2021 Environmental Health

Question 1

List the environmental health roles for the different jurisdiction (public health unit, muicipal government, provincial and Territorial Government, Federal Government and International )

Answer 1

Public Health Unit

• Enforcement of water and food safety regulations (including restaurant food safety)
• Assessment of local environmental risks
• Monitoring and follow-up of reportable diseases
• Investigation of environmental contamination, clusters of disease

Municipal Government

• Waste disposal, recycling, water and sewage treatment/collection/distribution

Provincial and Territorial Government

• Water and air quality standards
• Industrial emission regulation
• Toxic waste disposal

Federal Government

• Designating and regulating toxic substances
• Regulating food products (e.g. Health Canada (drugs), CFIA)
• Setting policy for pollutants that can travel across provincial boundaries

International

Multilateral agreements (e.g. Kyoto Protocol, UN Convention on Climate Change, International Joint Commission)

Question 2

Name three ways to categorize in Toxicants with an example of each?

Answer 2

1. chemical class (e.g., alcohols, heavy metals) 2. source of exposure (e.g., industrial waste, air pollution, food additives) 3. affected organ system (e.g., carcinogen, mutagen)

Question 3

What do you understand by a Stochastic/random model in a dose-response curve? Give an example?

Answer 3

A Stochastic/random model refers to a Dose vs. risk of outcome; assumes no safe threshold; increased dose increases risk of health outcome of interest (not higher dose therefore bigger tumour) *Non-threshold relationship Generally applies to binary responses EG Cancer - presence of a tumour: yes/no

Question 4

What do you understand by a Non-stochastic/deterministic model in a dose-response curve? Give an example?

Answer 4

A Non-stochastic/deterministic model refers to a Dose vs. severity of outcome; assumes a threshold; increased dose increases severity of outcome of interest (higher dose results in bigger tumour) *Threshold relationship Generally graded responses EG Sunburn severity

Question 5

Describe what dose response you see and give an example of what could have this effect?

Answer 5

Hormesis: substance that is beneficial at one concentration but harmful at another concentration

Eg. Fluoride in water (low dose = beneficial for teeth; high dose = skeletal fluorosis = bad)

Question 6

As the MOH, you learn from your emergency response team that there has been a leak of chlorine gas at the local pool.

What are the human health effects from chlorine exposure?

Answer 6

Acute Effects:
- Irritant – eyes, throat, nose, lungs - cough (less than 1 ppm)
- NOTE – odor threshold is 0.31ppm
- Eye and resp irritation, cough, SOB, headache >1ppm
- SOBb, cough, chest pain, vomiting (30 ppm),
- Toxic pneumonitis, pulmonary edema at high levels (46-60ppm)
- can cause severe burns in humans
· Acute animal tests in rats and mice have shown chlorine to have high acute toxicity via inhalation.
Chronic Effects (Noncancer):
· Eye and throat irritation, and airflow obstruction
· Animal studies: decreased body weight gain, eye and nose irritation, and non-neoplastic lesions and respiratory epithelial hyperplasia from inhalational exposure
· The Reference Dose (RfD) for chlorine is 0.1 milligrams per kilogram body weight per day (mg/kg/d)
Cancer Risk:
· No information is available on the carcinogenic effects of chlorine in humans from inhalation exposure.
· Association between bladder and rectal cancer and chlorination byproducts in drinking water.

Question 7

Describe the 5 steps in a risk management?

Answer 7

Steps in risk management

1. Define the problem and put it in context: Use the risk assessment to define the problem; determine the risk management goals, identify the risk managers with the responsibility and authority to act, and develop a process for engaging stakeholders
2. Analyze the risks associated with the problem in context: Consider the nature, probability, and severity of adverse effects on human health or the environment
3. Examine options for addressing the risks: Identify and evaluate options for reducing or eliminating risk; assess feasibility, costs, and benefits, as well as legal, social, and cultural impacts
4. Make decisions about which options to implement: Base the decision on the best available scientific, economic, and other technical information, consider uncertainty and acceptability of risk (social construct)
5. Take actions to implement the decisions (see also: Risk communication) , Conduct an evaluation of the actions

Question 8

List three disinfection by-products found in drinking water and one health effect associated with each one.

