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PubMed1993

AIDS and the limits of control: public health orders, quarantine, and recalcitrant behavior.

We undertook a survey to document the extent to which public health powers have been used to warn or restrict individuals infected with human immunodeficiency virus (HIV) whose behavior poses a risk of transmission to others. In the period from 1981 through 1990, 24 state health departments either had no mechanism for receiving reports about individuals whose behavior posed a risk of HIV transmission or took no action if they had received such reports. In states that had developed programs for dealing with such individuals, the most common response was the use of cease and desist orders. As of 1992, 10 instances of quarantine had been reported, almost all of which involved relatively brief periods of isolation. Whatever justification exists for using public health authority to confront individuals whose behavior poses a risk of HIV transmission to others, it is clear that the central focus of HIV prevention efforts must remain education, counseling, voluntary testing and partner notification, drug abuse treatment, and needle exchange programs.

Behavior↗

PubMedDate not supplied

Education day. The evolution of a learning experience.

Education Day in our hospital was created as a way of increasing attendance at annual mandatory inservices. Since beginning the program, compliance with mandatory inservice has increased from 50% to 97%. The Education Day format consolidates resources and provides consistency in the delivery of required information. The format is also flexible; it responds to changes and specialized educational needs of the nursing staff.

Education, Nursing, Continuing↗

PubMed1998

Low risk for tuberculosis in a regional pediatric hospital: nine-year study of community rates and the mandatory employee tuberculin skin-test program.

OBJECTIVE: To assess the risk of Mycobacterium tuberculosis infection and disease among patients and workers in a regional pediatric hospital. DESIGN: Descriptive epidemiological study of the mandatory tuberculin skin testing program of hospital employees at hire and during annual reevaluation, pediatric patients with tuberculosis (TB), efficacy of hospital infection control measures, and community rates of TB. SETTING: 361-bed, university, pediatric hospital serving Cincinnati (1.7 million population). RESULTS: During 1986 through 1994, 2,275 to 4,356 employees were compliant with Mantoux skin testing and screening each year. This represented >97% of the population who were eligible for screening. The cumulative rate of M tuberculosis infection from a previous positive tuberculin skin test was 10% to 12% per year during 1986 through 1994. Among new Mantoux skin-test converters in employees at annual reevaluation, the risk of TB infection was 0.3% in 1993 and 1994. There were no active cases of TB identified during new employee screening or annual reevaluation. Of 62 new Mantoux skin-test converters in 9 years, 23% were foreign-born, 13% were Asian, 23% were African American, 11% received the bacillus of Calmette-Guérin vaccine, and 60% had direct patient care or indirect patient contact. A cluster of five converters occurred in a department with no patient care or contact. Mantoux conversion rates were 1.9 per 1,000 employee patient-care or contact-years and 2.2 per 1,000 employee non-patient-contact years. Twenty pediatric patients with active TB were identified during 1991 to 1994, with < or =6 cases per year, placing this hospital in the low-risk category for M tuberculosis disease. Three children with pulmonary TB were admitted without immediate respiratory isolation, possibly exposing 9 patients and 42 employees; none converted their Mantoux skin tests on retesting. Rates of active TB in Cincinnati were stable during the period (eg, 8/100,000 population in 1994). CONCLUSIONS: Despite intense active surveillance among thousands of hospital employees with >97% annual compliance, tuberculin conversion rates were low, and no cases of active TB were identified during 9 years of follow-up. There was no evidence of transmission of M tuberculosis from infected patients to employees during uncontrolled exposures. Rates of TB in the community were low. These data suggest that rigorous application of the Centers for Disease Control and Prevention guidelines and Occupation Safety and Health Administration regulations for preventing nosocomial TB in pediatric hospitals may be excessive and costly. Special provisions should be made for pediatric hospitals with a proven low risk of transmission of M tuberculosis.

Adult↗

PubMed1992

HIV prevention and the two faces of partner notification.

