Capitol hill staff workers' experiences of bioterrorism: qualitative findings from focus groups

Journal of Traumatic Stress, Vol. 18, No. 1, February 2005, pp. 79–88 ( C 2005) Capitol Hill Staff Workers’ Experiences of Bioterrorism:
Qualitative Findings From Focus Groups

Carol S. North,1,6 David E. Pollio,1,2 Betty Pfefferbaum,3 Deborah Megivern,2
Meena Vythilingam,4 Elizabeth Terry Westerhaus,1
Gregory J. Martin,5 and Barry A. Hong1
Little systematic information is available on mental health issues related to bioterrorism. Five focusgroups were conducted with Capitol Hill office staff (n = 28 total participants) to learn about theirexperience of the anthrax incident on October 15, 2001. More than 2,000 verbal passages werecoded into categories and themes by using qualitative analysis software. Issues emerging from thediscussions included difficulties utilizing customary social supports, concerns over potential long-term dangers created by efforts to eradicate the anthrax, and nonadherence to antianthrax medicationregimens. Nonadherence to antibiotic prophylaxis is of immediate concern for response to futurebioterrorist events as well as infectious disease epidemics. Other topics that warrant attention aresocial support and mental health interventions.
Qualitative research with focus groups has been used counseling, and sex education programs in an undevel- to explore varied topics in depth, such as health attitudes, oped country (Castle, 2003). Novel and unexpected find- beliefs, and behaviors, including medication adherence ings have sometimes emerged from this exploratory re- among low-income urban African Americans who have search: For example, many highly educated people in chronic asthma (Freedman, Norfleet, Feldman, & Apter, the latter study expressed disbelief about the existence 2003), differences in physicians’ and patients’ opinions of acquired immunodeficiency syndrome (AIDS) (Castle, on medical error disclosure procedures (Gallagher, Wa- 2003). Focus groups also provide a relatively straight- terman, Ebers, Fraser, & Levinson, 2003), and promo- forward means of obtaining preliminary data for new in- tion of human immunodeficiency virus (HIV) testing, vestigations of poorly understood topics such as bioterror-ism, about which little systematic information is currentlyavailable to guide interventions.
1Department of Psychiatry, School of Medicine, Washington University, Few pertinent systematic data pertaining to men- tal health effects of bioterrorism are available; however, 2George Warren Brown School of Social Work, Washington University, previous literature has identified characteristics for in- vestigation, including risk communication, management Department of Psychiatry and Behavioral Sciences, The University ofOklahoma Health Sciences Center, Oklahoma City, Oklahoma.
of misattributed somatic symptoms, and the role of so- 4The National Institute of Mental Health, Bethesda, Maryland.
cial support (Covello, Peters, Wojteki, & Hyde, 2001; 5Department of Medicine, The Uniformed Services University, Holloway, Norwood, Fullerton, Engel, & Ursano, 1997; Kawana, Ishimatsu, & Kanda, 2001; Norwood, Holloway, 6To whom correspondence should be addressed at Department of & Ursano, 2001). Relevance to these deliberate acts Psychiatry, Washington University School of Medicine, 660 S. Eu-clid Avenue, Campus Box 8134, St. Louis, Missouri 63110; e-mail: may be found in studies of disasters, including toxic contaminant spills, industrial accidents, and infectious C 2005 International Society for Traumatic Stress Studies • Published online in Wiley InterScience ( DOI: 10.1002/jts.20006 North, Pollio, Pfefferbaum, Megivern, Vythilingam, Westerhaus, Martin, and Hong
epidemics, which share uncertainties about personal ex- separate, unexposed buildings and remote sites, including posure, boundaries of the exposure, and duration of two House offices. Approval for the research was obtained risk. Anticipated psychological and social repercussions from the Washington University School of Medicine Insti- may include potential for mass “psychogenic” or “so- tutional Review Board. A federal Certificate of Confiden- ciogenic” illness in multitudes of unexposed individ- tiality was obtained for further protection of participants’ uals who have medically unexplained symptoms who privacy. Participating congressional offices provided ap- may seek access to and overwhelm the medical care proval for the conduct of this study in their offices. Indi- system (Alexander & Fedoruk, 1986; Amin, Hamdi, & vidual participation was voluntary and written informed Eapen, 1997; Bartholomew & Wessely, 2002; Pastel, 2001; Schoch-Spana, 2000). Systematically observed out- The sample was 61% female and 96% Caucasian.
comes that followed toxic exposure to dioxin contamina- Mean age (SD) was 28.3 (7.1), 77% were single, and 32% tion, however, included neither somatoform symptoms (Smith, Robins, Przybeck, Goldring, & Solomon, 1986) The two facilitators (CSN, DEP) conducting these nor posttraumatic stress disorder (Robins, et al, 1986).
