Week 13: Bioterrorism/Adverse Effects of PH Interventions

Question 1

Define bioterrorism.

Answer 1

The use of infective organisms to achieve political, religious or ideological objectives

Question 2

What are 3 historical examples of bioterrorism?

Answer 2

6th century BC: Assyrians used rye ergot to poison the wells of its enemies

400 BC: Scythian archers dipped arrows in decomposing bodies or manure to
cause wound infections

15th-18th centuries: smallpox-laden clothing and blankets were given to
enemies to induce outbreaks

Question 3

What are 3 details about modern day bioterrorism?

Answer 3

In the first half of the 20th century, many industrialized nations, including the US, had offensive biological weapons programs

Biological Weapons Convention (1972): treaty developed by the international community preventing the stockpiling of biological agents and research into offensive biological weapons

Despite being signatories of the treaty, several countries, particularly Iraq and the Soviet Union, continued active biological weapons production

Question 4

What are the 5 reasons why the CDC identified 6 “Category A” biological agents as high priority?

Answer 4

Ease of dissemination or transmissibility from person-to-person

High mortality rates;

Serious public health implications;

Ability to cause social disruption and public panic

Special preparedness requirements

Question 5

What are the 6 “Category A” biological agents?

Answer 5

Smallpox

Anthrax

Plague

Tularemia

Botulism

Viral hemorrhagic fevers

Question 6

What are 2 details about anthrax?

Answer 6

Caused by the organism Bacillus anthracis

Transmitted as spores which can survive for long periods in the environment

Question 7

What is the clinical presentation of anthrax? What 3 infections does it cause?

Answer 7

Clinical presentation: anthrax causes three different types of infection

Cutaneous (skin form): black lesion

Intestinal (abdominal form)

Inhalation (lung form): presents with high fever, chest pain, cough and severe shortness of breath; 89-96% fatal if untreated

Question 8

What are 2 details about the anthrax treatment? What are 4 public health strategies?

Answer 8

Treatable with antibiotics

Not contagious (no person-to-person spread)

Public health strategies:
Identification of source of release and population exposed
Institution of treatment and prophylactic protocols
Information management
Coordination of the local, state and federal response

Question 9

What are 2 details about smallpox?

Answer 9

Caused by a virus

Naturally occurring smallpox was
eradicated in 1977 through a vigorous
worldwide vaccination campaign

Question 10

What is the clinical presentation of smallpox?

Answer 10

Clinical presentation: approximately 12 days after exposure, patient develops flu-like symptoms then the characteristic rash; similar to chickenpox, but all lesions are in the same stage of development and tend to be more prominent on the face and extremities

Question 11

What are 3 details about smallpox treatment? What are 5 public health strategies?

Answer 11

Highly contagious

No proven treatment, just supportive therapy

Vaccination is available for exposures

Key public health strategies:
Disease surveillance
Rapid laboratory confirmation
Isolation of contagious patients
Contact tracing
Institution of an aggressive vaccination program

Question 12

What are 2 details about the plague?

Answer 12

Caused by the bacteria Yersinia pestis

Naturally occurring outbreaks still occur worldwide

Question 13

What are 3 details about the plague’s clinical presentation?

Answer 13

Clinical presentation: plague can take on many forms

Most notorious form is bubonic plague
which is transmitted by fleas and
causes large, painful swollen lymph
nodes (glands) termed “buboes”

An aerosol attack would result in
pneumonic (lung) plague, presenting as
flu-like symptoms with watery then
bloody sputum leading to severe
respiratory distress, shock and death

Question 14

What are 2 details about plague treatment? What are 4 public health strategies?

Answer 14

Treatable with antibiotics if detected early

Nearly 100% fatality rate when not treated

Public health strategies:
Syndromic surveillance
Identification of the source of the outbreak and exposed population
Contact tracing
Distribution of prophylactic antibiotics

Question 15

What is 1 detail about botulism?

Answer 15

Caused by botulinum toxin, a nerve toxin produced by the bacteria Clostridium botulinum

Question 16

What is the clinical presentation of botulism? What are 4 symptoms?

Answer 16

Clinical presentation—following a terrorist attack with aerosolized botulinum toxin, patients will present with paralysis in a descending fashion

Weakness of the eye muscles causes double vision

Weakness of the face and neck muscles causes difficulty speaking and swallowing

Ultimately, weakness of the respiratory muscles leads to respiratory arrest

Mental status is unaffected

Question 17

What are 5 reasons why bioterrorism poses a challenge to public health?