In the cases of medical patients with sexually transmitted diseases (particularly those with the human immunodeficiency virus), two distinct approaches exist to notifying sexual and/or needle-sharing partners of possible risk. Each approach has its own history (including unique practical problems of implementation) and provokes its own ethical dilemmas. The first approach--the moral "duty to warn"--arose out of clinical situations in which a physician knew the identity of a person deemed to be at risk. The second approach--that of contact tracing--emerged from sexually transmitted disease control programs in which the clinician typically did not know the identity of those who might have been exposed. Confusion between the two approaches has led many to mistake processes that are fundamentally voluntary as mandatory and those that respect confidentiality as invasive of privacy. In the context of the AIDS epidemic and the vicissitudes of the two approaches, we describe the complex problems of partner notification and underscore the ethical and political contexts within which policy decisions have been made.

Confidentiality↗

PubMed1988

Mandatory HMO enrollment in Medicaid: the issue of freedom of choice.

In areas where HMOs have enrolled a small proportion of the general population, physician participation is less in mandatory HMO programs for Medicaid beneficiaries than in fee-for-service Medicaid. But where HMOs have enrolled over one-quarter of the general population, participation rates are indistinguishable under the two systems. In those areas, mandatory enrollment restricts freedom of choice of provider. A plausible reason for this is that individual practice associations, which contract with large numbers of physicians with both fee-for-service and HMO patients, are becoming the lead form of HMO.

Civil Rights↗

PubMed1977

State supplementation under SSI, 1975.

This article summarizes State supplementation activities under SSI for 1975. It discusses changes in the State programs that occurred during 1975 and presents some comparisons with data for 1974--the initial year of the SSI program. A slight shift occurred in the distribution of recipients by eligibility category for Federal and State supplementation from 1974 to 1975. During 1975 a few States changed from Federal administration to State administration of their mandatory supplementation programs while a few others initiated or expanded their optional supplementation programs. Several States also increased their supplements during the year.

Financing, Government↗

PubMed1992

The feasibility of mandatory HIV testing for health professionals and other special populations.

Infection with the human immunodeficiency virus (HIV) has become an increasingly important public health problem. Due to the profound increase in the incidence of the disease, testing has become an important tool in prevention efforts as well as treatment. In view of the dire prognosis associated with the diagnosis of HIV infection, there is a great deal of interest in mandatory HIV testing of special groups. Mandatory testing has been implemented for several groups such as the United States military. However, there are a number of issues to be considered before implementing a mandatory testing program. These include the predictive value and accuracy of the tests themselves, confidentiality and the social ramifications of breaches in confidentiality, the likelihood of forcing high risk persons underground to avoid testing, and the constitutionality of a mandatory testing policy. Since the discovery of the apparent transmission of HIV infection from a dentist to his patients, there has been increasing interest in a policy mandating the testing of health professionals. However, in view of the low risk of transmission to patients, it would be ill-advised to require HIV testing of health care workers. In general, the benefits of a mandatory testing policy do not outweigh the human and financial costs it would engender.

AIDS Serodiagnosis↗

PubMed1990

Technical workshop report: Working Group II: agricultural occupational health and safety services for farmers and ranchers.

This work group felt that there is compelling evidence that effective occupational health services are essential to improve the serious occupational safety and health problems in agriculture. Program initiatives may be stimulated by federal and state governments, but development and implementation must involve the grassroots farm community and local resources. Other countries (Sweden, Finland, Canada) are far ahead of the United States in this area and serve as examples. Developing services should be comprehensive and should include clinical, technical, and educational efforts. Marketing programs to the public must include grassroots involvement. Surveillance and program evaluation are essential in any new program efforts. Funding such programs must be shared by federal, state, local, and private resources. Regulatory options should be a minimal part of such a program, but mandatory rollover protective devices and mandatory reporting seems to be one feasible regulatory option.

Accidents, Occupational↗

PubMed1980

Antabuse: medication in exchange for a limited freedom--is it legal?

Recidivism among alcohol offenders--drunken drivers in particular--has led courts to experiment with programs that attempt to rehabilitate problem drinkers. One such program, in El Cajon, California, offers defendants the choice of going to jail or of submitting to a year of treatment with Antabuse, a potent drug that reacts with alcohol to produce intensely painful physical symptoms. In addition, Antabuse subjects the recipient to the risk of toxic side effects. According to the authors, the El Cajon program fails to inform defendants of the full risks and effects of Antabuse. Further, the authors maintain that the program uses the threat of a jail sentence to coerce defendants into consenting to Antabuse therapy. The authors conclude that defendants' consent is so tained by these factors that the program amounts to involuntary treatment. Consequently, the authors suggest that the El Cajon program violates defendants' constitutional right to privacy. Finally, the severity of the Antabuse-alcohol reaction leads the authors to contend that the program constitutes cruel and unusual punishment.