groups had previous experience in nondirective interview- In the fall of 2001, anthrax-filled letters were mailed ing techniques or training in conducting of groups. Group through the U.S. Postal Service to several sites, including discussions of approximately 60 to 90 minutes were au- Capitol Hill, killing 5 and infecting 12 others (none on diotaped. The groups began with an opening instruction Capitol Hill). On October 15, an office worker in Senate by one of the facilitators explaining the purpose of the fo- Majority Leader Tom Daschle’s sixth-floor Hart Building cus group (to learn about their issues related to the Capitol office opened a letter that contained suspicious powder Hill experience with anthrax). Because the anthrax letters later confirmed to be anthrax. The office was closed and were part of a series of unsettling national events that orig- staff workers briefly quarantined. Hundreds of potentially inated with the September 11 terrorist attacks, participants exposed individuals were tested for anthrax, and antibi- were invited to begin by describing their experiences of otic prophylaxis (ciprofloxacin) was provided (Hsu et al., both events. A protocol of primary questions developed 2002). Buildings across Capitol Hill were subjected to A recent comprehensive study of 16 individuals (1) How did you learn of the anthrax on Capitol Hill, who were infected by anthrax during the attacks in the fall of 2001 identified indications of persistent medically (2) How has your behavior or your life changed unexplained health problems, psychological symptoms, and poor life adjustment (Reissman et al., 2004). A report (3) How did you react when you first learned of the (currently in press) of focus groups, which studied 36 Brentwood postal workers and 7 Capitol Hill workersmore than 1 year after the anthrax exposures, describes Thereafter, group facilitators avoided further direc- concerns about demographic inequality in their medical tion. Questions such as “Can you tell us a little more about treatment (Blanchard et al., in press). The current report that?” or “What else happened?” were interjected only as describes results of focus groups of Capitol Hill staff that needed to stimulate discussion from prior statements to inquired about their attitudes, beliefs, and postexposure prevent inserting new topics. Thus, the groups provided behaviors to explore the themes identified, identify distinct content without direct bias or structure imposed appropriate concerns for mental health interventions, and Data Analysis
Qualitative methods used NVivo software to orga- Five focus groups of four to eight members each were nize and interpret data from transcriptions of audiotapes conducted between January 14 and February 1, 2002, ap- of the focus group by labeling passages of text with codes proximately 3 months after the Capitol Hill anthrax inci- identifying specified content. The text of the five focus dent (4 months after the September 11 terrorist attacks).
groups was reviewed for recurring themes, and “nodes” The 28 study participants constituted a convenience sam- (codes) were created for nine thematic categories identi- ple of staff recruited by word of mouth from six offices, fied: context of 9/11 and anthrax incidents, personal ex- ranging from the highly exposed Hart offices to offices in posure, personal safety, emotional reactions, psychiatric Bioterrorism Focus Groups
symptoms, social support, social disruptions, authorities’ The September 11 attacks may have primed the response, and medical response. Two independent raters Capitol Hill population to react vigorously to the next reviewed 2,162 passages, tagging passages that identified the themes with one or more of the nine nodes. NVivo tabu-lated the number of items coded into each category, allow- The only time I was ever really frightened and my heart ing assignment of relative frequencies of response types.
started pounding was [during a false alarm] a few days Kappa measures of interrater reliability on items included after September 11th. I was in the Capitol and the guards in the nine categories ranged from .83 to .88 (calculated just started yelling, “Everybody get out! Everybody get on nonnegatively scored response pairs only), statistics out!” and there was this big evacuation of the building . . .
all within the excellent range of reliability (Fleiss, 1981).
this was like a mad dash by everyone to the door.
Differences in ratings were subsequently discussed by theteam and resolved by agreement.
Choice of footwear was a new concern in the post-9/11 workplace: “I definitely make a point sinceSeptember 11th not to wear shoes to work that I can’trun very fast in.” In comparing the anthrax experience with 9/11, per- ceptions of the two events sometimes blurred together, This report presents findings regarding the context as if reflecting a single event. “In my mind it seems so and perceptions of individuals’ experiences relating to hard sometimes to separate September 11 [from] the an- eight categories (context, exposure, personal safety, med- thrax. . . . I can’t get the timeline right in my mind, because ical procedures, disruptions, emotional reactions, psychi- it all folds into one big mess.” This relationship was cap- atric symptoms, and social context) that constitute 77% of tured in new terminology, for example, “bioterrorism at- the responses coded from these groups. Authorities’ re- tacks.” One focus group participant described the Capitol actions (23% of responses) are detailed in a forthcoming Hill experience as “the Ground Zero of anthrax.” Famil- report (North et al., in press). Category item frequencies iar quotations found novel applications in discussions of in this report ranged from 17% (personal safety) to 4% the bioterrorism experience: “‘You are living history’—as scary as it is, the first bioterrorism attack on the UnitedStates.” Contrasts between 9/11 and the anthrax attack on Context of Anthrax and September 11
Capitol Hill were also considered: “It’s a lot different withanthrax than it is with September 11th. . . . On the Hill, During the September 11 terrorist attacks, the cog- we didn’t know anyone who died from anthrax or that nizance of Capitol Hill workers of their status as a terror- was really affected; while September 11th, we all saw the ist target provided potential candidacy for posttraumatic emotional consequences. Anthrax attacks in the follow- After the debut of anthrax in Florida and New York ing month added layers of concern to this backdrop. The City news stations, a vivid expectancy arose: “We kind of concern was relative, however: A worker from a directly knew something else was probably going to happen.” “We exposed office explained, “September 11 was horrible, it had just discussed that it was probably only time before was awful and I will never forget it, but it did not hit me Anticipation of the next terrorist event kindled anx- In the penumbra of the September 11 terrorist attacks, iety: “I really don’t have any idea of what it could be; Capitol Hill staffers pondered their workplace safety. They I just feel like something is going to happen again. I sensed that the Capitol Building, rather than the surround- feel like it’s inevitable.” “People who want to hurt the ing Senate and House offices where they worked, was the government or cause mass terror, they’ve seen how easy intended target of the attacks. “It could have easily been us.