Answer 8

Trihalomethanes - increased risk of cancer; liver, kidney, or CNS problems (formed with chlorine/chloramine and organic/inorganic matter)

• Haloacetic acid - increased risk of cancer (formed with chlorine/chloramine and organic/inorganic matter)
• Bromate - increased risk of cancer (formed with bromide and ozone)
• Chlorite - CNS effects, anemia (formed when chlorine dioxide breaks down)

Question 9

What two biological systems are primarily affected by lead exposure?

Answer 9

• Blood cells (hematic system) - anemia
• Nervous system - encephalopathy, neuropsychological deficits, especially in children

Question 10

Name four common air pollutants in the urban environment?

Answer 10

● Ozone
● Particulate Matter
● Carbon Monoxide
● Nitrogen Oxides
● Sulfur Dioxide
● Lead

Question 11

How would you reduce the risk of high radon gas concentrations in a home?

Answer 11

● Increase the ventilation to allow an exchange of air.

● Seal all cracks and openings in foundation walls and floors, and around pipes and drains.

● Renovate existing basement floors, particularly earth floors.

● Active soil depressurization (usually done by a contractor): preventing radon gas from beneath the home to enter into the interior of the home using a PVC tube and an exhaust fan venting it out to the outdoor air above the home where it quickly dilutes into the atmosphere.

Question 12

You have been advised that there has been a municipal water breakage and that raw sewage and river surface water may have contaminated the water supply. This occurred 30
minutes ago. The operator says that the chlorine residual did not drop during this timeperiod. Despite this,
a. What two binfectious agents are you still concerned about?
b. What three actions will you take in the next 4 hours to address this issue?

Answer 12

a.Two infectious agents:
• total coliform
• E. coli
b. Three actions:
• Increase disinfectants
• Flush mains
• Consider issuing BWA/DWA

Question 13

A chemical contaminant was added into bread at a bakery.

List four steps that you would take to reduce the public risk

Answer 13

A.

1. Stop the consumption of the bread immediately

Contact schools, community centers and hospitals

• disposal of those still around
• information on product contamination
• if possible, track who may have consumed them

2. Risk assessment (consulting with experts - toxicologist - as needed and using environmental PH to assist)

• What was in the chemical? (hazard identification)?
• What are the human health effects – dose response assessment have there been any noted health effects? (vomiting, diarrhoea etc)
• How much would people be exposed to in one slice of bread? (exposure route being oral)

Also consider exposure to cooks in bakery (dermal and inhalation too)

• Characterize the risk

3. Risk management

• Once recall done, advise schools, community centres and hospitals to inititate active

surveillance/case finding based on known consumption or expected signs and symptoms

• Identify those who might be most vulnerable to adverse outcomes
• Offer any interventions to mediate risk
• Offer appropriate treatment to reduce risk, if possible
• Reassure if no expected adverse health outcomes
• Education at bakery – consider revoking food license

○ Proper labelling of products

○ Separation of cleaning products from kitchen area

4. Communication

• To all stakeholders (internal and external)
• To public – what happened, what we are doing, what individuals who think they consumed the bread should do (ie watch for these symptoms and seek medical care if these things occur)

Question 14

Recent investigations at the site of a major railway and crude oil explosive disaster have revealed soil and water contamination with hydrocarbons from the fuel spill. There are residential neighborhoods located 500m from the site of the spill, and residents of that neighborhood are concerned that they may have been exposed or may be exposed in the
future to these hydrocarbons. What investigations would you do to find out whether the neighbors are at risk?

Answer 14

Hazard identification is the point of entry. Use the existing epidemiological, toxicological, and experimental evidence.
Looking at any database of toxicological or chemical exposures, we will see that total petroleum
hydrocarbons do have health effects, especially with respect to CNS effects, peripheral neuropathies, hematological cancers, and immunological disorders.
Dose-Response is the next step because (a) it is an important BH criterion for enviro health and
(b) the shape of the dose-response curve will contribute to understanding risk in context.
Variable dose-response effect for different hydrocarbons.
Exposure assessment is population specific, and refers to magnitude, duration, timing and route.
Context specific. May involve biomarker or human samples, and/or environmental sampling.
Risk characterization unites the first three components and includes the context-specific risk,
type of risk, and severity. Should include declarations of uncertainty, limitations and
assumptions. (Context specific)

Question 15

What are the immediate control measures for confirmed cases of Escherichia Coli O157:H7 infection?

