk about their experiences
• provide information if you have it and help people plan for next steps

It is also important to look after your own mental health and wellbeing as responders.

UKHSA has developed a free online training course in psychological first aid.

For Tier 2 interventions, short-term one-to-one support may be required for acute feelings of distress and anxiety. This should be delivered by trained responders, face to face, for example at community rest centres, or via helplines.

In some flood affected areas phone or face-to-face ‘check-in’ models have been used in the weeks to months after a flood to assess what practical and psychosocial support people continue to need.

Evidence suggests that positive health behaviours, particularly physical activity and fostering social connections, are associated with fewer mental health symptoms following a flood.

Therefore, promoting and enabling a wellbeing approach to flood recovery is likely to be helpful in reducing the burden of mental distress.

This could include making use of resources produced to promote the 5 ways to wellbeing:

1. Connect with other people.
2. Be physically active.
3. Learn new skills.
4. Give to others.
5. Pay attention to the present moment (mindfulness).

Ideas which can be tailored for a local audience

The NHS provides 5 steps to mental wellbeing.

Making personal action plans

This is used to address emotional and practical needs and can help increase people’s sense of control over the situation and help manage distress.

Support via health and social care services

Individuals who regularly use health and social care services and support should be supported with continued access to these services, with particular consideration of people who have been displaced by flooding. Volunteers and responders should be given a role in advising health and care services regarding health and care needs in affected communities.

Community engagement to support response and recovery

VCSE organisations and informal networks typically play a significant role in the flood recovery process and can continue to play a role in building resilience and preparedness for future events. Importantly, the psychological burden on community volunteers and frontline responders themselves can be high, although there is limited evidence of the impact on volunteers and responders in England.

Suggestions for community engagement to support response and recovery

The following suggestions apply to commissioners of VCSE organisations, local resilience forums and lead local flood authorities.

Collaborations with specialist organisations

Collaborate with organisations such as the Red Cross and the National Flood Forum, who can provide or coordinate suitably trained volunteers to deliver social and emotional support as required. Support continuity of support over a timescale of months to years, as required, as many effects may be delayed or fluctuate over time.

Collaborate with other voluntary and community organisations

Responders may wish to also engage non-specialist organisations, for example faith groups or leaders of community initiatives, to ensure maximum distribution of core messages and to take advantage of what is already available that can be scaled up or adapted. However, it is not advisable to deliver psychological first aid without training.

Advice for facilitation and networking

This should involve providing practical advice to facilitate the creation or expansion of groups or networks that can promote opportunities for self-help and support community and psychosocial resilience. For example, people affected by the flood may wish to meet with others who have been similarly affected.

Mental wellbeing support

Employers and volunteer coordinators should seek to make mental wellbeing support available to response staff and volunteers in the aftermath of a flood. This should be accompanied by a debrief process and opportunities for reflection and learning for future events.

Advice for the reinstatement industry and utilities

Many households lack adequate insurance and will have additional needs for financial and reinstatement support following a flood. However, for those that have insurance delays to reinstatement, which is often not a transparent process to policyholders, this can cause significant stress and is associated with poorer mental health outcomes. The reinstatement industry can play a significant role in reducing sources of ongoing or delayed stress following a flood event.

Insurance providers and businesses involved in the building, renovation and construction industries can help mitigate some of the stress post flooding by ensuring that they have appropriate measures in place to help affected individuals navigate insurance claims and reconstruction processes. They should provide accessible support to people to navigate claims and repair processes. Insurance companies should familiarise themselves with guidance developed by the Department for Environment, Food and Rural Affairs (Defra) on how to support resilient repair and minimise delays to the recovery process.

Tier 3 interventions

Tiers 3 and 4 represent increasing levels of support, for those with psychological needs that cannot be met by general responders and need specialist support provided by a health professional. For example, NHS England provides the NHS talking therapies, formerly known as Improving Access to Psychosocial Therapies (IAPT).