it can be. . . . I mean, good grief, look at those freaks Perhaps, if the plane hadn’t gone down in Pennsylvania.” who’ve been sending [hoax] letters. . . . There are people Comments of participants from the Senate side of Capitol out there who are going to realize that you don’t even Hill seemed to reflect more upset and preoccupation with have to kill a lot of people.” These worries generalized to the anthrax experience, whereas those from the House side a variety of potential catastrophes: “I worry more about indicated more concern about the September 11 attacks.
stuff that they can’t protect you against, like car bombs, A House worker stated, “It seems easier to accept anthrax or chemical attacks.” “I’ve always personally been much more concerned about [terrorism] committed against this North, Pollio, Pfefferbaum, Megivern, Vythilingam, Westerhaus, Martin, and Hong
building by more conventional means than anthrax. . . .
back positive” convinced the worker to take the incident It’s much easier for your common garden-variety lunatic seriously. Many workers did not appreciate at the time that to blow up a pickup truck, a panel truck outside of our the nasal swab test result was not an indicator of infec- building . . . or a car bomb, or someone just runs in with tion for any individual, but rather an epidemiologic tool a bomb.” “Maybe the difference between September 11 for defining boundaries of anthrax contamination levels.
and the anthrax is we weren’t expecting September 11. . . .
“When our office . . . tested negative, I think that’s when After the anthrax came, we knew something else was go- all of us kind of breathed somewhat of a collective sigh of ing to happen so you’re kind of expecting it. September Uncertainty about exposure complicated efforts to establish personal temporal and spatial boundaries to thedanger. “OK, I am not as safe as I thought; I am kind of Perceptions of Exposure
back and forth on it, I am safe, I’m not safe.” Participantsdescribed difficulty interpreting and attributing physical The perceptions of exposure category describes peo- sensations, as the worst imaginable scenarios played out in ple’s ability to perceive and accept the dangers of the life-and-death struggles against disease, blending fear and anthrax attacks they experienced. Participants’ emotional fact. “If you have the sniffles, that’s a cold, but if you don’t, responses varied across the evolving time frame of events that’s possibly . . . anthrax. . . . ‘Is this normal? How do described. Initially, the reality of the anthrax letter was I feel?”’ “Oh my God, I am going to die of anthrax and hard to accept, and denial was prominent. “I think I was it’s horrible.” Common physical sensations and bodily feeling complete denial that something like that was going changes were misconstrued as anthrax infection: “I was to happen to us. That was my first instinct. I went through allergic to the holder for my badge and I got a rash. . . .
the ‘No, this isn’t real, it’s not going to be real, it’s going I [thought], ‘A rash! Maybe I was exposed to anthrax.’ I to be fine, we are all going to be fine,’ and . . . deep down had already gone through a whole rationalization: There I knew this was bad.” Incidents of false alarms, threats, or hoaxes occur regularly on Capitol Hill. Comments sug-gested they may have had various effects, sensitizing somepeople to danger yet reinforcing complacency among oth- Disruption
ers. One worker stated that over 8 years of employment onCapitol Hill, “I’ve opened a lot of letters and talked to a lot Disruptions to usual work activities during weeks to of people who were really mean, but after a while, you stop months of displacement from Senate Hart Building offices taking them seriously because you get threat after threat were described as a major source of personal hardship and after nasty letter and nothing ever happens. . . . Probably emotional burden. “For a week and a half, except for the we took it all way less seriously than we should have.” essentials, we were completely, completely interrupted.” Another participant identified the September 11 terrorist The uncertainty of how long the work shutdown would attacks as helping him realize the anthrax incident was continue further increased the distress: “It was a day-to- day status. You couldn’t make plans . . . but because you Participants in the focus groups indicated that the were waiting each day with expectations that it might open gravity of the anthrax exposure sank in only gradually.
