1. Introduction to Health Care and Public Health in the US
Welcome to the Introduction to Healthcare in the US: Public Health, Part 2. This is Lecture b.
The component, Introduction to Healthcare in the U.S., is a survey of how healthcare and public health are organized and services are delivered in the US.
Public Health (Part 2)
Lecture b
This material (Comp1_Unit8b) was developed by Oregon Health and Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC

2. Introduction to Healthcare in the US Learning Objectives
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 )
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 )
The 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;
compare and contrast the different types of terrorism and the different public health response; and
describe chronic disease activities and achievements of public health, and the work of public health in the realm of environmental health hazards.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US Public Health, Part Lecture b

3. Terrorism and Public Health
The specter of terrorism continues to concern US 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 US public. 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/radiation terrorism.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US Public Health, Part Lecture b

4. Bioterrorism
Definition: intentional use of microorganisms or their derived products, to produce death or disease in humans, animals, or plants
Classified as Overt (announced) or Covert (unannounced)
Overt attacks - intended to create psychological (panic) damage along with physical damage, as well as to encourage spread of an agent (exposed people fleeing an area take the agent with them)
Covert attacks - intended to cause maximum damage before a response can be mounted. Methods debated for detection for covert attacks include laboratory results and syndromic surveillance.
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. Terrorism may be either overt (announced) or covert (unannounced). In addition to physical damage, overt attacks are designed to also create psychological damage or panic. Panic also induces flight, which can help to spread an agent. Covert attacks are intended to cause as much damage as possible before an effective response can be mounted.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US Public Health, Part Lecture b

5. Bioterrorism (continued)
In the United States, the history of bioterrorism is relatively short. Some of the most notable events were:
1984 Oregon. Considered by some to be the first incident of BT on US soil (others disagree, citing examples such as the military’s apparently deliberate distribution of smallpox-contaminated blankets to Native Americans in the 1700s). The 1984 incident was discovered by a small clinical laboratory, which noticed high numbers of Salmonella typhimurium results and alerted public health officials. It was eventually determined that the central Oregon cult of the Rajneeshees intentionally contaminated salad bars in The Dalles, resulting in 751 cases of infection.
2001. Letters containing anthrax were mailed to various targets. Five people were killed.
2003 Greenville, SC, and 2004 Washington DC. Ricin letter incidents.
In the US, there have been few bioterrorism attacks. The short list might include the military’s apparent distribution of smallpox-contaminated blankets to Native Americans in the 1700’s. The list definitely includes a 1984 incident in Oregon when a cult intentionally contaminated salad bars, causing 751 cases of food poisoning. 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 (no injuries).
Health IT Workforce Curriculum Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US Public Health, Part Lecture b

6. Bioterrorism (continued)
Bioterrorism agents are separated into three categories by CDC, depending on their ease of transmission and severity of effect
Category A: Highest risk
Easily transmitted from person to person
High death rates (mortality)
Could cause public panic
Require special public health preparedness response
Examples: Anthrax, Botulism, Pneumonic Plague, Smallpox, Tularemia, Ebola
Category B: Next highest risk
Moderately easy to spread
Moderate illness rates, low death rates
Response would require specific enhancements of existing laboratory capacity and enhanced disease monitoring systems
Examples: Ricin Toxin, Brucellosis, Q Fever, Typhus, food and waterborne pathogens
Category C: Third highest risk – emerging pathogens
Easily available and spread
Potential for high illness (morbidity) and death (mortality) rates and major health impact
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.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US Public Health, Part Lecture b

7. Terrorism Public Health Preparedness and Response
Planning, monitoring, and education are three of the main activities
The Lab 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 Lab Response Network is also a part of public health response.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US Public Health, Part Lecture b

8. Lab Response Network – LRN
LRN - national network of local, state and federal public health, food testing, veterinary diagnostic, and environmental testing 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 Lab Response Network or LRN is a network of testing laboratories that provide 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.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US Public Health, Part Lecture b

