Public response to an anthrax attack: reactions to mass prophylaxis in a scenario involving inhalation anthrax from an unidentified source

An attack with Bacillus anthracis ("anthrax") is a known threat to the United States. When weaponized, it can cause inhalation anthrax, the deadliest form of the disease. Due to the rapid course of inhalation anthrax, delays in initiation of antibiotics may decrease survival chances. Because a rapid response would require cooperation from the public, there is a need to understand the public's response to possible mass dispensing programs. To examine the public's response to a mass prophylaxis program, this study used a nationally representative poll of 1,092 adults, supplemented by a targeted focus on 3 metropolitan areas where anthrax attacks occurred in 2001: New York City (n=517), Washington, DC (n=509), and Trenton/Mercer County, NJ (n=507). The poll was built around a "worst-case scenario" in which cases of inhalation anthrax are discovered without an identified source and the entire population of a city or town is asked to receive antibiotic prophylaxis within a 48-hour period. Findings from this poll provide important signs of public willingness to comply with public health recommendations for obtaining antibiotics from a dispensing site, although they also indicate that public health officials may face several challenges to compliance, including misinformation about the contagiousness of inhalation anthrax; fears about personal safety in crowds; distrust of government agencies to provide sufficient, safe, and effective medicine; and hesitation about ingesting antibiotic pills after receiving them. In general, people living in areas where anthrax attacks occurred in 2001 had responses similar to those of the nation as a whole.     

A bitter pill to swallow: nonadherence with prophylactic antibiotics during the anthrax attacks and the role of private physicians

To generate recommendations for improving adherence to public health advice during public health crises, we conducted semi-structured interviews with employees at the Brentwood Road Postal Facility and on Capitol Hill to identify key themes associated with decisions to adhere to recommended antibiotic prophylaxis during the 2001 anthrax attacks. Factors used in deciding to adhere to recommended prophylactic antibiotics and concerns about the official response were similar in Brentwood and Capitol Hill employees, and in adherent and nonadherent participants. All participants used multiple sources of information and support as they weighed the risk from anthrax against the advantages and disadvantages of antibiotics. We found that nonadherent participants were commonly following the advice of private physicians, whereas adherent participants commonly described ongoing support from multiple sources when discussing their decisions. Our findings highlight the need for better integration between the public and private health care systems during public health crises and the importance of equipping private physicians for their key role in aiding decision-making during a public health crisis. Special attention also should be given to enhancing support and information from multiple sources throughout the entire period of risk.     

Postal workers' perspectives on communication during the anthrax attack

In 2001, the nation experienced its first bioterrorism attack, in the form of anthrax sent through the U.S. Postal Service, and public health professionals were challenged to communicate with a critical audience, U.S. postal workers. Postal workers, the first cohort to receive public health messages during a bioterrorist crisis, offer a crucial viewpoint that can be used in the development of best practices in crisis and emergency risk communication. This article reports results of qualitative interviews and focus groups with 65 postal workers employed at three facilities: Trenton, New Jersey; New York City; and Washington, DC. The social context and changing messages were among the factors that damaged trust between postal workers and public health professionals. Lessons learned from this attack contribute to the growing body of knowledge available to guide communications experts and public health professionals charged with crisis and emergency risk communication with the public.     

Anthrax toxins and the host: a story of intimacy

Although the dramatic events of the year 2001 have revitalized the interest in anthrax, research on Bacillus anthracis and its major virulence factors is one of the oldest theme in microbiology and started with the early works of Robert Koch and Louis Pasteur. The anthrax toxins are central to anthrax pathogenesis. They were discovered in the mid-1950s and since then there has been an enormous amount of work to elucidate both the molecular and physiopathological details of their mode of action. In this review, after a brief introduction of B. anthracis, we will focus on the latest findings that concern two aspects of anthrax toxin research: the environmental signals and the molecular mechanisms that regulate toxin synthesis, and the mechanisms of intoxication. We hope to convince the reader that the anthrax toxins are highly specialized determinants of B. anthracis pathogenicity: their synthesis is integrated within a global virulence programme and they target key eukaryotic cell proteins. We conclude with a consideration of the therapeutic perspectives arising from our current knowledge of how the toxins work.     

