Introduction to Health Care and Public Health in the U.S. Public Health, Part 2 Welcome to the Introduction to health care in the U.S.: Public Health, Part 2. This is lecture b. The component, Introduction to health care in the U.S., is a survey of how health care and public health are organized and services are delivered in the U.S. Lecture b This material (Comp 1 Unit 8) was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0001. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.

Public Health, Part 2 Learning Objectives - 1 Give examples of and explain the general program categories of public health, including communicable disease, chronic disease, terrorism response, and environmental public health (Lecture a) Discuss the activities and achievements of public health in the realm of communicable disease (Lecture a ) The learning objectives for Public Health, Part 2, are to: Give examples of and explain the general program categories of public health, including communicable disease, chronic disease, terrorism response, and environmental public health, Discuss the activities and achievements of public health in the realm of communicable disease,

Public Health, Part 2 Learning Objectives - 2 Compare and contrast the different types of terrorism and the different public health responses (Lecture b) Describe chronic disease activities and achievements of public health, and the work of public health in the realm of environmental health hazards (Lecture c) Compare and contrast the different types of terrorism and the different public health responses, and Describe chronic disease activities and achievements of public health, and the work of public health in the realm of environmental health hazards.

Terrorism and Public Health The specter of terrorism continues to concern U.S. government and public Emergency Preparedness and Response – public health programs Categories of Terrorism Bioterrorism Agricultural terrorism Chemical terrorism Nuclear/radiation terrorism This lecture will discuss Public Health and terrorism. Concern over terrorism continues in the U.S. Public health has responded by forming Emergency Preparedness and Response programs. There are four main categories of terrorism: bioterrorism, agricultural terrorism, chemical terrorism, and nuclear or radiation terrorism.

Bioterrorism (BT) Definition: intentional use of microorganisms or their derived products, to produce death or disease in humans, animals, or plants Bioterrorism is defined as the intentional use of either microbes or their derivations to produce death or disease. The target of bioterrorism may be humans, animals, or plants.

Overt versus Covert Bioterrorism Classified as Overt (announced) or Covert (unannounced) Overt attacks - intend to create psychological (panic) damage along with physical damage, as well as to encourage spread of an agent (exposed people fleeing spread the agent) Covert attacks - intend to cause maximum damage before a response can be mounted. Methods debated for detection for covert attacks include laboratory results and syndromic surveillance Terrorism may be either overt, announced, or covert, unannounced. In addition to physical damage, overt attacks are designed to create psychological damage or panic. Panic also induces flight, which can help spread an agent. Covert attacks are intended to cause as much damage as possible before an effective response can be mounted.

Bioterrorism in the U.S.: History - 1 1984 Rajneeshi attack – The Dalles, OR First BT incident on U.S. soil? 751 cases of foodborne illness Discovered by a small clinical laboratory, which noticed high numbers of Salmonella typhimurium results and alerted public health officials Eventually determined that central Oregon cult of the Rajneeshees intentionally contaminated salad bars in The Dalles In the U.S., there have been few bioterrorism, or BT, attacks. A short list might include the military’s apparent distribution of smallpox-contaminated blankets to Native Americans in the 1700s. The list definitely includes a 1984 incident in Oregon when a cult intentionally contaminated salad bars, causing 751 cases of food poisoning. This event was considered by some to be the first incident of BT on U.S. soil. Others disagree, citing examples like the one mentioned earlier.

Bioterrorism in the U.S.: History - 2 2001 Letters containing anthrax were mailed to various targets, resulting in five casualties 2003 Greenville, SC, and 2004 Washington DC. Ricin letter incidents In 2001 anthrax-contaminated letters killed five people. And in 2003 and 2004, several letters were found to be contaminated with the plant toxin ricin; however, no injuries resulted.

CDC Bioterrorism Categories Category A: Highest Risk Category B: Next Highest Risk Category C: Emerging Pathogens Easily transmitted between people High death rates (mortality) Could cause public panic Require special public health preparedness response Moderately easy to spread Moderate illness rates, low death rates Response would require specific enhancements of existing laboratory capacity; enhanced monitoring systems Easily available and spread Potential for high illness (morbidity) and death (mortality) rates and major health effect Examples: Anthrax, Botulism, Pneumonic Plague, Smallpox, Tularemia, Ebola Examples: Ricin Toxin, Brucellosis, Q Fever, Typhus, food and waterborne pathogens Examples: Nipah Virus, Hantaviruses, Yellow Fever, Multidrug-resistant Tuberculosis Bioterrorism agents are categorized by CDC according to their ease of transmission and severity. The highest risk is Category A – these agents are easily transmitted and have high mortality. Examples include anthrax and botulism. Category B agents are the next highest risk – they are moderately easy to spread and cause moderate illness rates. An example is ricin toxin. Category C agents are the third highest risk – these emerging pathogens are easily available and have the potential for high illness rates. Examples include the Hantaviruses and multi-drug resistant Tuberculosis. Table 8.1. CDC Bioterrorism categories. Based on NIAID, 2016.