the next day, it was a constant mind tease.” “It wasn’t until maybe the next day that everything was Resuming business, entire offices were forced to quarantined and they told us, ‘You have to come . . . and conduct their work in other locations, doubling up with get a nasal swab.’ That’s when we [realized] . . . ‘Oh, other offices, sometimes with rivals. “We started shar- my gosh, wow, we actually have to get tested for this.’ ing offices . . . took over the conference table in the other You know, that’s huge.” Early concerns over the poten- room. . . . People had to be creative with coming up with tial danger evolved with continuous unfolding of new ways to continue to get work done, so you had to get along events. “I started to get a little bit more concerned. We with the people you were with.” “Trying to move major got nose swabs, and then on Wednesday the news came pieces of legislation” proceeded without U.S. mail service, out . . . Daschle and Feingold staffers had tested positive; without access to any paperwork including filed docu- it was the [close proximity of the] Feingold staffers that ments and address files, and often without personal com- panicked me.” Another worker said, “I had to be told three puters, telephones, or email. “We’ve gotten no mail . . . no times that my [nasal swab] test [for anthrax] came back FedEx deliveries, no courier deliveries, no UPS deliveries positive.” It wasn’t until 2 days later that a 7:00 A.M. tele- still to this day. . . . It brought the place to its knees and phone call with the news “Your name was one that came it’s still having an impact now.” “I wasn’t jealous [that Bioterrorism Focus Groups
I didn’t have a work space]; I was mad. I was watching exposure to danger working on Capitol Hill and living in everybody work like we had never left the building; I was Washington, weighing the satisfaction of their job against mad. I’m like, how can you people pretend that nothing the risk. “At what point [do] you draw the line and say, ever happened?” Workplace disruption displaced the an- ‘I’m going to quit my job because I don’t feel safe?”’ thrax as a major source of distress: “Now it’s really not Workers could not always agree on the level of danger.
the anthrax anymore; it’s not the bombing anymore; it’s Upon being told by a coworker, “Oh, stop stressing out. . . .
none of that; it’s that I am not in my office.” You’re just obsessing about this,” one staff worker replied, Perceptions of the effects of the anthrax incident on “I am not obsessing; this is dangerous!” workplace stress appeared to differ by exposure. Com-ments from the House side of Capitol Hill suggested thatclosure of the buildings was taken more in stride. “To be Medical Procedures
brutally honest, anthrax then came almost as a relief. . . .
I almost needed time to just get away from everything.” Before antibiotics and vaccinations were adminis- tered, nasal swab testing was conducted widely. Somedescribed the nasal swab procedure for anthrax testing— Safety Issues
typically a relatively innocuous process—as unpleasantand uncomfortable: “They hit two nerves on each side of Safety was a prime personal consideration after the your nose . . . I was actually sick that night. I felt like I appearance of the anthrax letter. Safety concerns extended had a bad cold, fever.” “It was just awful. I would never do not just to the anthrax itself, but also to health effects of the it again, because I was miserable for the entire evening. It remedies used to control the anthrax, including chemicals felt like my head was just drained and my eyes were wa- for its cleanup and irradiation of mail handled by the tered. . . . I just kept thinking about the test and how much it battered me.” One individual described “an incrediblylong swab inserted all the way up the nasal passages that They never applied [these chemicals] within an office en- brings tears to the eyes—I had no idea my nasal passages vironment, they never used it on anthrax before, and I am went back so far.” The implements were called “brain much more concerned about the cure than I am about the disease in this instance. What impact is that going to have Completing the medical protocols on hundreds of on a building that has no open ventilation, and everythingis recirculated; and what impact is that going to have on people in a short time created occasional awkward mo- breathing in these fumes constantly from a carpet that’s ments. The workers recalled receiving their antibiotic pre- completely been treated with chlorine dioxide, walls, fur- scriptions in groups. Assembled together, they were asked what medications they were taking, to prevent potentialantibiotic drug interactions. Workers learned surprising The period of concern did not end with the current personal information about colleagues who disclosed use period. “You just wonder . . . 30 years from now am I of certain medications such as birth control pills, antiretro- going to get cancer because I was exposed to irradiated viral agents, chemotherapy, Viagra, or psychotropics.
Despite known dangers including death caused by The irradiation of mail affected the paper in ways infection with anthrax, adherence to a 2- or 3-month reg- imen of twice-a-day antibiotic administration was not assimple as imagined. When a physician admonished one Now the mail is . . . sent to Ohio. Then they bring it back of the workers that she would need to take the medication here and it’s sorted again and brought to us and it smells faithfully even though it would be easy to forget doses, funny. . . . It’s all stuck together. . . . That almost freaked she thought, “Forget! Are you kidding me? How would me out more than the actual anthrax. . . . This stuff is I forget?” But she did forget: “The first couple of days grotesque; I don’t want to touch it. . . . Sometimes it’s still you have to take it on time. I took it 15 minutes late— sticky and I am still opening it and the letter is wet. . . . It oh, no! And after a while, [it was] like, ‘Yeah whatever, sticks together like a stamp you can’t open up.