Predicting response to reassurances and uncertainties in bioterrorism communications for urban populations in New York and California

Recent national plans for recovery from bioterrorism acts perpetrated in densely populated urban areas acknowledge the formidable technical and social challenges of consequence management. Effective risk and crisis communication is one priority to strengthen the U.S.'s response and resilience. However, several notable risk events since September 11, 2001, have revealed vulnerabilities in risk/crisis communication strategies and infrastructure of agencies responsible for protecting civilian populations. During recovery from a significant biocontamination event, 2 goals are essential: (1) effective communication of changing risk circumstances and uncertainties related to cleanup, restoration, and reoccupancy; and (2) adequate responsiveness to emerging information needs and priorities of diverse populations in high-threat, vulnerable locations. This telephone survey study explored predictors of public reactions to uncertainty communications and reassurances from leaders related to the remediation stage of an urban-based bioterrorism incident. African American and Hispanic adults (N=320) were randomly sampled from 2 ethnically and socioeconomically diverse geographic areas in New York and California assessed as high threat, high vulnerability for terrorism and other public health emergencies. Results suggest that considerable heterogeneity exists in risk perspectives and information needs within certain sociodemographic groups; that success of risk/crisis communication during recovery is likely to be uneven; that common assumptions about public responsiveness to particular risk communications need further consideration; and that communication effectiveness depends partly on preexisting values and risk perceptions and prior trust in leaders. Needed improvements in communication strategies are possible with recognition of where individuals start as a reference point for reasoning about risk information, and comprehension of how this influences subsequent interpretation of agencies' actions and communications.     

Broadening the voice of science: Promoting scientific communication in the undergraduate classroom

Effective and accurate communication of scientific findings is essential. Unfortunately, scientists are not always well trained in how to best communicate their results with other scientists nor do all appreciate the importance of speaking with the public. Here, we provide an example of how the development of oral communication skills can be integrated with research experiences at the undergraduate level. We describe our experiences developing, running, and evaluating a course for undergraduates that complemented their existing undergraduate research experiences with instruction on the nature of science and intensive training on the development of science communication skills. Students delivered science talks, research monologues, and poster presentations about the ecological and evolutionary research in which they were involved. We evaluated the effectiveness of our approach using the CURE survey and a focus group. As expected, undergraduates reported strong benefits to communication skills and confidence. We provide guidance for college researchers, instructors, and administrators interested in motivating and equipping the next generation of scientists to be excellent science communicators.     

Public Experiences of Mass Casualty Decontamination

In this article, we analyze feedback from simulated casualties who took part in field exercises involving mass decontamination, to gain an understanding of how responder communication can affect people's experiences of and compliance with decontamination. We analyzed questionnaire data gathered from 402 volunteers using the framework approach, to provide an insight into the public's experiences of decontamination and how these experiences are shaped by the actions of emergency responders. Factors that affected casualties' experiences of the decontamination process included the need for greater practical information and better communication from responders, and the need for privacy. Results support previous findings from small-scale incidents that involved decontamination in showing that participants wanted better communication from responders during the process of decontamination, including more practical information, and that the failure of responders to communicate effectively with members of the public led to anxiety about the decontamination process. The similarity between the findings from the exercises described in this article and previous research into real incidents involving decontamination suggests that field exercises provide a useful way to examine the effect of responder communication strategies on the public's experiences of decontamination. Future exercises should examine in more detail the effect of various communication strategies on the public's experiences of decontamination. This will facilitate the development of evidence-based communication strategies intended to reduce anxiety about decontamination and increase compliance among members of the public during real-life incidents that involve mass decontamination.     

Anthrax vaccination strategies

The biological attack conducted through the US postal system in 2001 broadened the threat posed by anthrax from one pertinent mainly to soldiers on the battlefield to one understood to exist throughout our society. The expansion of the threatened population placed greater emphasis on the reexamination of how we vaccinate against Bacillus anthracis. The currently-licensed Anthrax Vaccine, Adsorbed (AVA) and Anthrax Vaccine, Precipitated (AVP) are capable of generating a protective immune response but are hampered by shortcomings that make their widespread use undesirable or infeasible. Efforts to gain US Food and Drug Administration (FDA) approval for licensure of a second generation recombinant protective antigen (rPA)-based anthrax vaccine are ongoing. However, this vaccine’s reliance on the generation of a humoral immune response against a single virulence factor has led a number of scientists to conclude that the vaccine is likely not the final solution to optimal anthrax vaccine design. Other vaccine approaches, which seek a more comprehensive immune response targeted at multiple components of the B. anthracis organism, are under active investigation. This review seeks to summarize work that has been done to build on the current PA-based vaccine methodology and to evaluate the search for future anthrax prophylaxis strategies.     