Accident Prevention↗

PubMed1992

The stigma of disease: implications of genetic screening.

As the field of human genetics successfully continues to unravel the secrets of an individual's genetic makeup, the social processes of stigmatization and ostracism of those with "undesirable" traits have the potential to increase. An historical example that may shed light on the problems of applying genetic technology to disease prevention is the institution of quarantine. This essay discusses the concept of "quarantine mentality" and the desire for healthy society to separate itself from those labeled "ill" or abnormal, and addresses two episodes in American history when genetics was applied to the formulation of social policy toward the "diseased": the eugenics movement of the early 20th century and the early attempts of genetic screening programs for sickle cell anemia during the 1970s.

Anemia, Sickle Cell↗

PubMed1988

Concerns of medical and pediatric house officers about acquiring AIDS from their patients.

To assess the degree of house officers' concerns about acquiring AIDS (acquired immunodeficiency syndrome) from their patients, we surveyed 263 medical and pediatric interns and residents in four housestaff training programs affiliated with seven New York City hospitals with large AIDS patient populations; 258 questionnaires (98 per cent) were returned. Thirty-six per cent of medical and 17 per cent of pediatric house officers reported percutaneous exposures to needles contaminated with blood of AIDS patients. Forty-eight per cent of medical and 30 per cent of pediatric house officers reported a moderate to major concern about acquiring AIDS from their patients. Greater concern about personal risk was noted in those house officers who were earlier in their residency training, who reported having treated a greater number of AIDS patients, and who were in medicine rather than pediatrics programs. Twenty-five per cent of all respondents reported that they would not continue to care for AIDS patients if given a choice. The results demonstrate a substantial degree of concern about acquiring AIDS among house officers caring for AIDS patients and suggest the need for housestaff program administrators for formally address these concerns.

Acquired Immunodeficiency Syndrome↗

PubMed1990

Expanding health insurance coverage: who will pay?

Recent discussions on extending health insurance to the more than thirty million uninsured Americans have focused on two strategies: expanding the Medicaid program and mandating that employers sponsor coverage for their employees. This analysis, using a microsimulation model of the U.S. health care financing system, suggests that these two options would result in very different distributions of financial burden. Employer-sponsored coverage is financed in a highly regressive fashion, in contrast to the Medicaid program, which is proportional to income. Furthermore, the burden of paying for health care under Medicaid varies little among generations, whereas the cost of employer-sponsored care is lowest in households headed by persons over sixty-five years old. Low health status populations do not pay disproportionately higher taxes or premiums to finance either the Medicaid program or employer-sponsored coverage. Their incomes, however, are more effectively protected by Medicaid, because it offers more comprehensive benefits.

Costs and Cost Analysis↗

PubMed1991

Compulsory treatment for drug-dependent persons: justifications for a public health approach to drug dependency.

Compulsory treatment for drug users is often rejected as neither an effective nor an acceptable exercise of state authority. Recent research studies indicate that compulsory treatment can work and that, if carefully put into effect, it can represent an important public health component of the response to drug use. Finally, a program of compulsory treatment can be shaped with concerns for due process in mind, so that civil liberties will not be violated.

Behavior Control↗

PubMed1990

HIV infection, pregnant women, and newborns: A policy proposal for information and testing.

As the public health impact of human immunodeficiency virus (HIV) infection in women and children has increased, so has interest in screening pregnant women and newborns for evidence of HIV infection. However, screening of pregnant women and newborns raises profound moral, legal, and policy issues. In this article, we present and defend a detailed 10-point program of policy recommendations for both pregnant women and newborns. We advocate informing all pregnant women and new mothers about the HIV epidemic and the availability of testing.

AIDS Serodiagnosis↗

PubMed1987

The prevention of acquired immunodeficiency syndrome in the United States. An objective strategy for medicine, public health, business, and the community.

