Ethical issues in surveillance, screening and outbreak investigation

EMPHNET

Ghaiath M. A. HusseinMBBS, MHSc. (Bioethics), PhD Researcher

Email :.ghaiathme@gmail com

Regency Palace, Amman, Jordan15-19 June, 2014

Module’s objectives• Analyze the ethical issues associated with the

practice of surveillance and screening• Discuss the global approaches and differences

in research and surveillance and other activities similar to research

• Apply the ethical frameworks to define, analyse and decide on the ethical issues encountered in real life when conducting outbreak investigation, surveillance and/or screening

Module’s Outline

• Definitions and concepts of surveillance, screening, and outbreak investigation

• The ethical issues in surveillance and screening– Respect for autonomy and informed choices:– Privacy and confidentiality– Justice

• How to manage ethical issues in practice?

Public health surveillance• Definition: – “the continuous, systematic collection, analysis and

interpretation of health-related data needed for the planning, implementation, and evaluation of public health practice.” (WHO)

• Functions: – early warning system;– document the impact of an intervention, or track

progress towards specified goals; and – monitor and clarify the epidemiology of health

problems

Screening of diseases

• "the presumptive identification of unrecognized disease or defect by the application of tests, examinations, or other procedures which can be applied rapidly.” (ICC, WHO)

• Examples:– Premarital genetic– Prenatal genetic– Paediatric genetic– Cancer genetic

Outbreak Investigation

• “activities undertaken to establish the existence of an outbreak, describe the outbreak, and to identify the source, transmission mechanism and contributory factors, as a basis for outbreak response.” (NZ CDC)

Steps in Outbreak Investigation• Verify the diagnosis• Confirm the outbreak• Case definition• Descriptive epidemiology• Develop a hypothesis• Test the hypothesis• Refine hypothesis / Execute additional studies• Implement control and prevention measures• Communicate findings

Sources of Ethical Issues

•Privacy •Confidentiality

•Autonomy (consent)

Data/sample collection

•Benefits •Harms

•Autonomy (consent)

Methods used

•Justice •Trust Outcomes

Ethical issues in outbreak investigation

• Privacy: – Consider MOH cars in front of a house, spraying

around it• Confidentiality:– Patient’s address and contacts are shared with

teams• Autonomy:– Do patients have right to say no to outbreak

investigation?• Do you consider any other issues?

Case for Discussion

References• Fairchild, A. L. (2003), Dealing with Humpty Dumpty: Research, Practice, and

the Ethics of Public Health Surveillance. The Journal of Law, Medicine & Ethics, 31: 615–623. doi: 10.1111/j.1748-720X.2003.tb00129.x

• Coughlin, S. S. 2006, "Ethical issues in epidemiologic research and public health practice", Emerging Themes in Epidemiology, vol. 3, no. 1, p. 16.

• Kass NE: Public health ethics: from foundations and frameworks to justice and global public health. J Law Med Ethics 2004, 32:232-42

• Genetic Screening, Nuffield Council on Bioethics, URL: http://www.nuffieldbioethics.org/genetic-screening/genetic-screening-chapter-downloads

• Guidelines for the Investigation and Control of Disease Outbreaks. Porirua: Institute of Environmental Science & Research Limited; Updated 2011.

ETHICAL ISSUES IN HEALTH PROMOTION

Module’s objectives

• Define the concepts and scope of health promotion

• List the ethical principles that arise from health promotion activities

• Discuss the ethical issues that arise from health promotion, and

• Analyse and manage the ethical issues utilizing the ethical frameworks

Module’s Outline

• Definition and scope of health promotion• What are the ethical principles that are

applicable to health promotion?• How to approach ethical issues in health

promotion?

Definition and scope of health promotion

• “the process of enabling people to increase control over, and to improve, their health.

• Health is a positive concept emphasizing social and personal resources, as well as physical capacities.”

• Prerequisites for health– peace, shelter, education, food, income, a stable

ecosystem, sustainable resources, social justice and equity.

Ottawa Charter for Health Promotion, 1986

Definition and scope of health promotion

Ottawa Charter for Health Promotion, 1986

Advocate•Political, economic, social,

cultural, environmental, behavioural and biological factors

Enable•reducing differences in

current health status and ensuring equal opportunities and resources to enable all people to achieve their fullest health potential

Mediate•health promotion demands

coordinated action •should be adapted to the

local needs and possibilities of individual countries and regions to take into account differing social, cultural and economic systems.

Targets of health promotion

Credit: Tasmanian Government Department of Health and Human Services. http://www.dhhs.tas.gov.au/healthpromotion/wihpw

Examples of health promotion interventions

•

Ethical Issues in health Promotion

• Informed choices and respect for autonomy• Responsibility/empowerment • Altruism• Reciprocity• Justice

What are your thoughts?