The Relationship between Therapeutic Alliance and Service User Satisfaction in Mental Health Inpatient Wards and Crisis House Alternatives: A Cross-Sectional Study

Background

Poor service user experiences are often reported on mental health inpatient wards. Crisis houses are an alternative, but evidence is limited. This paper investigates therapeutic alliances in acute wards and crisis houses, exploring how far stronger therapeutic alliance may underlie greater client satisfaction in crisis houses.

Methods and Findings

Mixed methods were used. In the quantitative component, 108 crisis house and 247 acute ward service users responded to measures of satisfaction, therapeutic relationships, informal peer support, recovery and negative events experienced during the admission. Linear regressions were conducted to estimate the association between service setting and measures, and to model the factors associated with satisfaction. Qualitative interviews exploring therapeutic alliances were conducted with service users and staff in each setting and analysed thematically.

Results

We found that therapeutic alliances, service user satisfaction and informal peer support were greater in crisis houses than on acute wards, whilst self-rated recovery and numbers of negative events were lower. Adjusted multivariable analyses suggest that therapeutic relationships, informal peer support and negative experiences related to staff may be important factors in accounting for greater satisfaction in crisis houses. Qualitative results suggest factors that influence therapeutic alliances include service user perceptions of basic human qualities such as kindness and empathy in staff and, at service level, the extent of loss of liberty and autonomy.

Conclusions and Implications

We found that service users experience better therapeutic relationships and higher satisfaction in crisis houses compared to acute wards, although we cannot exclude the possibility that differences in service user characteristics contribute to this. This finding provides some support for the expansion of crisis house provision. Further research is needed to investigate why acute ward service users experience a lack of compassion and humanity from ward staff and how this could be changed.     

An Evaluation of Alternative Designs for a Grid Information Service

Computational grids consisting of large and diverse sets of distributed resources have recently been adopted by organizations such as NASA and the NSF. One key component of a computational grid is an information services that provides information about resources, services, and applications to users and their tools. This information is required to use a computational grid and therefore should be available in a timely and reliable manner. In this work, we describe the Globus information service, describe how this service is used, analyze its current performance, and perform trace-driven simulations to evaluate alternative implementations of this grid information service. We find that the majority of the transactions with the information service are changes to the data maintained by the service. We also find that of the three servers we evaluate, one of the commercial products provides the best performance for our workload and that the response time of the information service was not improved during the single experiment we performed with data distributed across two servers.     

Resolving current disagreements and ambiguities in the terminology of animal communication

Communication is central to most interactions between organisms. There is currently considerable controversy about the evolution, function and even about the most basic definition of communication. The controversy is linked to definitional ambiguities and disagreements. Here we discuss how some recent disagreements can be resolved and offer a clear set of definitions. Central to our approach is a definition of communication as being a trade between one organism (the informer) and another (the perceiver). The informer exerts influence on the perceiver through the communication process, and the perceiver experiences a change in its informational state (that is, gains information) as a consequence of detecting the communication. We define both influence and information explicitly and delineate between signalling, deceptive communication, and situations where perceivers respond to cues rather than signals. We demonstrate how our definitions allow resolution of conflicts arising in recent publications on the definitions on communication and related terms.     

Parallel and divergent landscapes: cultural encounters in the ethnographic space of Tuareg medicine

This essay explores the dialogue between the local quest for healing and the anthropological quest for healing knowledge, and local assessments of knowledge-power relationships in these processes. The context is medical discourse among the Tuareg of Niger Republic, West Africa, and my research experiences among these people. I examine local medical specialists and their traditional and changing practice in terms of how they perceive and respond to wider knowledge and power systems that impinge on local health care. Paramount in these systems are central state policies and medical anthropological research on healing, as these intersect in a postcolonial and post-separatist/rebellion setting. The essay analyzes parallels between the exchange of medicine and the exchange of knowledge and reflects upon how anthropological knowledge of African healing systems is constructed in an environment highly charged with power and danger--of political violence and economic crisis. The broader issue addressed here is how to give greater empowerment to local residents' voices in their "indigenous critique" of the medical anthropological project.     

