EG notes

Question 1

What are risk factors for falls and available interventions to reduce the risk?

Answer 1

Risk factors for falls:
Children: Bunk beds, play structures
Adolescents: Alcohol, risk-taking behaviour

Seniors (>65):

• Biological risk factors: Acute illness, balance and gait deficits, chronic conditions and disabilities (e.g., stroke, CVD), cognitive impairment, low vision, muscle weakness
• Behavioural risk factors: Malfunctioning or misused assistive devices, excessive alcohol, fear of calling, loose/smooth/thick footwear or clothing, inadequate diet, medications (e.g., sedatives), risk-taking behaviour
• Socioeconomic risk factors: Limited social networks, low SES
• Environmental risk factors: Community hazards (e.g., lack of handrails, lack of curb cuts), home hazards (e.g., rugs, poor lighting), weather (e.g., ice)
• *Interventions**
• Falls risk assessment in primary care

- Education (Canadian Falls Prevention Curriculum)

• Exercise programs (e.g., Tai Chi)
• Home modification (e.g., occupational therapist visit)
• Assistive devices and other protective equipment
• Clinical disease management, including chronic and acute illness (vision/cataract surgery, CV/pacer, hypotension, podiatry/footwear, nutrition).
• Medication review and deprescribing (psychotropics)
• *Canadian epidemiology**
• Between 20-30% of seniors fall each year
• Amongst seniors, falls are the leading cause of injury-related hospitalizations
• Absolute numbers of falls and deaths due to falls in seniors is rising
• Falls are the cause of 95% of hip fractures

Question 2

Explain meta-leadership.

Answer 2

The person of the Meta-Leader (self-knowledge, awareness, and regulation): Meta-leaders develop high self-awareness, self-knowledge, and self-regulation. They build the capacity to confront fear and lead themselves and others out of the “emotional basement” to higher levels of thinking and functioning.

The situation (discerning the context for leadership): With often incomplete information, the meta-leader maps the situation to determine what is happening, who are the stakeholders, what is likely to happen next, and what are the critical choice points and options for action.

Connectivity (fostering positive, productive relationships): The meta-leader charts a course forward, making decisions, operationalizing those decisions, and communicating effectively to recruit wide engagement and support. The meta-leader navigates the distinct dynamics and complexities of leading four facets of connectivity.

- leading down the formal chain of command to subordinates (within one’s silo), creating a cohesive high-performance team with a unified mission;

- leading up to superiors, inspiring confidence and delivering on expectations; enabling and supporting good decisions and priority setting;

- leading across to peers and intra-organizational units (other silos) to foster collaboration and coordination;

- leading beyond by engaging external entities, including affected agencies, the general public and the media to create unity of purpose and effort in large-scale response to complex events.[8]

Question 3

Describe the Dahlgren model of the social determinants of health

Answer 3

Question 4

What is a biofilm in water distribution system, why can it be a problem and how can it be controlled?

Answer 4

Biofilms
- Definition: “Complex mixture of microbes, organic and inorganic material accumulated
amidst a microbially-produced organic polymer matrix attached to the inner surface of
the distribution system”
- Protect microbes from disinfection and environmental stress
- Increase pipe corrosion and adversely affect pipe hydraulics
- Can result in the generation of bad tastes and odours, proliferation of
macroinvertebrates, and allow subsequent contamination to become stuck in the biofilm
- Material in the biofilm can be released into the water, resulting in persistent
contamination

• Biofilms exist in all water distribution system; growth is enhanced by:
• Presence of nutrients (biodegradable organic material)
• Lack of competitive microbial interactions
• Distribution system materials (iron, silicon, PVC, and rubber support the growth
  more than glass or steel)
• System hydraulics (slow flow, shear due to backflow/water hammer, areas where
  sediments accumulate)
• Lack of residual in distribution system
• Sediment accumulation
• Examples of aquatic, pathogenic microbes well-adapted to biofilms include:
  Pseudomonas aeruginosa, Legionella pneumophila, and the Mycobacterium avium
  complex (MAC)
• *- Control and prevention measures:**
• Nutrient control
• Reduce contamination
• Mitigate system hydraulic problems
• Prevent backflow and cross-connections
• Increase disinfectant residuals
• Corrosion control
• Infrastructure replacement and repair

Question 5

Define leadership and management.

Name modes of influence.

Name leadership styles.

List the 5 components of emotional intelligence.

What are qualities of good leaders?

Answer 5

• *Leadership**: Skill of inspiring a group of individuals to work together to fulfill a shared vision
• Leaders vs. managers: Leaders articulate a vision and an execution plan to reach the vision; managers allocate resources in order to accomplish tasks and are responsible for the work of others; see diagram below
• Most people are motivated by autonomy, mastery, and purpose

Emotional intelligence (mnemonic MESS): motivation, empathy, self-awareness, self-regulation, and social skills
Reflective practice: Deliberate reflection on experiences, and the beliefs, emotions, and values that were part of those experiences, to further learning and improve future practice

Qualities of good leaders: capable, credible, charismatic, visionary, empowering, fair.