Terrorism Public Health Preparedness and Response Planning, monitoring, and education are three of the main activities The Laboratory Response Network is an important part of public health activities Public health preparedness and response programs have three main activities – planning, monitoring, and education. The Laboratory Response Network is also a part of public health response.

Laboratory Response Network (LRN) LRN - national network of local, state, and federal public health laboratories Provide response capacity for biological and chemical terrorism, as well as other public health emergencies More than 150 biological and 62 chemical LRN labs Most are state public health labs, but veterinary, military, and international labs are also important participants The Laboratory Response Network or LRN is a network of testing laboratories. These laboratories include food testing, veterinary diagnostic, and environmental testing laboratories. The LRN provides response capacity for biological and chemical terrorism, as well as other public health emergencies. There are more than 150 biological and 62 chemical LRN labs. Most of the labs are state public health labs, but veterinary, military, and international labs are also important participants.

Agricultural Terrorism - 1 Chemical and biological weapons are often manufactured from readily-available raw materials Usually in common use or found in nature Agriculture, a building block of all civilizations, is an attractive target Agricultural terrorism is thought by many to be an underrated threat. Agriculture is essentially the foundation of all civilizations, and thus makes an attractive target.

Agricultural Terrorism - 2 Although there have been an unfortunately large number of introductions of agricultural pests and pathogens (example, chestnut blight, which effectively exterminated the American chestnut tree), they have been caused by accident, neglect, or ignorance - not terrorism. The USDA Animal and Plant Inspection Service (APHIS) attempts to prevent importation of agricultural hazards There have been many unfortunate instances of importation of foreign pests and pathogens, both in the U.S. and other countries. A prime example of this is chestnut blight, a fungus which effectively wiped out the beloved American chestnut tree. However, to date these incidents have been caused by accident, neglect, or ignorance, and not by terrorist efforts. The U.S. Department of Agriculture, or USDA Animal and Plant Inspection Service, or APHIS, is the main line of defense against agricultural terrorism and hazards in the U.S.

Chemical Terrorism Results from covert or overt exposure of chemical hazards to the population A wide variety of chemical compounds are potential vehicles of chemical terrorism Chemical terrorism, or exposure of the population to chemical hazards, is another concern of public health. As with other categories of terrorism, an attack could be either covert or overt. Both the National Toxic Substance Incidents Program and the Agency for Toxic Substances and Disease Registry participate in monitoring and efforts to mitigate risk of chemical terrorism.

CDC Hazardous Chemical Categories Categorized by chemical type and exposure effects (13 total) -Examples of content type categories: Bio-toxins: Poisons from plants or animals Metals: Agents consisting of metallic poisons Examples of exposure effects categories: Caustics (acids): Burn or corrode skin, eyes, and mucus membranes Incapacitating agents: Cause mental confusion or altered state of consciousness The CDC categorizes hazardous chemicals into 13 groups, based on chemical type and exposure effects. The slide lists examples of categories based on the chemical type: bio-toxins—poisons from plants or animals; and metals—metallic poisons. The slide also lists examples of chemical categories based on the effects of the agent: caustics, which are chemicals that burn or corrode, and incapacitating agents, which cause mental confusion or altered states of consciousness.

Chemical Terrorism and Public Health Chief surveillance agency in the U.S.: CDC’s Agency for Toxic Substances and Disease Registry (ATSDR) National Toxic Substance Incidents Program (NTSIP) Launched in 2009 Successor to the HSEES program Chemical terrorism, or exposure of the population to chemical hazards, is another concern of public health. As with other categories of terrorism, an attack could be either covert or overt. The National Toxic Substance Incidents Program, housed at the Agency for Toxic Substances and Disease Registry, was created in 2009 and replaced the Hazardous Substances Emergency Events Surveillance program. Among the purposes of the Agency for Toxic Substances and Disease Registry is to prepare for and mitigate the risks related to chemical terrorism.