Answer 15

• Education: All cases should be instructed about disease transmission, appropriate personal hygiene, routine practices, and contact precautions.
• Exclusion: All symptomatic and asymptomatic persons who are:

o Food handlers

o Healthcare, daycare or other staff who have contact through serving food with highly susceptible patients or persons in whom an intestinal infection would have

particularly serious consequences

o Those involved in patient care or care of young children, elderly or dependent persons,

o Children attending daycares or similar facilities who are diapered or unable to implement good standards of personal hygiene,

o Older children or adults who are unable to implement good standards of personal hygiene (e.g., mentally or physically challenged)

Exclusion applies until two stool specimens taken from the infected person not less than 24 hours apart and at least 48 hours after normal stools have resumed are reported as negative

Question 16

What do you understand by a One Health Approach?

Answer 16

Approach that addresses the health of humans, animals, and the environment simultaneously, acknowledging that the health of one impacts on the health of the others (e.g., 60% of infectious diseases in humans are zoonoses)

Question 17

Name 3 diseases associated with an electromagnetic field exposure (e.g. through living in proximity to a high voltage power line)

Answer 17

• Childhood Leukemia or ALL, acute lymphoblastic leukemia
• testicular cancer and lung cancer

Question 18

What do you understand by primary and secondary air pollutants? Give an exampe of each

Answer 18

• primary: emitted directly from a source (examples : CO, NH3 (precursor to PM) )
• secondary: forms in the atmosphere (examples03, SO2, PM)

Question 19

List some limist of the Air Quality Index (AQI)?

Answer 19

• monitoring involves average of continuous measurements q3 hours
• provides info on acute exposure doesn’t take into account long term risk/exposure
• doesn’t take temperature into account (which can affect air quality)
• doesn’t monitor indoor air (even though outdoor air can enter indoors)
• health risks based on mortality data

Question 20

What do you understand by Sick Building Syndrome?

Answer 20

Definition: Occupants of a building experience acute but non-specific health-related effects that seem to be linked directly to the time spent in the building

• Symptoms (Headache, eye, nose or throat irritation, dry cough, dry or itchy skin, dizziness and nausea, difficulty concentrating, fatigue, sensitivity to odours, rash) that improve when individual leaves the building, but no cause can be identified
• Population-related phenomenon
• Groups of people in a common environment where symptoms occur higher than baseline (ex. compared to CCHS – Canadian Community Health Survey)
• Symptoms > signs

Question 21

What do you understand by Building-related illness?

Answer 21

Definition: Occupants of a building experience acute and specific health-related effects that seem to be linked directly to the time spent in the buildingSigns and symptoms that are attributable to an identifiable, building-related cause (e.g., Legionnaire’s disease, occupational asthma, hypersensitivity pneumonitis)

Diagnosable at individual level

Question 22

Using the 6 E framework describe Risk Mitigation for Mould (Persistent dampness and microbial growth on interior surfaces and in building structures)?

Answer 22

• Engineering
  
  • Management of moisture requires proper control of temperatures and ventilation to avoid excess humidity, condensation on surfaces and excess moisture in material
  • Ventilation should be distributed effectively throughout spaces, and stagnant air zones should be avoided
  • Repair sources of moisture from outside (e.g., roof leaks) and inside (e.g., plumbing, A/C units)
  • Design of building envelope
• Enforcement
  
  • Building standards and regulations with regard to comfort and health do not sufficiently emphasize requirements for preventing and controlling excess moisture and dampness currently
  • Building owners are responsible for providing a healthy workplace or living environment free of excess moisture and mould, by ensuring proper building construction and maintenance; this may be particularly prevalent in poorly maintained housing for low-income people
  • Occupants are responsible for managing use of water, heating, ventilation in a manner that does not lead to dampness and mould growth; avoid activities that generate too much humidity (e.g., marijuana grow-ops)
• Environment
  
  • Wet soils: poor drainage system (flooding), grading, leaf piles, standing water
• Education
  
  • Control humidity
  • Proper ventilation
  • Repair all leaks and plumbing problems
  • If you have mould, scrub with a detergent, dry quickly & thoroughly, use a disposable dust mask & rubber gloves
• Empowerment
  
  • Testing: In the absence of exposure limits, tests for the presence of fungi in air cannot be used to assess health risks; 2:1 ratio may show indoor source>outdoor source; may be useful for legal purposes or to show effectiveness of remediation
• Economic

Question 23

List direct and indirect effects of Climate change?