Spores and soil from six sides: interdisciplinarity and the environmental biology of anthrax (Bacillus anthracis)

Environmentally transmitted diseases are comparatively poorly understood and managed, and their ecology is particularly understudied. Here we identify challenges of studying environmental transmission and persistence with a six‐sided interdisciplinary review of the biology of anthrax (Bacillus anthracis). Anthrax is a zoonotic disease capable of maintaining infectious spore banks in soil for decades (or even potentially centuries), and the mechanisms of its environmental persistence have been the topic of significant research and controversy. Where anthrax is endemic, it plays an important ecological role, shaping the dynamics of entire herbivore communities. The complex eco‐epidemiology of anthrax, and the mysterious biology of Bacillus anthracis during its environmental stage, have necessitated an interdisciplinary approach to pathogen research. Here, we illustrate different disciplinary perspectives through key advances made by researchers working in Etosha National Park, a long‐term ecological research site in Namibia that has exemplified the complexities of the enzootic process of anthrax over decades of surveillance. In Etosha, the role of scavengers and alternative routes (waterborne transmission and flies) has proved unimportant relative to the long‐term persistence of anthrax spores in soil and their infection of herbivore hosts. Carcass deposition facilitates green‐ups of vegetation to attract herbivores, potentially facilitated by the role of anthrax spores in the rhizosphere. The underlying seasonal pattern of vegetation, and herbivores' immune and behavioural responses to anthrax risk, interact to produce regular ‘anthrax seasons’ that appear to be a stable feature of the Etosha ecosystem. Through the lens of microbiologists, geneticists, immunologists, ecologists, epidemiologists, and clinicians, we discuss how anthrax dynamics are shaped at the smallest scale by population genetics and interactions within the bacterial communities up to the broadest scales of ecosystem structure. We illustrate the benefits and challenges of this interdisciplinary approach to disease ecology, and suggest ways anthrax might offer insights into the biology of other important pathogens. Bacillus anthracis, and the more recently emerged Bacillus cereus biovar anthracis, share key features with other environmentally transmitted pathogens, including several zoonoses and panzootics of special interest for global health and conservation efforts. Understanding the dynamics of anthrax, and developing interdisciplinary research programs that explore environmental persistence, is a critical step forward for understanding these emerging threats.     

A visual metaphor describing neural dynamics in schizophrenia

Background

In many scientific disciplines the use of a metaphor as an heuristic aid is not uncommon. A well known example in somatic medicine is the ‘defense army metaphor’ used to characterize the immune system. In fact, probably a large part of the everyday work of doctors consists of ‘translating’ scientific and clinical information (i.e. causes of disease, percentage of succes versus risk of side-effects) into information tailored to the needs and capacities of the individual patient. The ability to do so in an effective way is at least partly what makes a clinician a good communicator. Schizophrenia is a severe psychiatric disorder which affects approximately 1% of the population. Over the last two decades a large amount of molecular-biological, imaging and genetic data have been accumulated regarding the biological underpinnings of schizophrenia. However, it remains difficult to understand how the characteristic symptoms of schizophrenia such as hallucinations and delusions are related to disturbances on the molecular-biological level. In general, psychiatry seems to lack a conceptual framework with sufficient explanatory power to link the mental- and molecular-biological domains.

Methodology/Principal Findings

Here, we present an essay-like study in which we propose to use visualized concepts stemming from the theory on dynamical complex systems as a ‘visual metaphor’ to bridge the mental- and molecular-biological domains in schizophrenia. We first describe a computer model of neural information processing; we show how the information processing in this model can be visualized, using concepts from the theory on complex systems. We then describe two computer models which have been used to investigate the primary theory on schizophrenia, the neurodevelopmental model, and show how disturbed information processing in these two computer models can be presented in terms of the visual metaphor previously described. Finally, we describe the effects of dopamine neuromodulation, of which disturbances have been frequently described in schizophrenia, in terms of the same visualized metaphor.

Conclusions/Significance

The conceptual framework and metaphor described offers a heuristic tool to understand the relationship between the mental- and molecular-biological domains in an intuitive way. The concepts we present may serve to facilitate communication between researchers, clinicians and patients.     