it kind of makes me sick; oh, I don’t think I’ll take it.”’Succinctly stated by another: “These are not fun antibi- Confronting uncertain risks, people resorted to mea- otics.” Workers described media reports they thought they sures such as cleaning their computer keyboards with al- had heard warning people not to take antibiotics for more cohol swabs and donning gloves and masks to handle than 3 days lest they “become immune” to them (clearly irradiated mail. They pondered the wisdom of continued incorrect information and advice). A worker who heard North, Pollio, Pfefferbaum, Megivern, Vythilingam, Westerhaus, Martin, and Hong
one of these reports admitted, “I took it for I don’t even couldn’t focus.” Arousal and intrusive recollection were think 3 days, to be honest with you.” Another said, “I directly observed by the focus group facilitators in one of don’t even think I took it for 3 days; I think I took it for the study’s groups, when the discussion was diverted to attend to some noises outside the window. The group de-scribed it as a “whooshing sound” and pondered whether I haven’t been taking it as regularly as I should, and in my it was an airplane. This discussion prompted one partici- head that’s OK, because I’ll save some for when we finally pant to mention sounds of sirens along with airplanes as go back to the Hart [Building]. . . . I know how antibiotics work; that’s bad . . . I don’t take it because I’m sick of Avoidance and denial received more extensive de- taking it and I don’t remind myself to take it as often. I’ve scriptions. “For the 3 first days of the anthrax thing I been tired of it. And I hate taking it. But then, when I forget stopped reading the newspaper, I just zoned out, I was to take it, I don’t beat myself up about it as much as I did in denial.” “I didn’t want anything to do with politics, the first 60 days because I am really OK now, but I am just or . . . anything to do with Washington. I just wanted to forget about it for a while.” Their denial extended to be-haviors involving decisions to cooperate with the medical The public seemed to have a fascination with response. “I didn’t know if I had [anthrax]; I didn’t want ciprofloxacin. One participant observed: “Cipro became to get tested ’cause I was believing that I didn’t have [it].” the status drug of D.C. . . . It replaced Ecstasy. . . . If Avoidance even extended beyond the workplace to other you were taking Cipro . . . it meant you must have been parts of people’s lives. “I stay at home a lot more now.
some place really cool.” People they met were drawn to I used to be the kind of person who would fill up every their experience. “People would ask me, ‘Oh, you are taking Cipro?’ and it was like a novelty or you are a Early psychological interventions to help workers celebrity. They were definitely excited. . . . ‘Can I see the cope with their feelings about the anthrax incident in the Cipro?’ . . . It was the hit drug of November 2001.” workplace received mixed reviews. Some comments werequite critical. “The Employment Assistance Office set up Emotional Responses
group therapy sessions . . . most of these people have beento a couple of those. I didn’t think of those as very pro- Initial emotional responses reflected various forms ductive at all.” “The way [this] psychologist approached of disbelief. The anthrax incident felt “like a mind game,” it, it was, ‘So, tell us about your feelings’ or . . . ‘That’s a hoax or a joke or part of a scenario being enacted for normal,’ every time we said [anything] . . . ‘That’s nor- a disaster training drill. “I remember thinking, it can’t be mal.’ Don’t just tell me that what I’m feeling is OK. Tell happening. My first reaction was complete denial, like me why I’m feeling what I’m feeling.” Others were more they are overreacting or somebody is screwing around positive. “We went to a really good one that talked about coping skills.” Some felt their own emotional support of As disbelief gave way to the reality of exposure to one another was more helpful. “We all talked [to each anthrax, immediate emotional reactions included an array other] about what we are doing to get by, but in a lot of of feelings, from fear (“terrified,” “nervous,” “fearful,” ways we were getting therapy from each other. . . . So, “it was disturbing,” “freaking out”) to anger (“angry,” yeah, there’s psychologists out there who are experts on trauma, but we are experts on this trauma.” Symptoms
Social Support
Symptoms received surprisingly little mention rela- Workers reported receiving extensive emotional and tive to the amount of other material covered in the groups.
social support from one another in the wake of the an- One worker described new onset of upper gastrointestinal thrax exposure. Participants explained that offices well symptoms and exacerbation of previous problems with known for their cohesiveness even before the event found headaches after the anthrax incident. After a thorough their support systems had “intensified tremendously.” Un- evaluation involving several medical tests, her doctor con- pleasant business such as standing in lines for anthrax cluded, “Well, I think it’s stress.” testing fostered opportunities for interpersonal support.
One worker described concentration difficulties: “Waiting to be tested . . . [I] made friends with everyone “There were days when people just couldn’t work. They else around. . . . I could go to any of those offices [of Bioterrorism Focus Groups
people] we were in [line] with and say, ‘You remember with the fact [that] I don’t want to talk about it anymore.” me. . . . ”’ They considered their support of one another as The apparent prevalence of this situation is reflected in one therapeutic: “I needed to be back out here with people who worker’s summary of it: “Almost everybody had some- had gone through it, so we had our own support group.” body in their family who was making them miserable.” You would think we would want to run as far away In social situations, workers encountered celebrity from each other as you can get, but . . . everybody under- status as anthrax victims, such as the worker who was in- stood. . . . If you needed somebody to talk to, there was troduced as “the anthrax bridesmaid” at a wedding. “They somebody there and if you needed to not talk there was introduced me at the rehearsal dinner as ‘My friend [—]; somebody who would help you find something else to talk she has anthrax’ . . . like it’s part of your identity now.” This was not the kind of celebrity status one might wel- Within the Capitol Hill community, however, not ev- come: “Yeah, I wanted to be famous, but not this way. Not eryone was a source of social support. The participants ex- plained, “You have to figure out who among your friendsyou can share information with,” to guard against personalinformation’s leaking to the media.
