Week 6, Chapter 10 - Communicable Disease Control Strategies

Question 1

What are the three approaches to disease control?

Answer 1

1. Biological/Microbial - Targeting the pathogen/etiological agent directly
2. Behavioral - Targeting human actions that contribute to the spread of disease
3. Ecological - Targeting broader social factors and policy to control disease, a holistic approach

Question 2

What are some PH statutes that follow the Biological approach?

Hint: Think about Clinical Medicine and Epidemiology!

Answer 2

• Immunization
• Screening/Testing
• Disease Surveillance
• Contract tracing/partner notification
• personal control measures (quarantine, isolation…See Ch.11),
• Vector Control, Environmental Testing, Food/Drug Inspection (FDA)

Question 3

What are some PH interventions that follow the Behavioral approach?

Hint: Think about Health Education and Psychology!

Answer 3

• Smoking Cessation
• Sex Education
• Nutrition Programs
• Raising Drinking age

Question 4

What are some PH statutes that follow the Ecological approach?

Hint: Think about Systems Theory and Anthropology!

Answer 4

• Controlling poverty (addressing systemic inequality, sexism, racism, etc.),
• Environmental legislation (Air, water Quality, EPA),
• Head Start programs (child developmental growth),
• Title IX
• “Proactive Policing,”
• City Planning (bikes, parks, fresh food availability)

Question 5

Describe Hardin’s idea of “The Tragedy of the Commons”

Answer 5

The protection offered by herd immunity will break down if enough people utilize their ability refuse vaccines through religious or “philosophical (personal, moral reasons)” exemptions currently provided by most immunization laws.

• 48 states have religious exemptions available, 21 have philosophical.

Question 6

Name the two primary Supreme Court cases that upheld state police powers to enforce vaccination laws.

Answer 6

• Jacobson v. Massachusetts, 1905
• Zucht v. King, 1922 (this case extended Jacobson to schools, allowing for vaccinations to be a prerequisite to admission)

Question 7

Overview the history of medical countermeasures for infectious disease.

Answer 7

• 1796- Jenner develops the first vaccine for smallpox using cowpox immunity
• Late 19th Century - Pasteur, Koch, and Hansen develop the germ theory of disease by finding etiological agents
• 1890 - Koch and the Tuberculin skin test
• 1928 - Fleming discovers penicillin

Question 8

What vaccine liability and compensation provisions exist to protect individuals?

Answer 8

• National Childhood Vaccine Injury Act, 1986
• National Vaccine Injury Compensation Program - “no fault” system that pays for injuries caused by specific vaccines

Question 9

Vaccination vs. Religion: How have courts dealt with challenges to First Amendment rights?

Answer 9

• Although exemptions exist in most states, it would be constitutional to compel a person to submit to vaccination against their religious beliefs
• “Freedom to act according to religious beliefs is subject to reasonable regulation for the benefit of society…”
• Courts have tried to limit the scope of exceptions by applying them to only “recognized” religions

Question 10

What is the difference between Testing and Screening?

Answer 10

Testing - a clinical procedure that determines the presence or absence of a disease in an individual. They are typically given when an individual presents with symptoms.

Screening - application of a test to a defined population for the public health purpose of case finding. People need not be symptomatic to be screened.

Question 11

Sensitivity & Specificity. Difference please.

Answer 11

Sensitivity - the ability of a medical test to correctly identify people who have a particular disease

Specificity - the ability of a medical test to correctly identify when a person does not have a disease.

• Sensitivity, specificity, reliability, and yield all contribute to a test’s Positive Predictive Value, the proportion of people with positive test results who actually have the disease.

Question 12

What are the degrees of compulsion and consent in screening programs?

Answer 12

• Compulsory
• Conditional
• Routine with Advanced Agreement (Opt-in)
• Routine without Advanced Agreement (Opt-out)

Voluntary - the norm in medicine, includes full information about the nature of the test given to a competent person, and the freedom to accept or decline

Question 13

Explain Compulsory Screening.

Answer 13

Compulsory - the state compells a person to submit to testing without informed consent.

Question 14

What is Conditional Screening?

Answer 14

Conditional - the state restricts access to certain privileges or services until the individual submits to testing.

Question 15

Explain Routine with Advanced Agreement (Opt-in) Screening.