Individuals may not always progress between the tiers and some people with pre-existing or complex mental health needs may require specialist support more immediately. It is appropriate to signpost them to more specialist services at the same time as providing basic psychosocial support. The 4-tiered pyramid for flood response illustrates the need and corresponding scale of intervention that is likely to be distributed within an affected population. Planning the response in line with this structure will help to provide co-ordinated, accessible information and evidence-informed support to all those affected during flooding.

Recommendations for responders in tier 3 focus on:

• providing active monitoring and seeking to identify and support individuals with more acute psychological support needs
• recognising the specific needs of children through an active screening programme for those exposed, and providing mental health support as appropriate

Screening and monitoring of at-risk individuals

Many affected individuals do not seek mental healthcare following a flood. In addition to the degree in which someone has been affected by a flood, there are wider risk factors that may increase the likelihood of mental distress and include:

• pre-existing mental health problems
• a previous history of trauma
• family history of mental health problems
• absence of social networks
• concurrent stressful life events
• substance misuse
• bereavement

Furthermore, the stigma associated with mental health can reduce the likelihood of someone seeking care. Therefore, addressing this barrier, for example by engaging with a range of sectors and stakeholders that are perceived as a trusted source of information and support within the community, for example religious leaders, may be beneficial.

Suggestions for identification and support of more acute needs

Volunteer and professional responders should be advised on risk factors and signs that someone may need additional support so that they can signpost or refer accordingly. See Tiers 3 and 4 for advice on where to signpost.

Children and young people

Children also experience emotional and psychological impacts of flooding. Parents who were interviewed following the 2005 flooding in Carlisle reported their children still became distressed by heavy rain over a year after the event. Children and young people may experience and display different symptoms of mental ill health to adults. For example, they may have altered moods and behaviour and disrupted sleep patterns.

In the immediate aftermath, responders, teachers, parents and others working with children and young people can use PFA given by responders who have trained in PFA for children. Following a flood, schools play an important role in meeting the mental health needs of children. Evidence suggests that cognitive behavioural therapy (CBT) programmes delivered in collaboration with schools can help distress levels in children affected by floods, and may reduce depression and emotional or behavioural symptoms as well as symptoms of attention deficit hyperactivity disorder (ADHD). This includes both formal counselling services offered within or facilitated by schools as well as the pastoral support provided by teachers to children and their families. Education providers can also facilitate treatment of more severe mental health disorders via regular follow-up screening of pupils affected by floods in order to identify delayed symptom onset.

Suggestions for support to children and young people

Local authorities should consider how best to work with local education providers to develop plans that can be activated when needed to deliver programmes to support recovery where a flood has affected multiple pupils within a school.

Education providers should seek to follow up and screen pupils known to have been affected by flooding, directly or indirectly, to facilitate referral to appropriate treatment and support. A small proportion of children and young people may require access to specialist mental healthcare. This can be accessed via GPs, or by self-referral to a local NHS talking therapies service for children and young people.

Training in psychological first aid for professionals and volunteers who work with children and young people in emergency situations is available.

Tier 4 interventions

In the medium to longer term recovery phase following a flood, people experiencing more severe or prolonged mental health symptoms may or may not seek help with their mental health needs or may seek help from informal sources. It is therefore likely there is a significant unrecognised burden of mental health within communities after flooding occurs.

Recommendations for responders in tier 4 focus on:

• advising individuals with severe or long-lasting symptom on how to access psychological support – referrals should be made to specialist clinical teams, ensuring support is given as soon as possible
• ensuring that mental health and social care specialists continue to offer advice to responder organisations

Suggestions for longer-term clinical interventions

Individuals who experience persistent symptoms or have concerns about their own or others’ mental health or wellbeing, should visit their GP or call NHS 111 and request help to identify further sources of support.

Individuals can self-refer to NHS talking therapies to access CBT, which for some people can help address flood-related mental distress via cognitive reappraisal. The NHS Better Health resources have further advice on how to deal with stress or anxiety as well as information about sources of support.