Answer 23

• Direct effects due to changes in temperature and precipitation, occurrence of heat waves, floods, droughts and fires
• Indirect effects due to ecological disruptions (e.g., crop failures, shifting patterns of disease vectors) or social responses (e.g., displacement of populations due to prolonged drought)
• Until mid-century, climate change will act mainly by exacerbating health problems that already exist and existing diseases (e.g., vector-borne infections) may extend their range into areas that are presently unaffected
• Largest risks will apply in populations that are currently most affected by climate-related diseases (e.g., under-nutrition in areas that are already food insecure such as global South or country foods in Northern Canada)

Question 24

Lead A) List two most of the most common non-occupational sources of lead exposure for the general population in Canada B) What group in the population is most sensitive to harmful effects of lead? C) What is the most sensitive endpoint of lead toxicity in infants and children? D) What specimen is usually used for monitoring of lead in humans? E) Identify 5 mechanisms by which young children are more susceptible to the harmful effects of lead compared to adults F) List 4 organs or systems that may be affected by chronic lead exposure in humans and identify one effect on each organ system

Answer 24

A) 1. Ingestion of contaminated food 2. Ingestion of contaminated drinking water B) 1. Infants and toddlers C) Reduction of intelligence quotient D) Blood (Blood lead level) E) 1. Greater ingestion of lead due to hand-mouth activity 2. Greater ingestion to body weight ratio 3. Greater absorption in the gastrointestinal tract 4. Blood-brain barrier is still developing 5. Undergoing neurological development 6. More years of life ahead therefore greater time for delayed effects F) 1. Nervous - ataxia 2. Renal/Kidney - reduced GFR 3. Hematological - anemia (hypochromic and normo/microcytic with reticulocytosis) 4. Cardiovascular - hypertension 5. Reproductive - reduced sperm count/fertility https://www.canada.ca/en/health-canada/services/food-nutrition/food-safety/chemical-contaminants/environmental-contaminants/lead.html https://www.atsdr.cdc.gov/csem/csem.asp?csem=34&po=10#:~:text=Lead%20serves%20no%20useful%20purpose,can%20affect%20every%20organ%20system.

Question 25

Your are a new MOH for a regional health authority and have been advised by the local municipality that the municipal water system at the treatment plant has returned a positive result for total coliforms and negative E. coli. List 5 pieces of information you would seek to inform your actions and recommendations

Answer 25

1. What are the current and recent free residual chlorine levels? 2. Have adjacent sites tested positive? 3. Has the contaminated site been retested? 4. What is the level of total coliform? 5. Does this system have a history of prior contamination? 6. Is there any current known gastrointestinal illness outbreak in the community that might be associated with water consumption?

Question 26

You are a MOH in a regional health authority and receive a phone call from a concerned community member who reports that there have been many cases of cancer diagnosed in the community recently and she thinks something is causing the cancer A) List 5 pieces of information you would seek from this individual during this initial period of contact B) If you decide to pursue past the first stage of initial contact, what is the measure of association you would calculate to determine the presence and statistical significance of a cluster? C) Identify 4 characteristics identified early in an investigation of a reported cluster that suggest an etiologic cluster may exist D) In a complete cancer cluster investigation, identify one common important aspect of each stage of the investigation E) In an epidemiological study of a possible cancer cluster of residents and workers in a neighbourhood where the exposure of concern is related to an adjacent industrial site, list 2 data sources that would assist in identifying cases/assigning outcome and 2 data sources that would assist in identifying exposure status.

Answer 26

A) 1. How many cases of cancer are there 2. What are the types of cancer 3. Over what period of time have the cancers been diagnosed 4. Is there any particular environmental exposure of concern? 5. What is the age and sex of the individuals with cancer 6. How did the reporter learn about the supposed cluster? B) Standardised incidence ratio C) 1. All cases have same type of cancer that is rare 2. Exposure of concern is a known carcinogen to humans 3. All cases have plausible exposure history and timeframe for developing cancer 4. SIR is greater than 1 with 95% CI that do not cross zero/large number of cases D) Maintain open and frequent communication with inquirer/community E) Outcomes 1. Cancer registry 2. Death registry 3. Hospitalisation database 4. Physicians claims database Exposure 1. Housing records 2. Employment records 3. Municipal land development/business records