Effective communication:
Accept 100% of the accountability for the impact of your words on others. (“They don’t have to
listen better; you need to communicate more effectively.” - Malandro)
Effective listening:
1. Listen to what the speaker is saying. Do not plan your response.
2. Identify what is important to the speaker. Identifying the values and beliefs the speaker
is expressing?
3. Check in with the speaker to ensure you understand (e.g., “I think I heard you say … Is
that correct?”)
4. Identify what else you need to know. Ask clarifying questions.
5. Respond to the speaker.
How you know you are communicating effectively to your team:
1. People are inspired.
2. People recreate your message for others.
3. People know what is important.
4. People are emotionally and intellectually engaged.

Modes of influence:
- Authority: Formal power over another individual granted by the structure of the
organization
- Rapport: Relationship based on mutual understanding between two people (face to face)
- Assertiveness: Calm self-confidence; respectful
- Aggressiveness: Hostile behaviour; can be initially effective, but toxic over the long term
- Credibility: In public health, usually based on professionalism and expertise; “you know
your stuff” (or at least you are perceived to know your stuff)
- Team building: Rapport amongst a whole team created by working with people side-byside
over time
- Logic: Appealing to evidence
- Culture: Informal power over another individual granted by the culture of the organization

Leadership styles:
- Coercive/commanding: Demand compliance
- Authoritative/visionary: Mobilize towards a vision (concern for productivity trumps
concern for people)
- Affiliative: Create emotional bonds (aka “country club manager”: concern for people
trumps concern for productivity)
- Democratic: Consensus through participation
- Pacesetting: Expect excellence and self-direction
- Coaching: Focus on developing employees for the future
- Impoverished: Provides minimum amount of effort to sustain the organization

Question 6

What are the minimal ages to be able to consent to sexual activity in Canada?

Answer 6

• Age of consent: The age at which a person can legally consent to sexual activity, from
  kissing to seual intercourse
• Canada’s age of consent: 16 years of age; sexual activity with a child under the age of
  16 is sexual interference under the Criminal Code; caveats:
• Anal sex: 18 years (there is a current bill under consideration to reduce this to
  the age of consent for any other sexual activity)
• Position of authority: 18 years (e.g., teacher, coach, babysitter)
• Close-in-age exceptions: 12- and 13-year-olds may consent to sexual activity
  with another person who is < 2 years older than them; 14- and 15-year-olds may
  consent to sexual activity with another person who is < 5 years older than them;
  exception: youth cannot consent to sexual exploitation (sexual activity with a
  person in a position of authority, sex work, pornography)

Question 7

Describe program planning models:

• APIE model
• PRECEDE/PROCEED model (8 phases)

Answer 7

Program planning cycle:

• *APIE model**
• *Assessment**
• Define: Define the issue or problem
• Search: Consider the evidence, assess needs
• Synthesize: Identify target and priority populations, assess options
• *Plan**
• Adapt: Develop a logic model, activity plan, and evaluation plan based on evidence, local needs, and context
• *Implementation**
• Implement: Act on the evidence, while documenting barriers and progress
• *Evaluation**
• Evaluate: Assess effectiveness

PRECEDE-PROCEED framework
The PRECEDE-PROCEED framework combines epidemiological; social, behavioural, and educational sciences; and health administration literature to describe the steps in designing and
evaluating health-behaviour change programs. It has 7 or 8 phases, depending on the version of the framework.
PRECEDE: Predisposing, Reinforcing, and Enabling factors, and Causes in Educational Diagnosis and Evaluation
PROCEED: Policy, Regulatory, Organizational Constructs in Educational and Environmental Development

Phase Description S - EBE - EE - AP

1. Social diagnosis: What are the social issues concerning the community? (Sources might include community forums, interviews, surveys)
2. Epidemiological, behavioural, and environmental diagnosis: What are the health impacts that result from the social issue defined by the community? What are the epidemiological, behavioural, and environmental risk factors for the health impacts? (Sources might include vital statistics, administrative records)
3. Educational and ecological diagnosis: What are the causes of the behavioural risk factors identified in phase 2 (e.g., attitudes, beliefs, legislation, rewards, peer pressure)? Which factors are modifiable?
4. Administrative and policy diagnosis: What resources and policies are required to address the modifiable factors identified in phase 3?
5. Implementation Implement a program
6. Process evaluation Evaluate the process of the implementation (i.e., outputs)
7. Impact evaluation Evaluate the intermediate outcomes of the program
8. Outcome evaluation Evaluate the long-term outcomes of the program

ROPE (regulatory, organizational, policy, educational factors) context leads to…

PRE (predisposing, reinforcing, enabling) factors determining…

Lifestyle/environment that ultimately affect…
Health status and quality of life

Question 8

Name 4 human activites that release mercury in the environment.

