R. Gregory Evans

Theoretical Perspectives on Public Communication Preparedness for Terrorist Attacks

The experience of federal health authorities in responding to the mailed anthrax attacks in the Fall of 2001 sheds light on the challenges of public information dissemination in emergencies. Lessons learned from the Fall of 2001 have guided more recent efforts related to crisis communication and preparedness goals. This article applies theories and evidence from the field of communication to provide an orientation to how public health communication can best contribute to the preparedness effort. This theoretical orientation provides a framework to systematically assess current recommendations for preparedness communication.

A Medical Follow-Up of the Health Effects of Long-Term Exposure to 2,3,7,8-Tetrachlorodibenzo-p-Dioxin

The human health effects of long-term exposure to low levels of 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) have not been well established. The results of a prior study showed that persons exposed to TCDD had depressed cell-mediated immunity, and 18 of 51 persons had anergy or relative anergy on skin testing. This paper presents the results of a medical follow-up on participants who were reported to be anergic or relatively anergic in the earlier study. None of the participants in the follow-up study was anergic, and only one exposed and one unexposed participant were relatively anergic. Several technical and biological possibilities for the difference in results of the two studies are presented. The possibility that recovery from the effects of TCDD exposure caused the differing results is the least plausible explanation for the changes in the skin test results.

Organophosphate Antidote Auto-Injectors vs. Traditional Administration: A Time Motion Study

Organophosphates may be used as weapons in chemical attacks on civilian or military populations. Antidotes are available to counter the effects of organophosphates, but they must be administered shortly after exposure. Timing required to administer organophosphate antidotes using traditional equipment vs. auto-injectors has not been studied. This study is intended to quantify and compare the time required to administer organophosphate antidotes using traditional equipment vs. auto-injectors in different treatment conditions. The study was a randomized, un-blinded design. There were 62 participants assigned to one of three groups: Mark I, ATNAA (antidote treatment nerve agent auto-injector), and traditional needle/syringe; however, the results from only 56 participants could be analyzed. Injection trials were videotaped. Subjects also completed a 14-item survey containing demographic questions, perceived ease of injection, receipt of prior training, and preferred training format for organophosphate treatment. Injection time differentials were compared using one-way analysis of variance; post hoc evaluation was performed using the Scheffe test with Bonferroni correction. Fifty-six subjects completed this study. The ATNAA required less time to administer than the Mark I or traditional needle/syringe devices (p < .001). There was no difference in time to administer the Mark I auto-injectors vs. a traditional needle/syringe. There were no differences between injection time and occupation, receipt of prior training, wearing of personal protective equipment, or perceived ease of injection device use. The use of auto-injectors shortens response time for administering organophosphate antidote treatment. An ATNAA auto-injector can be administered in less than half the time it takes to administer a single injection using a needle and syringe or two injections using a Mark I. Mark I can be administered in approximately the same amount of time it takes to administer a single injection using a needle and syringe. The difference between injection time for the ATNAA and needle and syringe would have been even larger if two injections were given with the needle and syringe. The wearing or absence of personal protective equipment does not affect injection time.

Effectiveness of cleaning and health education in reducing childhood lead poisoning among children residing near superfund sites in Missouri

In this study, the authors evaluated whether a combination of tailored education, lead dust removal by trained cleaning specialists, and family follow-up visits would be more effective than conventional health educational programs in reducing elevated blood lead levels in children living in or near lead mining hazardous waste sites. The authors randomized children between 6 and 72 mo of age with blood lead levels between 10 and 20 μg/dl into 3 groups: standard care, tailored newsletters, or tailored newsletters and specialized cleaning. The authors obtained questionnaires, blood lead levels, and environmental lead samples during initiation and compared them with the same items obtained at 3, 6, and 9 mo follow-up. They used a linear mixed effect model to evaluate the intervention effect. Blood lead levels decreased overall 1.54 μg/dl (12.1%) during the study. The authors found that tailored newsletters and specialized cleaning produced the greatest decline in blood lead levels, but no statistical differences were found among the methodologies. The small decline observed in blood lead levels reduced levels to below 10 mUg/dl for 40% of the children.

The doctor's role in bioterrorism

At the beginning of this new millennium, the promise of the future is tainted by the emergence of terrorist threats, including bioterrorism. Terrorist doctrine and fanaticism have continued to evolve since the end of the Cold War. Historically, the goals of terrorism were to attract media attention and political concessions. These aims were pursued through high-visibility attacks that resulted in few casualties. However, the shifting goals of terrorism over the past decade indicate an increasing desire to inflict mass casualties. This fundamental change has spanned the extremes of terror organisations from the ideological right to the ideological left while cutting across ethnic, religious, state-sponsored, and single-issue terror groups. As this shift toward a higher order of violence occurs, terrorism arsenals are likely to expand beyond improvised explosive devices and aircraft hijackings. In the future, the greatest terrorism challenge modern medicine may face will probably be bioterrorism. Doctors stand at the forefront in preparing for this threat. In the past, doctors have also contributed to the creation and proliferation of these weapons. The emergence of new terrorist threats has created new responsibilities for the medical community. Unlike other forms of terrorism, in which an acute exposure or traumatic injury is rapidly inflicted and quickly recognised, bioterrorism may involve an incubation period of days or even weeks. During these events, patients will turn to their most trusted adviser on health issues, their doctor, who will be expected to recognise and take action against the rare diseases that top most threat lists.

