This is a series of presentations I gave in the Eastern Mediterranean Public Health Network (EMPHNET)'s Public Health Ethics (PHE) that was held in Amman in June 2014. This presentation outlines the ethical issues related to surveillance, screening, and outbreak investigation.

1. Ethical issues in surveillance, screening and
outbreak investigation
EMPHNET
Ghaiath M. A. Hussein
MBBS, MHSc. (Bioethics), PhD Researcher
Email: ghaiathme@gmail.com
Regency Palace, Amman, Jordan
15-19 June, 2014

2. 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

3. 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?

4. 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

5. 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

6. 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)

7. 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

8. Sources of Ethical Issues
• Privacy
• Confidentiality
• Autonomy (consent)
Data/sample
collection
• Benefits
• Harms
• Autonomy (consent)
Methods
used
• Justice
• Trust Outcomes

9. 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?

10. Case for Discussion

11. 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.

12. ETHICAL ISSUES IN HEALTH PROMOTION

13. 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

14. 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?

15. 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

16. Definition and scope of health
promotion
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
Ottawa Charter for Health Promotion, 1986
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.

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

18. Examples of health promotion
interventions
•

19. Ethical Issues in health
Promotion
• Informed choices and respect for autonomy
• Responsibility/empowerment
• Altruism
• Reciprocity
• Justice
What are your thoughts?

20. 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

21. ETHICAL ISSUES IN VACCINATION

22. 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
22

23. 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

24. 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)

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

26. 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)

27. 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

28. Harms & Benefits
Individual
protection
Herd immunity
Reduced morbidity
& mortality
Side effects (local)
Long term?
Vulnerability
Compulsion (lack of
freedom?)

29. 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?

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

31. 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
the interference done on
persons to act (or inact) in
behalf of individuals who
a certain way without
are not able to take their
their consent to achieve
decisions properly,
the public good
Examples?

32. 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

33. 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