Human immunodeficiency virus (HIV) is one of the most virulent infectious agents ever encountered. This virus, estimated to kill up to a half of those infected, has spread to more than 1 million Americans. There is no safe and effective treatment. Nor is there a vaccine. From our understanding of HIV transmission, further spread of the virus can be stopped by the use of various techniques. The combined use of education-motivation-skill building, serologic screening, and contact tracing/notification could eliminate or substantially reduce transmission. To accomplish this reduction an immense concerted effort by physicians, public health practitioners, business, and community organizations is required to get across the simple prevention messages. Those messages are: Any sexual intercourse (outside of mutually monogamous or HIV antibody-negative relationships) must be protected with a condom. Do not share unsterile needles or syringes. All women who may have been exposed should seek HIV-antibody testing before becoming pregnant and, if positive, avoid pregnancy. Only through a concerted, vigorous, and sustained prevention program that deals frankly with this problem will those individuals at risk be reached and motivated to take personal responsibility to protect themselves. Without such an effort, acquired immunodeficiency syndrome will continue to kill ever-increasing numbers of Americans.

Acquired Immunodeficiency Syndrome↗

PubMed1996

Who are the donors in organ donation? The family's perspective in mandated choice.

Evidence that families requested to permit organ donation refuse half the time has led to proposals for mandated choice. Under mandated choice, a person's donation wishes would be collected and retrieved at death, and requests to families would be avoided. There are both ethical and logistic problems with mandated choice. The view of the family should be respected in organ requests, even when patient wishes are known. Public sentiment against overriding family wishes could cause low rates of pro-donation registration. Caregivers have usually refused to take organs when families oppose donation. Logistic issues with mandated choice include the cost and complexity of maintaining a national database on donors and the enforcement of registration. No such database of adults currently exists, even for tax purposes. Two states that have mandated choice programs through departments of motor vehicles report relatively low number of pro-donation registrants compared with nondonors or undecided persons. Public education and voluntary donor identification hold more potential to increase donation.

Adult↗

PubMed1979

Structured educational program for staff development.

The development of a mandatory continuing education program for the pharmacy staff of a 675-bed hospital with 10 decentralized pharmacy satellites is described. The therapeutic topics selected for presentation were antibiotics, immunology and adverse drug reactions, diabetes mellitus and acid-base disorders. The format for each subject included a pretest of basic knowledge, a comprehensive lecture, a tape recording, supplemental handout material and readings, and a posttest. Posttests were scheduled three to four weeks following lectures to allow preparation time. Questionnaires were used to evaluate acceptance of the program. Posttest scores for each of the four topics were significantly better than pretest scores (p less than or equal to 0.0001). Questionnaire responses indicated that 97% of the participants believed the program to be worthwhile, and 94% voted to continue the series. The success and acceptance of this approach to continuing education support its application to a comprehensive program of staff development.

Chicago↗

PubMed1993

Economic analysis of a mastitis monitoring and control program in four dairy herds.

Mastitis monitoring and control programs were instituted in 4 Illinois dairy herds for 12 months. Two herds had high mean monthly bulk tank somatic cell counts (> 490,000 cells/ml) and 2 had low mean monthly bulk tank somatic cell counts (< 260,000 cells/ml) at the start of the study. The mastitis monitoring and control programs included mandatory mastitis control measures, as well as individualized control measures that were based on results of bacterial cultures of milk, bulk tank milk analyses, milking machine and milking procedure evaluations, and environmental inspections in each herd. Changes in mastitis prevalence, clinical mastitis incidence, milk yield, and individual cow somatic cell counts were evaluated, and an economic analysis was performed for each herd. Mastitis-associated economic losses during the study period ranged from $161.79 to $344.16/lactating cow in the 4 herds. Gross economic benefits resulted when mastitis-associated losses were lower with the monitoring and control program than predicted without it. There were no gross economic benefits in the herds with low somatic cell counts, and, when the marginal costs of the programs were added, there were large net losses ($84.06 and $113.01/lactating cow) in those herds. Gross economic benefits resulted in both of the herds with high somatic cell counts. However, in 1 of the herds, the marginal costs of the program exceeded the benefits, resulting in a net loss of $12.96/lactating cow. The net loss was attributed primarily to poor producer compliance with recommendations. There was a net economic benefit of $19.11/lactating cow in the other herd with high somatic cell counts, in which producer compliance was better.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