Anyone who identifies someone, or who meets someone who has self-assessed themselves as in need, can be signposted to this or to further resources listed in How to respond to flooding.

For the minority of individuals whose symptoms persist in the longer term, psychological support provided by specialist clinical teams may be appropriate. These individuals should be identified and formally assessed in terms of their need for either health, or health and social care services.

Mental health and social care specialists should continue to provide advice to responder organisations until recovery phase responses have been completed.

Appendix 1: English National Cohort Study of Flooding and Health

In the immediate aftermath of flooding, people can suffer from injuries, infections, exposure to chemical hazards and disruption to health services. These risks are generally well understood. However, the longer-term impacts of flooding on health have been less well described and until recently there has been limited evidence available to help us understand the scale, intensity, or duration of these impacts.

The storms of winter 2013 to 2014 brought the wettest winter to England in 250 years. Following them, PHE established the ‘English National Cohort Study of Flooding and Health’ with a range of academic partners. These partners include the NIHR Health Protection Research Units on Evaluation of Interventions at the University of Bristol, Emergency Preparedness and Response at King’s College London and Environmental Change at the London School of Hygiene and Tropical Medicine.

The study investigated the participants annually for 3 years, in order to identify the duration of psychological impacts of flooding, to help inform preventive and follow-up actions and to reduce harm from future floods.

Psychological impacts from flooding often range from natural feelings of stress or anxiety that pass naturally with time, to more severe mental health impacts, which may have long-lasting complications and require specialist interventions. The English National Cohort Study investigated how flooding affected rates of anxiety, depression, and PTSD in affected communities.

The study found that there can be a substantial mental health impact in communities affected by flooding. The main findings were:

• the percentage of people with probable depression, anxiety or PTSD was highest among people whose homes were flooded, and the risk of having these mental health issues was approximately 6 times higher in this group than in those who were unaffected by flooding
• the percentage of people with probable depression, anxiety or PTSD was also elevated among those who did not have floodwater in the liveable part of their homes, but whose lives were otherwise disrupted by the flood
• among those whose homes were flooded, the risk of poor mental health outcomes was greater the deeper the floodwater
• the risk of poor mental health outcomes was greater among those whose homes were flooded for more than 24 hours compared to those who were flooded for less than 24 hours
• among those who were flooded, having to evacuate further increased the risk of probable anxiety and PTSD
• among those whose homes were flooded, experiencing disruption to certain services including key domestic services, particularly so for domestic utilities or access to health and social care services, further increased the risk in those who needed and usually accessed them
• among those whose homes were not flooded, but whose lives were still disrupted by the flood, losing access to health and social care services (if such services were required) further increased the risk
• seeking help from any source during the first year post-flooding was increased among those whose homes were flooded or whose lives were disrupted
• the prevalence of probable psychological morbidity remained high among people whose homes were flooded 2 years after the event (depression 10.6%, anxiety 13.6%, PTSD 24.5%)
• 14 % of people reported persistent flood-related damage in their homes 2 years after flooding – these people had higher odds of mental health problems compared to the unaffected group; this was also statistically significantly higher than the odds of mental health problems among people who did not report persistent damage
• among the displaced, those who reported receiving no warning before flooding and subsequent displacement from their home were significantly more likely to report symptoms of probable depression and PTSD but not anxiety

Secondary stressors are also factors indirectly associated with flooding which may be amenable to action in order to reduce their public health impact. These include loss of personal items or financial losses, and difficulties with insurance and compensation. These secondary stressors were associated with symptoms of probable depression, anxiety and PTSD in the aftermath of flooding.

The most frequently experienced secondary stressors were concerns about house value, additional financial burden resulting from exposure to flooding, home repairs, and finding jobs or chores around the house more difficult.

Preparing for flooding

How to prepare for flooding.

Responding to flooding

How to respond to flooding.