Answer 17

Attack is likely to be covert

Delay in onset of illness (incubation period): makes identification of the
release site and other exposed individuals difficult

Many biological agents cause non-specific, flu-like illnesses initially, which
can delay diagnosis of the disease

Most clinicians are unfamiliar with diseases related to biological terrorism
due to the rarity of naturally occurring cases

Very mobile society: contagious diseases have the potential to spread
rapidly across borders

Question 18

What are 3 reasons why adverse effects of public health interventions exist?

Answer 18

Many public health interventions may have unintended effects.

PH contrasts markedly with clinical medicine, where there is a substantial
literature on adverse events and patient safety

Limited guidance is available on how to address this question in a structured way

Question 19

What 3 factors are the most likely to lead to success of public health interventions?

Answer 19

The unique social determinants

The needs and motivations

The implementation context

Question 20

What are 2 details about the failure of public health interventions?

Answer 20

Historically, PHI have been deemed appropriate for implementation if they abide by ethical principles and are based on a synthesis of effectiveness evidence

A fundamental pitfall of effectiveness evidence is that harm evaluation and
reporting are often absent or incomplete

Question 21

Define harm.

Answer 21

A deliberately inflicted actual or potential injury, ill effect, adverse event or danger

Question 22

What are 3 details about the harm principle?

Answer 22

The Harm Principle proposed in 1859 by John Stuart Mill has historically been used to determine when PHI are ethically justifiable

Evidence-based public health (EBPH)
now suggests that decisions regarding the ethical validity of a PHI should be based not only on the Harm Principle, but also on a gold standard of evidence (an up-to-date systematic review of well-executed research) together with preferences of the community

The harm principle holds that the actions of individuals should only be limited to prevent harm to other individuals

Question 23

What are the 5 different types of harms caused by public health intervention?

Answer 23

Direct harm

Psychological harm

Equity harm

Group & social harm

Opportunity cost harm

Question 24

What is 1 detail about direct harm? Give 2 examples.

Answer 24

Desired health outcomes may have directly harmful effects, regardless
of the content of the intervention targeting them

Examples:
Sun exposure is associated with a reduced risk of some cancers.
Programs to increase sports participation may increase injury risk

Question 25

What is 1 detail about psychological harm? Give 3 examples.

Answer 25

Indirect category of harms by having negative psychological impact

Examples:
Some universal psychological interventions, such as ‘debriefing’ after
traumatic events, may have adverse mental health impacts
Dissemination of health messages through educational or media
campaigns may generate damaging feelings of worry or guilt
Moderate consumption of alcohol may facilitate social interactions but interventions aimed at reducing alcohol consumption may reduce social interaction

Question 26

What are 2 details about equity harm?

Answer 26

Interventions may create harm by worsening health inequalities

Some successful interventions may improve outcomes across the population, but exacerbate existing inequalities by benefiting privileged groups more than disadvantaged groups

Question 27

What is 1 detail about group and social harm? Give 4 examples.

Answer 27

Group-based interventions may inadvertently create harms by singling out a particular subset of the population

Examples:
Targeting obese population for PH intervention
Alcohol restriction in Aboriginal communities in Australia
Advocacy to promote bicycle helmets may contribute to an exaggerated perception of the injury risks of cycling, and hence lower cycling rates
Social narratives—such as those which determine the boundaries of “appropriate” behavior by pregnant women (eg, around no consumption of alcohol)—may cause stress and guilt

Question 28

What is 1 detail about opportunity cost harm? Give an example.

Answer 28

Associated with potential benefits which may be forgone as a result of
committing resources to ineffective or to less serious public health problems

Example:
Money spent on certain awareness programs about diseases can be used to treat the actual disease in a population

Question 29

What are the 4 adaptations to the WHO Think Tank steps?

Answer 29

Describe the components of the intervention to the transdisciplinary team

Identify underlying factors and potential harmful UC and prioritize

Recommend adaptations to the intervention to account for the potential harmful UC

Conceptualize the influence and interaction of underlying harmful UC factors and redesign

Question 30

Identify examples of potential unintended harms for the question “What are you most worried about?”

Categories:
Cultural
Economic
Environmental
Physical
Political
Psychosocial
Omission

Answer 30

Cultural: empowerment of a group that does not have power may lead to conflicts of power and cultural pushback

Economic: limited resources (poverty) in community may lead to trade-offs

Environmental: possible negative impacts on wildlife AND water availability OR water quality

Physical: possible increased chance of infection from toilets if not kept clean due to an absence of water

Political: mobilizing youth without policy level support may lead to conflict

Psychosocial: knowledge with the inability to overcome resource barriers
may lead to disempowerment/helplessness

Omission: missing important populations: youth not in school