9. Agricultural Terrorism
Chemical and biological (unlike nuclear) weapons are often manufactured from readily available raw materials, raw materials that are usually in common use or found in nature.
Agriculture, a building block of all civilizations, is an attractive target.
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.
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. There have been many unfortunate instances of importation of foreign pests and pathogens, both in the US 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 USDA Animal and Plant Inspection Service is the main line of defense against agricultural terrorism and hazards in the US.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US Public Health, Part Lecture b

10. Chemical Terrorism
As with other categories of terrorism, chemical terrorism could result from covert or overt exposure of chemical hazards to the population
One system dealing with chemical hazards is the Hazardous Substances Emergency Events Surveillance (HSEES)
Hazardous substance release information is gathered from various sources including emergency response systems, state fire marshals, and the National Response Center
31 states as well as several territories and other jurisdictions provide info for the Agency for Toxic Substances and Disease Registry (ATSDR) national database
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 a surveillance system (Hazardous Substances Emergency Events Surveillance) and a registry (Agency for Toxic Substances and Disease Registry) attempt to mitigate this risk.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US Public Health, Part Lecture b

11. Chemical Emergencies
CDC categorizes hazardous chemicals by type of chemical and effects of exposure:
Bio-toxins —poisons from plants or animals
Blister agents —chemicals that severely blister the eyes, respiratory tract, and skin
Blood agents —poisons that affect the body by being absorbed into the blood
Caustics (acids) —chemicals that burn or corrode people's skin, eyes, and mucus membranes
Choking/lung/pulmonary agents —chemicals that cause severe irritation or swelling of the respiratory tract
Incapacitating agents —drugs that cause mental confusion or altered state of consciousness
Long-acting anticoagulants —poisons that prevent blood from clotting, which can lead to uncontrolled bleeding
Metals —agents that consist of metallic poisons
Nerve agents —highly poisonous chemicals that prevent the nervous system from working properly
Organic solvents —agents that damage the tissues of living things by dissolving fats and oils
Riot control agents/tear gas —highly irritating agents often by individuals for protection (for example, mace)
Toxic alcohols —poisonous alcohols that can damage the heart, kidneys and nervous system
Vomiting agents —chemicals that cause nausea and vomiting
CDC categorizes hazardous chemicals by chemical type and exposure effects. Some examples are bio-toxins (poisons from plants or animals), caustics (chemicals that burn or corrode), metals (metallic poisons), and organic solvents (damage tissue by dissolving fats or oils).
Health IT Workforce Curriculum Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US Public Health, Part Lecture b

12. 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, and X-rays
Nuclear terrorism threats are generally divided into
Radiological Dispersion Devices (RDDs), also known as "dirty bombs“. A means of dispersing radioactive materials
Radioactive contamination of drinking water or food supplies
Direct attacks on nuclear power plants or nuclear fuel reprocessing facilities
Use of nuclear weapons by countries
Locating radioactive sources in heavily populated areas
Public Health Preparedness and Response
Education and information for the public
Education and information for health care providers
Nuclear / 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. The public health response to nuclear threats consists primarily of education and information.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US Public Health, Part Lecture b

13. 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/radiation terrorism. Categorization of bioterrorism agents and the Laboratory Response Network are discussed.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US Public Health, Part Lecture b

14. Public Health (Part 2) References – Lecture b
Emergency Preparedness and Response - Bioterrorism Agents/Diseases. (n.d.). Retrieved December 6, 2011, from Centers for Disease Control and Prevention website:
Emergency Preparedness and Response - Chemical Emergencies. (n.d.). Retrieved December 6, 2011, from Centers for Disease Control and Prevention website:
Emergency Preparedness and Response - Radiation Emergencies. (n.d.). Retrieved December 6, 2011, from Centers for Disease Control and Prevention website:
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Health IT Workforce Curriculum Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US Public Health, Part Lecture b