Answer 15

Routine with Advanced Agreement (Opt-in) - each member of a population is offered the test (they are notified that it is part of a standard, universal course of treatment), more respectful of autonomy and consent

Question 16

Explain Routine without Advanced Agreement (Opt-out) Screening.

Answer 16

Routine without Advanced Agreement (Opt-out) - all individuals in a defined population are automatically screened unless they ask specifically not to be, reaches a larger population, but does not ensure consent

Question 17

What is Voluntary Screening?

Answer 17

Voluntary - the norm in medicine, includes full information about the nature of the test given to a competent person, and the freedom to accept or decline

Question 18

How has the Fourth Amendment been applied against Screening programs?

Answer 18

The main constitutional challenge against screening comes from the Fourth Amendment’s protection against “unreasonable search and seizure.” The collection of biological samples must be reasonable in that the government’s interest outweighs the loss of individual rights. This could apply to:

• criminal justice nessesity - ex. compulsory testing of people assused/convicted of sexual assult
• public health nessesity - ex. HIV testing for firefighters, paramedics, military, immigrants

Question 19

Ruling of Ferguson v. City of Charlestown (2001).

Answer 19

Although screening is usually upheld, the Supreme court ruled otherwise in Ferguson v. City of Charlestown (2001). The testing of pregnant patients for drugs without their consent and arresting positive cases, was not upheld despite PH goal becasue it was “indistinguishable” from crime control

Question 20

How has HIV Screening historically led to stigmatization and what is being done to change it?

Answer 20

• Public health response to a disease greatly contributes to its social contruction.
• Homosexual men have been targeted for discrimination and criminalized becasue they were singled out for screening.
• IOM and the CDC have generally lifted this focus to make HIV screening recommended for people in all health care settings and part fo a routine panel of prenatal tests in an opt-out format. It is recommended that High risk indiviudals are tested annually.

Question 21

When is physical examination and treatment typically mandated for indviduals by law?

Answer 21

Manditory treatment is included in most STI and TB laws for the benefit of individuals and public health, but it is a serious intrusion on bodily integrity and the right to refuse treatment.

Question 22

What is the source of the right to refuse treatment and what case law is related to the issue?

Answer 22

The “right to refuse treatment” is a common law grounded in federal and state constitutions and personal autonomy. Without a specific law imposing treatment, doctors are required to respect the wishes of competent patients. The Supreme Court has further recognized a protected liberty interest for competent people in refusing treatment, but this is not apsolute. Courts use a balancing test to weigh public interests with individual loss of liberty.

• City of New York v. Antoinette R. (1995) - court upheld a hospitolization order based on clear evidence of the patient’s inability to comply with the proper course of TB medication.
• Washington v. Harper (1990) - court defined that compelled treatment must include that the individual is a danger to self or others, treatment is in the person’s medical interest, and a licenced physician acts in accordance with the profession.
• Riggins v. Nevada (1992) - individuals have a protected liberty interest in refusal that only an “essential” or “overriding” state interest can overcome.

Constitutional Standard: For manditory treatment of competent adults, the state must demonstrate dangerousness and medical appropriateness of treatment.

Question 23

What is Directly Oberved Therapy and and what is it univerally recommended for?

Answer 23

DOT is a compliance enhancing method in which each dose of medication is observed by a family member, patient advocate, community worker, or health care professional.

• Generally unintrusive since no confinement is involved
• liberty, dignity and privacy issues remain
• effective at ensuring full medication compliance, and the reduction of drug resistance
• recommended as the universal treatment strategy for TB.

Question 24

What are the three state interests for manditory treatment?

Answer 24

• Preservation of Health or Life - ex. Parents may not withhold treatment for their children if it poses a serious health threat
• Harm Prevention - Basic public health reason, to control an infectious disease in a population
• Preservation of Effective Therapies - Effectiveness of antiviral or antibacterial medication (i.e. preventing drug resistance) partially depends on ensuring that individuals follow a drug regimen exactly and to completion

Question 25

What us Expedited Partner Therapy?

Answer 25

EPT is the treatment of the sex partners of persons with STIs without medical evaluation or counceling.

** EPT Benefits & Issues**

• reduction of re-infection rates
• treatment of potenitally asymptomatic partners that could spread the disease futher
• Medical and legal risks: misuse of the medication, increased drug resistance.