Question 27

TRAP A) List 4 traffic related air pollutants B) List 4 recommendations for individuals to reduce their exposure to TRAP C) List 4 recommendations for individuals to reduce their production of TRAP D) Identify 4 federa/provincial level policies that could be implemented to reduce the production of TRAP E) List 4 population groups that are particularly vulnerable to outdoor air pollution F) List 4 adverse health effects associated with exposure to air pollution

Answer 27

A) 1. Carbon monoxide 2. Fine particulate matter 3. Nitrogen dioxide 4. Volatile organic compounds B) 1. Choose low traffic routes for cycling, walking and running 2. Exercising in parks and green spaces away from major roadways 3. Reduce outdoor air pollution from entering the home by keeping windows and doors closed 4. Avoid high-traffic areas when choosing places to live, work, play, learn 5. Limit time outdoors when pollution levels are high 6. Avoid idling vehicles while in your garage at home C) 1. Choose alternative ways to travel such as walking/cycling, public transit, carpool 2. Maintaining a steady driving speed, while avoiding heavy braking or acceleration 3. warming your engine with a block heater on cold days before starting it 4. consulting the Fuel Consumption Ratings Search Tool before buying a vehicle 5. Turning off your engine when stopped for more than 10 seconds 6. Reducing fuel consumption and emissions by regular maintenance of vehicle and tires D) 1. Regulations to improve engine efficiency 2. Regulations requiring cleaner fuels with reduced sulphur content 3. Regulations to reduce engine emissions 4. Increase taxes on fuels 5. Increase accessibility and affordability of public transport and active transport E) 1. Infants and children 2. Elderly 3. Those with existing heart conditions 4. Those with existing lung conditions 5. Those who work outdoors 6. Those who are active outdoors 7. Those who live near high-traffic areas and roadways F) 1. Hypertension 2. Stroke 3. Exacerbation of asthma or COPD 4. Pneumonia 5. Ischemic heart disease 6. Lung cancer

Question 28

Climate change You are an MOH for your provincial health authority and are part of a working group to develop a provincial climate change strategy. A) List two major categories of actions that you would suggest to be part of the strategy and list 4 potential actions under each category B) Identify 4 direct and 4 indirect potential health effects from climate change C) Identify 4 different categories of geographical areas relevant to climate change effects and provide one unique consideration for climate change planning related to each location.

Answer 28

A) Mitigation 1. Invest in energy efficient public transportation 2. Change building codes to improve energy efficiency 3. Increase tax on motor vehicle fuels 4. Invest in renewable energy sources 5. Regulations requiring reduced vehicle emissions Adaptation 1. Improve disaster preparedness and response e.g. heat response planning 2. Enhance environmental monitoring e.g. Air Quality Health Index 3. Infrastructure upgrades to reduce heat island effect 4. Collaboration between sectors e.g. health, animal, emergency services 5. Increased disease/outcome surveillance e.g. heat-related illnesses B) Direct 1. Heat and cold-related illness and death 2. Deaths and injuries from weather disasters (floods, storms) 3. Psychological impacts from increased illness and deaths in families/communities 4. Increased skin cancers due to increased UV exposure Indirect 1. Changes to vector-borne disease patterns 2. Increased food and water borne infections due to decreased hygiene 3. Malnutrition 4. Injuries and illness due to overcrowding/displacement 5. Increased asthma and allergies due to changes in air pollution/pollens/spores C) 1. Urban - urban heat island effect 2. Coastal/waterfront areas - flooding 3. Rural - disruption of agriculture 4. Northern - disruption of communities dependent on country food 5. Communities that neighbour forested areas - wildfires

Question 29

Mercury A) List 3 broad categories of forms of mercury B) What is the most toxic form of mercury and what broad category from (A) does it belong to? C) What is the process by which mercury concentrations are higher in predatory fish that are higher in the food chain? D) List 4 human activities that have resulted in greater mercury levels in the environment E) What is the primary source of mercury exposure for the general Canadian population F) List the 2 major target organs for mercury G) What 2 population groups are recommended to consume less mercury-containing fish than the general population