Although “sometimes it was just too much and I needed to talk to someone else,” participants indicated Context of the Findings
that social support was not as readily found outside work.
They felt their friends and family “just don’t understand These focus groups provided a glimpse into Capitol and they don’t care and I can’t relate to them.” “I needed Hill workers’ experience of the October 15, 2001, an- to be around people that had gone through it. . . . My thrax exposures. Emerging topics of medical response, friends . . . don’t really talk about it.” One worker said personal safety issues, and social context are consistent her sibling would not allow her to talk about anthrax with the earlier literature’s suggestions of the importance “because I am unpleasant conversation.” Another said, of risk communication and social support in bioterrorism “My boyfriend didn’t deal with this well so we are no and with findings from relevant nonbioterrorism research longer dating.” Families did not provide the social sup- (Lamar & Malakooti, 2003; Norris & Kaniasty, 1996; port people usually expect of them: “I feel like I can’t dis- Patel & Zed, 2002). Concerns emphasized by exposed close challenges at work as much with family and close postal workers (Blanchard et al., 2004) and infected vic- friends because . . . there’s no reason to concern others tims of the anthrax attacks (Reissman et al., 2004) in other when . . . they can’t do much about it.” studies—equality of medical care, persistent medically Families’ needs for reassurance from the workers unexplained health problems, psychological symptoms, created more social liability than support from family and life adjustment problems—were not prominent in the members. One worker “had 14 messages from [my hus- Capitol Hill focus groups. The relative underemphasis band] trying to find me to figure out if I was OK.” of psychological symptoms and medically unexplainedsymptoms in the Capitol Hill study matches findings ofpublished studies of dioxin contamination (Robins et al., I had hysterical messages from my mother. . . . My dad called; my boyfriend called; my friends called;and they couldn’t find me and they were watching the The amount of legislation successfully enacted dur- news. And then Tuesday morning, I am in the meet- ing the postanthrax period on Capitol Hill is an indicator ing . . . and it breaks on CNN that 23 people . . . tested of thwarted terrorist effect (Congressional Management [positive] . . . and my mother called, and my father called Foundation, 2001). Despite the disruption, workers said and my boyfriend called and like, I used 1700 minutes on they pulled together and refused to allow derailment of my cell phone. . . . The media was very difficult for me.
their work, a testament to the resilience of this popula-tion. The 9/11 attacks a month earlier may have had both One worker’s mother had asked, “Are you sure you sensitizing and habituating effects in people’s response to want to risk your life for this job? . . . Maybe you should trauma and in the context of other stressors in individuals’ just leave there and go do something else.” Another mother made the worker promise never to go into the Hart Build-ing again. Workers found themselves reassuring their fam- Safety and Medical Concerns
ily rather than the reverse: “[I was] trying to weigh outinformation [that would be] easier for them to hear, what’s A concern identified by the focus groups was the going to make them feel better, and trying to weigh that unresolved issue of possible continuing danger in the North, Pollio, Pfefferbaum, Megivern, Vythilingam, Westerhaus, Martin, and Hong
perceptions of the workers. Although risk of anthrax expo- may differ), and psychological distress in this model are sure passed within days for most, and within 4 months for interrelated and may in turn be confounded with extra- the highest-exposure groups, longer-term worries lingered neous variables such as preexisting individual character- about potentially harmful effects of the irradiation of istics. Consistent with this model, combined effects of mail and chemicals used to clean up the contamination— anthrax exposure, the stigma of victimization, and na- consequences of the interventions, not the infectious ex- tional media attention may have conspired to weaken the primary support system of family and close friends out- Admission of nonadherence to antianthrax antibiotic side work. The Capitol Hill workers’ usual social supports prophylaxis in this setting is of immediate concern for ironically sometimes added to, rather than reducing, their response to future bioterrorist incidents and epidemics.
distress (or were perceived to do so). The support they Despite these intelligent and well-informed individuals’ could not find elsewhere they provided to one another, in- appreciation of the importance of medication, their ac- voking Lindy and Grace’s (1985) concept of the “trauma tions seemed inconsistent with their knowledge. Incon- membrane,” which isolates survivors in a self-contained sistent recommendations by authorities and conflicting unit of social support. The social support of exposed in- messages in the media in the weeks that followed the ex- dividuals for one another identified in these discussions posures, combined with the passage of time when no one should not be overlooked as a valuable source of strength on Capitol Hill became ill, may have contributed to com- to complement formal mental health interventions.
placency in the workers and perceptions that medical au-thorities’ application of antibiotics was overly broad andexcessively cautious. In circumstances of extended (60- Study Limitations and Future Directions
to 90-day) antibiotic prophylaxis for potentially exposedgroups, medication adherence may have less in common This study was limited by the small sample size and with familiar 7- to 14-day antibiotic courses for acute in- volunteer nature of its selection of participants, who rep- fections in the community that produce dramatic relief resented only a small portion of the workers on Capitol than with chronic medication maintenance among people Hill. The participants may not be fully representative of who do not feel ill without medication. In the long-term Capitol Hill workers; their experience may not generalize treatment of hypertension, for example, antihypertensive to other groups; and the findings here cannot necessarily medication side effects function as a potent disincentive, be considered to be representative of the general thoughts contributing to nonadherence (Menzin et al., 2004). Fur- and emotions of workers on Capitol Hill or other popula- ther investigation into treatment adherence and risk com- tions such as the Brentwood postal workers. This sample munication in the context of bioterrorism is crucial.