Lead Abatement Training for Underserved Populations: Lessons Learned

An environmental-justice (equity) grant program was used to make accessible an existing lead-training program to minority persons and residents of low-income communities. The purpose of the program was to enhance the knowledge base within the communities concerning lead hazards and intervention strategies and expand possibilities for employment in the lead abatement industry. Barriers to attendance were anticipated and addressed, and included transportation, meals, license application fees, reminders of course date and location, and day care. The program was evaluated through measures of recruitment rates, pre- and post-testing scores, and change in perception of confidence at pre-test, post-test, and at four-month follow-up. Fee-paying registrants over the same time period were used as a comparison group. First day attendance rates for individuals recruited into the equity-grant was 59 percent, of these 94 percent completed all days. Equity and fee-paying groups had similar scores on the pre-test (p = .209), while mean scores on the final exam differed significantly (p < .001) between the groups and were 77 percent and 85 percent, respectively. After adjusting for demographic and course type attended, perceptions of self-efficacy (benefit) and outcome-effectiveness (confidence) increased significantly from pre- to post-tests for both groups and remained at post-course levels at four months follow-up. Lessons learned include: (1) Lead abatement and other related activities can be successfully taught through traditional training methods; (2) A necessary element for delivery of educational services to minority groups is forming workable ties with local community groups, but eligibility requirements must be maintained; (3) Once barriers to first-day attendance are overcome, the information necessary to perform specific work skills can be taught; (4) Positive changes in belief are not dependent on minority status, income, or education levels; (5) Training and education increased confidence in ability to perform learned skills, and belief that there will be a beneficial outcome when performed for themselves, their families, and communities; and, (6) A consensus regarding applicability of regulations must be achieved among federal, state, and local communities.

Preparing for and Responding to Bioterrorist Attacks

Components of disease management that are applicable to the development of services for bioterrorism preparedness and response include collaborative practice models, population identification processes, reporting/feedback loops, process and outcome measurements, patient self-management education, and evidence-based practice guidelines. This management system should be flexible and applicable to all possible diseases associated with bioterrorism, while including specific management recommendations for each disease.There are many gaps in the US’s ability to respond to a bioterrorist attack that can only be filled by collaborative research among disciplines involved with bioterrorism preparedness; namely, basic, clinical, and behavioral sciences, public health, and law. Laboratory scientists will need to develop new and improved diagnostic tests, treatments, and protective measures. Behavioral science will have to treat many victims, both the sick and the ‘worried well’. While some states have adequate laws in place to facilitate public health authorities’ efforts to isolate sick patients and quarantine those exposed, many states do not, and their laws will require modification. Public health agencies must develop and evaluate information technologies and decision support systems for the early detection of a bioterrorist attack, for the tracking of victims who will require prophylactic treatment, and to assist physicians with diagnosis and treatment. Public health and hospitals must also prepare for the treatment of large numbers of patients by increasing surge capacity. Finally, one of the most notable deficiencies in response to recent bioterrorism events has been the inability of public health to provide timely and accurate information. Effective communication is a fundamental element of all aspects of an effective response to emergencies. Before a bioterrorist attack, the nation’s preparedness efforts should be evaluated through tabletop and full-scale exercises that are preceded by extensive professional and community education.The US Army Medical Research Institute of Infectious Diseases has identified six primary agents that may be potentially used in bioterrorism: Bacillus anthracis, variola virus, Yersinia pestis, Francisella tularensis, botulinum toxin, and the hemorrhagic fever viruses. These six were identified on the basis of the following criteria: availability of the agent, ease of production, lethality, infectivity, and stability. Disease management requires an understanding of exposure mechanisms and dose response because the route of exposure and the dose will impact on the way a disease presents. In addition to disease management strategies for bioterrorism in general, this article briefly reviews specific diagnosis, treatment, and infection control recommendations for the six primary bioterrorism diseases agents.

Health effects of long-term exposure to 2,3,7,8-tetrachlorodibenzo-p-dioxin

Abstract In 1971, sludge wastes contaminated with 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) were mixed with waste oil and sprayed on a dirt road in a residential mobile home park in Missouri, USA. In 1984, we performed a comprehensive examination of 154 persons exposed at that site and 155 unexposed persons to determine whether these environmental TCDD contaminations had induced any acute/subacute health effects. There were no consistent differences between the two groups on medical history, physical examination, serum and urinary chemistries, and neurologic tests. Results of liver function tests suggested possible subclinical effects: i.e., higher mean urinary uroporphyrin levels and lower mean serum bilirubin levels in the exposed group and statistically significant direct dose-response relationships of serum levels of five enzymes that may originate in the liver (i.e., SGOT, SGPT, GGTP, alanine aminopeptidase, and beta-glucuronidase) by years of residence at the contaminated site (i.e., a surrogate for cumulative TCDD dose). Although these findings may indicate the presence of subclinical hepatotoxic effects, their significance must be interpreted cautiously. Immunologic tests showed that the exposed group had an increased frequency of anergy (11.8% vs. 1.1%) and relative anergy (35.3% vs. 11.8%); the exposed group also had non-statistically significant increased frequencies of abnormal T-cell subset tests (10.4% vs. 6.8%), a T 4 T 8 ratio in vitro functional T-cell tests (12.6% vs. 8.5%). These findings suggest that long-term exposure to TCDD is associated with depressed cell mediated immunity, although the effects have not resulted in an excess of clinical illness in the exposed group. Further studies are indicated to elucidate the pathophysiology and clinical significance of all of these findings. Studies are in progress to follow affected individuals to see if normal cellular immune function and/or hepatic function is recovered or clinical disease develops; other studies are planned to correlate adipose tissue levels of TCDD with measured health effects.