摘要：Objectives. We evaluated perceptions of workers at the US Postal Service Brentwood Processing and Distribution Center and US Senate employees regarding public health responses to the anthrax mailings of October 2001. We generated recommendations for improving responses to bioterrorism on the basis of the perceptions we recorded. Methods . Transcripts from focus groups conducted with Brentwood and US Senate employees were examined, and qualitative analysis identified common domains. Results . Brentwood focus groups consisted of 36 participants (97% African American and 19% hearing impaired). US Senate focus groups consisted of 7 participants (71% White and 0% hearing impaired). The focus groups revealed that participants’ trust in public health agencies had eroded and that this erosion could threaten the effectiveness of communication during future public health emergencies. Among Brentwood participants, lack of trust involved the perception that unfair treatment on the basis of race/ethnicity and socioeconomic status had occurred; among US Senate participants, it derived from perceptions of inconsistent and disorganized messages. Conclusions . Effective communication during a public health emergency depends on the provision of clear messages and close involvement of the affected community. Diverse populations may require individualized approaches to ensure that messages are delivered appropriately. Special attention should be given to those who face barriers to traditional modes of communication. On October 15, 2001, a letter containing Bacillus anthracis was opened at Senator Tom Daschle’s Capitol Hill office, triggering a series of events that revealed serious gaps in the nation’s ability to respond to bioterrorism. By November 20, 2001, 22 cases of anthrax had been identified in the United States, and a wide spectrum of individuals had been exposed in the Washington, DC, area. 1 Although the first reports of positive anthrax exposures in Washington, DC, occurred at the Hart Senate Office Building, no actual cases were reported. The effect on the United States Postal Service facility on Brentwood Road, Washington, DC, through which the letter passed just days before it was opened, was more severe. Four cases of inhalational anthrax originated from this facility, resulting in 2 deaths. It was recommended that approximately 2743 people from the Brentwood population and 600 people from the Hart building take at least 60 days of antibiotic prophylaxis based on a presumed high risk for inhalational anthrax. 2– 4 Since that time, there has been much discussion about improving systemwide responses to bioterrorism. Recommendations have largely focused on surveillance for and management of biological agents, including medical treatment, containment, and decontamination. 5, 6 Few empirical data regarding communication with potentially exposed individuals have been provided. This issue is critical. Effective communication during a public health emergency can have profound effects, ranging from increased compliance with recommended treatment to decreased development of long-term psychological sequelae. A basic goal of public health communication is to provide accurate, accessible information that establishes a bond of trust between those in a position of responsibility and those potentially exposed to a bioterrorist agent. 7 This trust depends on perceptions of competence, objectivity, fairness, and consistency and on the general belief in the good will of those responsible for communication. 8 The events surrounding the anthrax exposures required communication by various public health entities to a highly diverse audience during a period of sustained uncertainty. Screening and treatment recommendations changed as knowledge about the infection and its treatment evolved. Although the Daschle letter came through the Brentwood facility on October 12, Senate workers on Capitol Hill were initially thought to be the primary exposed population, resulting in rapid testing and prophylactic treatment of that population on October 15 (Table 1 ▶ ). Medical and public health agencies did not immediately recognize that fatal doses of anthrax could disseminate through unopened envelopes, resulting in little initial recognition that postal employees might also be at risk. 1 Thus, workers at the Brentwood facility were not screened or treated until October 21, after anthrax cases had been confirmed in their coworkers. By that time it was recognized that all employees from the Brentwood facility would need postexposure prophylaxis; nasal swabbing for diagnosis was felt to be both unreliable and unnecessary. 9, 10 TABLE 1— Timeline of Events Associated With Anthrax Exposures: 2001, Washington, DC 2, 9, 25, 26 October 12, 2001 Two letters addressed to Senator Daschle and Senator Leahy, mailed or postmarked from Trenton, New Jersey, were processed at the Brentwood Road postal facility October 12 A letter addressed to NBC news anchor Tom Brokaw was found to be positive for anthrax October 13 Two New Jersey postal workers who apparently processed anthrax-contaminated letters reported suspicious skin lesions to New Jersey state health officials October 15 Staff worker in Senator Daschle’s office in the Hart Senate Office Building opened a letter containing Bacillus anthracis October 15 Environmental sampling initiated in Hart Senate Office Building Nasal swab testing and prophylactic antibiotics begun for staffers in area of exposure October 17 Hart Senate Office Building closed and remainder of staff received nasal swab testing and prophylactic antibiotics October 18 Cutaneous anthrax was confirmed in New Jersey postal workers October 18 USPS contractor conducted private field tests at Brentwood as a result of suspicions in New Jersey population October 19 State of New Jersey urged postal employees at Hamilton and West Trenton facilities to contact their private doctors or area hospitals and to initiate a regimen of antibiotics October 19 Brentwood postal worker admitted to hospital with suspected inhalational anthrax October 20 CDC team visited Brentwood October 20–22 Three additional cases of anthrax were identified in Brentwood postal workers During this period, 2 of the cases resulted in death October 21–22 Brentwood postal facility closed; nasal swab testing and initial treatment of Brentwood postal workers begun October 23 Extensive environmental sampling of Brentwood postal facility by CDC and USPS contractor begun Open in a separate window USPS = United States Postal Service; CDC = Centers for Disease Control and Prevention. Intense media coverage highlighted the delays in testing and treatment of the Brentwood workers, often making references to race and socioeconomic status; approximately 92% of Brentwood’s employees were African American, as opposed to the predominately White staffers of the US Senate. 11, 12 Following the initial diagnosis, employees at both facilities who were deemed to be at highest risk received prophylactic antibiotics for 60 days. Subsequent recommendations for postexposure prophylaxis extended the suggested length of antibiotic prophylaxis to 100 days or receipt of a vaccine, classified as investigational, to further reduce the chance of acquiring inhalational anthrax. 13 Antibiotic adherence was similar at both sites, with 64% of Brentwood and 58% of Senate workers completing at least 60 days of antibiotics. 3 However, the 2 groups differed sharply in their response to the vaccine recommendation. Thirty-eight percent of high-risk Senate workers chose to receive the anthrax vaccine, as compared to only 2% of Brentwood workers. 14 To date, there has been a paucity of information about how individuals exposed to anthrax perceived and responded to public health information, or how this may have affected subsequent health behaviors. There has been even less focus on communication with particularly vulnerable groups, such as African Americans or those with hearing impairments, both of whom are disproportionately represented in Brentwood’s population. 15 We studied the experience of Brentwood and Senate employees in order to better understand, from the perspectives of those affected, their response to these events. Our goal is to generate suggestions for improvement that will help improve communication during a public health emergency.