was young, highly educated, high-functioning, well in- In focus group comments, early psychological inter- formed, and resourceful. Volunteering to participate in ventions did not receive particularly high approval ratings.
the study in itself may reflect willingness or eagerness to Whereas some people felt that techniques such as relax- discuss personal reactions, characteristics that might not ation were helpful, others wanted them better tailored to be shared by nonparticipants, some of whom might be their needs. Even though their feelings were identified more symptomatic and avoidant than the participants, or, as “normal” for people in the context of extreme stress, alternatively, less concerned about or upset by the experi- these feelings were not normal in their usual experience, and therefore simple reassurance about the normality of The findings may be limited by participants’ con- cerns about confidentiality, despite measures taken to re-assure them that their privacy would be protected. Withone exception, the groups were conducted in closed rooms Social Support
within governmental offices (one group was conducted ina private room in a nearby hotel). Four of the five groups Facilitation of postdisaster recovery involves restor- were composed of members from a single office; the fifth ing effective social roles and returning people to their group comprised individuals from different offices. Al- usual sources of social support (Norwood et al., 2001).
though members may have been reluctant to discuss per- However, social support is a multifaceted phenomenon in- sonal topics in the presence of professional colleagues, volving complex systems, as Norris and Kaniasty (1996) who may have included supervisors, they may also have noted in their social support deterioration model devel- been more comfortable in the presence of their colleagues, oped by using longitudinal data on hurricane victims.
from whom they had received social support in the wake Disaster exposure, received and perceived support (which of the anthrax incident. Individual anecdotal comments Bioterrorism Focus Groups
by members indicated that both processes may have been References
Most comments from the focus groups about the Alexander, R.W., & Fedoruk, M.J. (1986). Epidemic psychogenic ill- management of the anthrax incident were negative. This ness in a telephone operators’ building. Journal of OccupationalMedicine, 28, 42–45.
response should not be taken to indicate general negativ- Amin, Y., Hamdi, E., & Eapen, V. (1997). Mass hysteria in an Arab ity in the overall perceptions of staff workers. Because the culture. International Journal of Social Psychiatry, 43, 303–306.
focus group study was not designed to generate represen- Bartholomew, R.E., & Wessely, S. (2002). Protean nature of mass so- ciogenic illness: From possessed nuns to chemical and biological tative data on opinions about medical and safety issues terrorism fears. British Journal of Psychiatry, 180, 300–306.
but rather to learn about issues the workers faced, the Blanchard, J., Haywood, Y. Stein, B., Tanielian, T., Stoto, M., & Lurie, N.
concerns elicited reflected generally negative content, in (in press). In their own words: Lessons learned from those exposedto anthrax. American Journal of Public Health.
part as a result of instructions to the focus groups to dis- Castle, S. (2003). Doubting the existence of AIDS: A barrier to volun- cuss their specific “issues and concerns” about the anthrax tary HIV testing and counseling in urban Mali. Health Policy and Congressional Management Foundation. (2001). Congress Online Further studies seeking more representative samples Project: How is anthrax changing Congress and how are offices and providing more systematic data with greater depth using technology to cope? Retrieved November 1, 2001 from are needed to confirm, refocus, and expand the findings Covello, C.T., Peters, R.G., Wojteki, J.G., & Hyde, R.C. (2001). Risk of the current study. Primary considerations of additional communication, the West Nile virus, and bioterrorism: Responding study should include assessment of more diverse sam- to the challenges posed by the intentional or unintentional release ples; examination of psychiatric diagnosis; consideration of a pathogen in an urban setting. Journal of Urban Health, 87,382–391.
of longer-term, slowly emerging effects of bioterrorist Fleiss, J. (1981). Statistics for rates of proportions (2nd ed.). New York: incidents; investigation of determinants of treatment ad- herence; and exploration of social support mechanisms.
Freedman, G.M., Norfleet, A.L., Feldman, H.I., & Apter, A.J. (2003).
Qualitative research-enhanced understanding of patients’ beliefs:Results of focus groups with low-income, urban, African Americanadults with asthma. Journal of Allergy and Clinical Immunology, Gallagher, T.H., Waterman, A.D., Ebers, A.G., Fraser, V.J., & Levinson, W. (2003). Patients’ and physicians’ attitudes regarding the disclo- These focus groups who described Capitol Hill staff sure of medical errors. Journal of the American Medical Associa- workers’ experience of the anthrax incident on October 15, 2001, indicated several concerns, including medical Holloway, H.C., Norwood, A.E., Fullerton, C.S., Engel, C.C., Jr., & Ursano, R.J. (1997). The threat of biological weapons: Prophylaxis and personal safety issues and social context. Psycho- and mitigation of psychological and social consequences. Journal logical and medically unexplained symptoms were not of the American Medical Association, 278, 425–427.
emphasized. Nonadherence to antianthrax antibiotic pro- Hsu, V.P., Handzel, T., Hayslett, J., Harper, S., Hales, T., Semenova, V.A., et al. (2002). Opening a Bacillus anthracis–containing enve- phylaxis is of immediate concern for bioterrorism and lope, Capitol Hill, Washington, DC: The public health response.