Answer 29

A) 1. Elemental 2. Organic 3. Inorganic B) Methylmercury - organic C) Biomagnification D) 1. Coal-fired power generation 2. Metal mining 3. Metal smelting 4. Waste incineration E) Ingestion of larger species of fish F) 1. Central nervous system 2. Kidneys G) 1. Pregnant and breastfeeding women 2. Children 11 years and under

Question 30

Toxic substances A) List 4 characteristics of a substance that must be met for it to be considered for virtual elimination in the environment under the toxic substances management policy B) What approach is taken if not all 4 criteria are met

Answer 30

A) 1. Toxicity 2. Predominantly a result of human activity 3. Bioaccumulative 4. Persistent in the environment B) Life cycle management to prevent or minimise release into the environment https://www.canada.ca/en/environment-climate-change/services/management-toxic-substances/policy.html

Question 31

Benzene A) What group of chemicals does benzene belong to? B) What is the primary exposure route for benzene in humans? C) List 2 significant contributors to indoor benzene levels D) List 4 acute health effects of benzene inhalation E) What organ system is primary affected by long term exposure to benzene and list 3 effects on this system

Answer 31

A) Volatile organic compounds B) Inhalation C) 1. Tobacco smoke 2. Attached garages D) 1. Confusion 2. Dizziness 3. Drowsiness 4. Headache E) Hematological - anemia, immunosuppression, leukemia

Question 32

You are MOH for a regional health authority and have been nominated to lead a health impact assessment related to the construction of a new sports facility in a community - the community is primarily concerned about adverse health effects from noise as the proposed construction is expected to take many months A) List 4 adverse health effects from noise B) Identify 5 strategies you could propose to reduce potential health effects from noise related to this project C) List 4 potential indicators you could use to monitor adverse noise effects related to this project once it is underway

Answer 32

A) 1. Noise induced hearing loss 2. Impaired speech comprehension 3. Sleep disturbance 4. Increased stress and annoyance B) 1. Change design/location of project to increase distance between construction and neigbhouring residents 2. Place sound walls to reduce noise that reaches residents 3. Use equipment and technologies that are quieter 4. Alter construction vehicle routes to minimise use of reversing alarms 5. Reduce peak blast noise levels 6. Limit hours of construction C) 1. % of residents surveyed reporting sleep disturbance 2. % of residents surveyed reporting extreme annoyance 3. Percent change in baseline noise levels during construction 4. Number of noise complaints made to local council

Question 33

You are an MOH for a municiipal health authority. There is a daycare on a university campus in your region in an old building where parents have tested the paint on the outside of the building which and reportedly the tests have come back identifying that it contains lead. The parents are concerned that the paint is crumbling in the soil around the building where the children often play. A) Apart from remedying the lead paint, identify 5 recommendations for that can be provided to staff and parents of children at the daycare to reduce exposure to lead while at the daycare. B) Identify 3 potential factors of this situation that are associated with increased outrage and 3 potential factors that are associated with decreased outrage.

Answer 33

A) 1. Practice good hand hygiene particularly before eating 2. Regularly clean and vacuum inside to reduce dust 3. Wet mop the floors to absorb dust 4. Erect fencing around the soil where paint chips are in the soil 5. Wash toys and other objects children play with regularly B) Factors associated with outrage 1. Affects children 2. Exposure due to human activities 3. Exposure was involuntary Decreased outrage 1. Elevated blood lead levels are reversible/treatable 2. Lead exposure is not associated with catastrophic outcomes 3. It is possible to control/reduce ongoing exposure Others depending on scenario: responsiveness, trustworthy sources, dreaded outcome, familiarity

Question 34

A) In a municipal water system, what are the 3 locations where drinking water is typically tested to ensure the drinking water is safe to consumed?

B) The Guideline for Canadian Drinking Water Quality was recently changed in 2019, what were the changes related to lead in drinking water?

Answer 34

ARaw water prior to treatment; Treated water leaving the treament plant; Water in the distribution system after leaving the treatment plan

B) Lead testing is done at the tap; MAC for total lead in drinking water is 5 ppb (0.005 mg/L)

Question 35

What are 4 components of West Nile Virusl control and provide one example of each?

Answer 35

1. Surveillance – testing of birds, testing mosquitoes in breeding grounds, human cases, horses
2. Source reduction – eliminate standing water
3. Mosquito control – larviciding, adulticiding
4. Education – personal protective measures – staying indoors when mosquito most active, light-coloured long-sleeved clothing, insect repellants containing deets,