Components of NTSIP - 1 National Toxic Substance Incidents Database Collects information related to chemical spills Sources include: Emergency response systems State fire marshals U.S. Coast Guard National Response Center (NRC) Reporting point-of-contact for all U.S. oil, chemical, radiological, and biological discharges into the environment The first component of the National Toxic Substance Incidents Program is the National Toxic Substance Incidents Database. This is a repository for information related to chemical spills. It aggregates data from a variety of sources, including emergency response teams, state fire marshals, and the National Response Center.

Components of NTSIP - 2 State partnerships for incident surveillance 15 states as of 2016 Assessment of Chemical Exposures (ACE) Program Provides local authorities resources to do epidemiological assessment The other components of the National Toxic Substance Incidents Program include state partnerships and the Assessment of Chemical Exposures, or ACE program, which provides training, materials, and support to local authorities to aid them in assessing incident impact.

Nuclear or Radiation Terrorism Both the sun and the earth are sources of natural, background radiation Man-made radiation occurs from sources such as TV sets, microwave ovens, X-rays A variety of tactics are used to disperse radioactive material Both the sun and the earth are sources of natural, background radiation. Man-made radiation occurs from sources such as TV sets, microwave ovens, and X-rays. A variety of tactics are used to disperse radioactive material as acts of terrorism.

Nuclear Terrorism Threats: Categories Categorized based on dispersal method: Radiological Dispersion Devices (RDDs), also known as "dirty bombs“ Radioactive contamination of drinking water or food supplies Direct attacks on nuclear power plants or nuclear fuel reprocessing facilities Use of nuclear weapons Placing radioactive source in heavily populated area Nuclear or radiation terrorism threats are divided by their means of dispersal: these vary from “dirty bombs” to the simple tactic of placing a radioactive source in a heavily populated area.

Response to Nuclear Terrorism Threats Public Health Preparedness and Response includes: Education and information for the public Education and information for health care providers The public health response to nuclear threats consists primarily of educating and informing.

Public Health, Part 2 Summary – Lecture b Four main categories of terrorism: Bioterrorism agricultural terrorism chemical terrorism nuclear/radiation terrorism Categorization of bioterrorism agents Laboratory Response Network This concludes lecture b of Public Health, Part 2. In summary, public health response is discussed for the four main categories of terrorism: bioterrorism, agricultural terrorism, chemical terrorism, and nuclear or radiation terrorism. Categorization of bioterrorism agents and the Laboratory Response Network are discussed.

Public Health, Part 2 References – 1 – Lecture b Agency for Toxic Substances and Disease Registry: National Toxic Substance Incidents Program (NTSIP). (n.d.). Retrieved January 31, 2017, from https://www.atsdr.cdc.gov/ntsip/ Centers for Disease Control and Prevention, Emergency Preparedness and Response, Specific Hazards, Chemical Emergencies, Chemical Categories. (n.d.). Retrieved January 31, 2017, from https://emergency.cdc.gov/agent/agentlistchem-category.asp Centers for Disease Control and Prevention, Emergency Preparedness and Response, Specific Hazards, Chemical Emergencies, Chemical Categories. (n.d.). Retrieved January 31, 2017, from https://emergency.cdc.gov/chemical/index.asp Centers for Disease Control and Prevention, Emergency Preparedness and Response, Information on Specific Types of Emergencies, Radiation Emergencies. (n.d.). Retrieved January 31, 2017, from https://emergency.cdc.gov/radiation/index.asp National Institute of Allergy and Infectious Diseases, NIAID Emerging Infectious Diseases/Pathogens, NIAID Biodefense Research. (n.d.). Retrieved January 31, 2017, from https://www.niaid.nih.gov/research/emerging-infectious-diseases-pathogens No Audio.

Public Health, Part 2 References – 2 – Lecture b Charts, Tables, Figures 8.1 Table: CDC Bioterrorism categories. Based on: National Institute of Allergy and Infectious Diseases. (2016). Biodefense category A, B, C pathogens. Retrieved from https://www.niaid.nih.gov/research/emerging-infectious-diseases-pathogens No Audio.

Introduction to Health Care and Public Health in the U. S Introduction to Health Care and Public Health in the U.S. Public Health, Part 2 Lecture b This material was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0001. No Audio.