Emerging Infectious Diseases, 8, 1039–1043.
Kawana, N., Ishimatsu, S., & Kanda, K. (2001). Psycho-physiological effects of the terrorist sarin attack on the Tokyo subway system.
Military Medicine, 166 (Suppl. 12), 23–26.
Lamar, J.E., & Malakooti, M.A. (2003). Tuberculosis outbreak inves- tigation of a U.S. Navy amphibious ship crew and the Marineexpeditionary unit aboard, 1998. Military Medicine, 168, 523– This research was supported by National Institute of Mental Health Grant MH40025 to Dr. North and by Award Lindy, J.D., & Grace, M. (1985). The recovery environment: Continuing MIPT106-113-2000-020 of the Oklahoma City National stressor versus a healing psychosocial space. In B.J. Sowder (Ed.),Disasters and mental health: Selected contemporary perspectives Memorial Institute for the Prevention of Terrorism (MIPT) (pp. 137–149). Rockville, MD: National Institute of Mental Health and the Office for Domestic Preparedness, U.S. Depart- Center for Mental Health Studies of Emergencies.
ment of Homeland Security, to Dr. Pfefferbaum. Points Menzin, J., Lang, K., Elliott, W.J., Boulanger, L., Arocho, R., Tran, M.H., et al. (2004). Adherence to calcium channel blocker therapy of view in this document are those of the authors and do in older adults: A comparison of amlodipine and felodipine. Journal not necessarily represent the official position of NIMH, of International Medical Research, 32, 233–239.
MIPT, or the U.S. Department of Homeland Security.
Norris, F.H., & Kaniasty, K. (1996). Received and perceived social support in times of stress: A test of the social support deterioration The authors gratefully acknowledge the assistance of Pam deterrence model. Journal of Personality and Social Psychology, Lokken; Laura Petrou; Rear Admiral John F. Eisold, The Attending Physician to Congress, United States Capitol; North, C.S., Pollio, D.E., Pfefferbaum, B., Megivern, D., Vythilingam, M., Westerhaus, E.T., et al. (in press). Concerns of Capitol Hill staff the participants in this study and Capitol Hill offices in- workers after bioterrorism: Focus group discussions of authorities’ response. Journal of Nervous and Mental Disease.
North, Pollio, Pfefferbaum, Megivern, Vythilingam, Westerhaus, Martin, and Hong
Norwood, A.E., Holloway, H.C., & Ursano, R.J. (2001). Psychological Robins, L.N., Fishbach, R.L., Smith, E.M., Cottler, L.B., Solomon, S.D., effects of biological warfare. Military Medicine, 166, 27–28.
& Goldring, E. (1986). Impact of disaster on previously assessed Pastel, R.H. (2001). Collective behaviors: Mass panic and outbreaks of mental health. In J.H. Shore (Ed.), Disaster stress studies: New multiple unexplained symptoms. Military Medicine, 166, 44–46.
methods and findings (pp. 22–48). Washington, DC: American Psy- Patel, P., & Zed, P.J. (2002). Drug-related visits to the emergency de- partment: How big is the problem? Pharmacotherapy, 22, 915–923.
Schoch-Spana, M. (2000). Implications of pandemic influenza for bioter- Reissman, D.B., Whitney, E.A., Taylor, T.H., Jr., Hayslett, J.A., rorism response. Clinical Infectious Diseases, 31, 1409–1413.
Dull, P.M., Arias, I., et al. (2004). One-year health as- Smith, E.M., Robins, L.N., Przybeck, T.R., Goldring, E., & Solomon, sessment of adult survivors of Bacillus anthracis infection.
S.D. (1986). Psychosocial consequences of a disaster. In J.H. Shore Journal of the American Medical Association, 291, 1994– (Ed.), Disaster stress studies: New methods and findings (pp. 49– 76). Washington, DC: American Psychiatric Association.


Material safety data sheet

MATERIAL SAFETY DATA SHEET COMPUDOSE 100, 200 AND 400 Revision No: 4.0, 20 March 2012 STATEMENT OF HAZARDOUS NATURE: The intact Compudose implant is not considered hazardous under normal handling procedures. The following Statement of Hazardous Nature refers to the contents of the implant which contain oestradiol: Hazardous according to the criteria of Worksafe Australia: Toxi

Berkshire local medical committee

Chairman Treasurer Secretary Dr John Rawlinson Dr Gurdip Hear Dr Paul Roblin Radnor House Surgery Crosby House Surgery Secretariat of Berks, Bucks & Oxon MCs 25 London Road 91 Stoke Poges Lane Mere House Dedmere Road Bucks SL7 1PB Tel: 01344 874011 Tel: 01753 520680 Tel: 01628 475727 Fax: 01344 628868 Fax: 01753 552780 Fax:

Copyright © 2011-2018 Health Abstracts