Metaphors we think with: the role of metaphor in reasoning

The way we talk about complex and abstract ideas is suffused with metaphor. In five experiments, we explore how these metaphors influence the way that we reason about complex issues and forage for further information about them. We find that even the subtlest instantiation of a metaphor (via a single word) can have a powerful influence over how people attempt to solve social problems like crime and how they gather information to make "well-informed" decisions. Interestingly, we find that the influence of the metaphorical framing effect is covert: people do not recognize metaphors as influential in their decisions; instead they point to more "substantive" (often numerical) information as the motivation for their problem-solving decision. Metaphors in language appear to instantiate frame-consistent knowledge structures and invite structurally consistent inferences. Far from being mere rhetorical flourishes, metaphors have profound influences on how we conceptualize and act with respect to important societal issues. We find that exposure to even a single metaphor can induce substantial differences in opinion about how to solve social problems: differences that are larger, for example, than pre-existing differences in opinion between Democrats and Republicans.     

基于因子分析法的医患信任危机成因研究

目的 探讨导致医患信任危机的多维影响因素与解决策略。方法 运用文献研究、专家咨询、现场调查及因子分析的方法,寻找对医患关系信任构成重要影响的潜在公因子,分析医患信任危机的成因。结果 医疗服务因子、医疗纠纷调解与行业监管因子、社会制度因素及文化价值因子、医患沟通因子是驱动医患信任危机形成的主因。结论 医患信任危机的形成受到医疗服务过程、外部社会制度及文化观念、行业监管及医患沟通和互动等多重因素的影响,需要政府、医疗机构和全社会共同努力,消解医患信任危机的坚冰,促进医患关系修复与和谐。     

A national register of historic and contemporary anthrax foci

Anthrax in Russia has for a long time posed a serious problem for public health and veterinary services. At the beginning of the century, 40-60 thousand cases of this infection were annually reported in the country in agricultural animals and about 10-20 thousand cases in people where each fourth (25%) was dying. In the Russian Federation the registration of anthrax foci is obligatory for veterinary as well as for sanitary-epidemiological services. So our initial project, funded by the International Technical and Scientific Center in Moscow, has envisaged the collection of all data of known anthrax foci, including the village name, agricultural council, region, oblast and year of occurrence. The objective is to assemble a reference handbook, "Register of stable anthrax sites in the Russian Federation", containing organized information on more than 10 000 anthrax foci occurring during the past 100 years. Such a study makes it possible to identify regions characterized by the highest concentrations of stationary anthrax sites in Russia, to identify trends in expressed activity of such sites through the periodic emergence of disease in humans and animals, and to determine the factors contributing to the formation of such trends. In doing this, it makes it possible to develop contingency plans for different risk locations (i.e. high risk of persistent infection, high risk of sporadic occurrence, low risk areas, etc.) in terms of anthrax in Russia, to identify high risk areas and develop a differentiated strategy of vaccination and other control strategies, and to develop preventive recommendations to reduce risk in high risk areas. It is now important to develop the second step of the project: to develop in depth studies of particular clusters to determine which factors are associated with Russian anthrax outbreaks. Maps will greatly enhance the value of this work in terms of spatial analysis. Furthermore, this supplementary project will allow the incorporation of powerful Geographic Information System (GIS) electronic mapping technology so that natural geographic features, such as soil type, climate, etc., can be compared with anthrax distributions in Russia using standard GIS and statistical analysis. At the present time, it is imperative to develop a detailed understanding of the world's distribution of anthrax and what geographic factors determine its prevalence.     

Ethnography, art, and death

A problem facing anthropologists, given the centrality of memory and imagination to all social life, is how to access memory and the imaginary when there is no independent access to consciousness. Moreover, the discipline has 'largely failed to distinguish itself' in response to understanding HIV/AIDS ( Annual Review of Anthropology 30 , 2001: 163). In response to these observations I would argue that orthodox approaches are limited and we need to create new forms of collaborative research and representation with regard to understanding experiences of illness. Accordingly this article attempts to bring to life the interior dialogue of persons living with HIV/AIDS through performance by 'mapping' the city of Kampala through its emotions and memories rather than buildings and streets.