References and readings• Mittelmark MB: Setting an ethical agenda for health promotion. Health

promotion international 2008, 23: 78-85.• Ten Have M, Van der Heide A, Mackenbach JP, de Beaufort. An ethical

framework for the prevention of overweight and obesity: a tool for thinking through a programme’s ethical aspects. The European Journal of Public Health 2013, 23: 299-305.

• Labonte, R. 1994, Health Promotion and Empowerment: Reflections on Professional Practice, Health Education & Behavior, vol. 21, no. 2, pp. 253-268

• Tasmanian Government Department of Health and Human Services. http://www.dhhs.tas.gov.au/healthpromotion/wihpw

• http://www.patient.co.uk/directory/health-promotion-lifestyle

ETHICAL ISSUES IN VACCINATION

Module’s objectives

• Identify the ethical issue related to vaccination

• Analyse the arguments that support and that reject making vaccination mandatory.

• Outline an ethical framework to vaccination in the EMR context

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Module’s Outline

• Overview on vaccines, vaccination and immunization

• Benefits and harms approach to vaccination• Duty to care for others (or not to harm other)• Compulsion and refusal of vaccination

Vaccine vs. Immunization

• A vaccine is a product that produces immunity from a disease and can be administered through needle injections, by mouth, or by aerosol.

• A vaccination is the injection of a killed or weakened organism that produces immunity in the body against that organism.

• An immunization is the process by which a person or animal becomes protected from a disease. Vaccines cause immunization, and there are also some diseases that cause immunization after an individual recovers from the disease.

(Source: http://www.vaccines.gov/basics/index.html)

Source: http://www.historyofvaccines.org/content/types-vaccines

Ethically relevant ‘facts’

• Vaccination is the only type of medical intervention that has eliminated a disease successfully.

• Vaccines stand out as being among the most efficacious and cost-effective of global medical interventions

• For example in the US:– The eradication of smallpox has probably saved 40 million lives

over the past two decades (spent US $25 million per year saved US $275 million annually)

What are the ethical issues related to vaccination?

• Are we doing good by vaccinating?• Is there a duty to vaccinate?• Is it ethical to make vaccination mandatory? On general

public? On practitioners?• If yes, which vaccines on which group?• Is it ethical to refuse vaccinating yourself?• Is it ethical to refuse vaccinating your children?• Conflict of interests • Allocation of scarce vaccines (national and int’l inequality)• Political (ab)use of vaccination to restrict some human

rights or as political tool

Harms & Benefits

Individual protectionHerd immunityReduced morbidity & mortality

Side effects (local)Long term?

VulnerabilityCompulsion (lack of freedom?)

Duty of Care

• Do we (as individuals) have duty to care for others not related to us?

• Do we (as professionals) have duty to care for others, even if this would threat our own safety?

Ethical framework for mandatory vaccination (R.Field and A.L. Caplan)

Against For

beneficence

utilitarianism

Justice/ solidarity

nonmaleficence

?

autonomy

Compulsion and refusal of vaccination

• Do we (as government) has the right to ‘force’ the people to be vaccinated?

Hard Paternalism Soft Paternalism

Forcing competent persons to act (or inact) in a certain way without their consent to achieve the public good

the interference done on behalf of individuals who are not able to take their decisions properly,Examples?

Compulsion and refusal of vaccination

• Children who are not vaccinated are not allowed to have their ‘birth certificates’

• Unvaccinated children are denied school admission• Unvaccinated adults are denied travelling to some

countries• Unvaccinated persons may be prevented from apply

for or doing some jobs

References • Dawson, A. 2011, "Vaccination ethics", Public Health Ethics pp. 143-153.• Krantz, I., Sachs, L., & Nilstun, T. 2004, "Ethics and vaccination", Scandinavian

Journal of Public Health, vol. 32, no. 3, pp. 172-178.• Omer, S. B., Salmon, D. A., Orenstein, W. A., deHart, M. P., & Halsey, N. 2009,

"Vaccine refusal, mandatory immunization, and the risks of vaccine-preventable diseases", New England Journal of Medicine, vol. 360, no. 19, pp. 1981-1988.

• Optional/additional readings:• Colgrove, J. 2006, "The ethics and politics of compulsory HPV vaccination", New

England Journal of Medicine, vol. 355, no. 23, pp. 2389-2391.• Van Delden, J. J., Ashcroft, R., Dawson, A., Marckmann, G., Upshur, R., & Verweij,

M. F. 2008, "The ethics of mandatory vaccination against influenza for health care workers", Vaccine, vol. 26, no. 44, pp. 5562-5566