Describe basic facts about the 3 types of mercury

Answer 8

Human activities that release mercury:

1) coal-fired power generation, 2) metal mining and 3) smelting and 4) waste incineration.

Metallic mercury (aka elemental Hg; liquid mercury)

Common sources: Thermometers, barometers, electrical switches, CFLs, dental fillings; exposure usually inhalational
Short-term effects: Delirium, hallucinations
Long-term effects: Erethrism (“mad hatter disease”): Behavioral changes (e.g., social phobia), tremor, memory loss, tremor
IARC 3

Inorganic mercury salts
Commone sources: Fungicide, disinfectant, antiseptic, thimerosal, skin-lightening cream
Short-term effects: Pneumonia, DIC, cerebral infarctions, renal cortical necrosis
Long-term effects: CNS effects
IARC 3

Organic mercury (methylmercury)
Common sources; Fish *Largest exposure globally occurred in 1970s in Iraq, when grain was
contaminated with fungicide, poisoning 6000 people
Short-term effects: Respiratory distress, nonspecific dermatitis

Long-term effects:

Minamata disease: Tremors, sensory loss, ataxia, visual field constriction, facial paresthesias.

Developmental effects: Developmental delay similar to lead, low birthweight
IARC 2B

Question 9

What are principles of medical expert testimony?

Answer 9

Legal testimony as a medical expert
- Physicians do not have an obligation to act as medical expert
- Consent to review personal health information must usually be obtained
- Legal requirements for records retention and access may be different in a legal
proceeding than from usual medical care

• Principles of medical expert testimony:
• Objective: Opinions must be substantiated by fact, evidence, or experience
• Impartial: Must not advocate for any party
• Within scope of expertise
• Comprehensive: All relevant information has been considered
• Accurate: Information physician relied on to form opinion is accurate
• Transparent: Be transparent about instructions you have been given and the
  process used to form your opinion
• Clear: Use lay language
• Timely

Question 10

Regarding vitaming D intake,

what are recent epi trends?

health impacts?

available interventions?

Answer 10

Recommended amounts

RDI Infants = 400 IU
Children and adults = 600 IU
Adults > 70 years = 800 IU

Epidemiology - 1 in 3 Canadians has serum levels of vitamin D insufficient for bone
health (40% in winter and 25% in summer)
- 10% of Canadians are vitamin D-deficient

Health impacts

• Hormone function: Enhances absorption of serum and calcium from
  the small intestine to maintain appropriate serum levels → deficiency
  leads to hyperparathyroidism and secondary osteoporosis, rickets in
  children and osteomalacia in adults
• Also has antiproliferative, prodifferentiative, and immunomodulatory
  effects → may reduce risk of breast CA, colorectal CA, and MS
• Probably improves muscle strength and reduces risk of DMII

Interventions

Fortification of milk (mandatory in Canada), cereal, and orange juice
Supplementation, especially for breastfed infants (400 IU/day)

Question 11

Describe basic facts about malaria

Organism, Reservoir, Mode of transmission

Incubation period, infectious period

Epidemiology

Presentation, Testing

Case management, Contact management

+/- Immunization

Answer 11

Malaria (reportable)
- Organism: 5 Plasmodium spp. (protozoan parasites)
- Mode of transmission: Vector-borne (Anopheles spp. mosquitoes); contaminated blood
or blood products; congenital malaria
- Epidemiology: No longer endemic in most temperate countries and some subtropical
countries
- Presentation: Fever, chills, headache, myalgias, N/V/D that typically occur in a daily or
alternate day cycle for up to a month; severe malaria (usually due to P. falciparum) may
cause LOC, seizures, acidosis, acute pulmonary edema, shock, ARF, splenomegaly
- Testing: Microscopy (thick and thin films) or rapid diagnostic test (antigen detection
assays)
- Case management: Prompt treatment; in non-endemic areas, patients should stay in
mosquito-proof rooms; untreated or insufficiently treated cases may infect mosquitoes
for up to 1 year (falciparum), 5 years (vivax), or decades (malariae)
- Contact management: Personal protective measures to prevent mosquito bites +
community prevention measures +/- chemoprophylaxis based on risk, contraindications,
and resistance patterns

Question 12

In the epidemiologic triangle,

what are the 3 different states for the host?

Answer 12

• Susceptible: Insufficient resistance against a particular pathogenic agent to prevent contracting the infection or disease when exposed to the agent
• Infectious
• Recoveved (immune)

Question 13

Regarding iron intake,

what are recent epi trends?

health impacts?

and available interventions?

Answer 13

Iron
RDI Adults = 8 mg/day for males and non-menstruating females and 18 mg/day for menstruating females

Epidemiology

• Globally, 1 in 4 people are iron deficient
• Iron deficiency is rare in Canada: prevalence of 5%
• Iron-deficiency anemia is rare in Canada: prevalence of 3%

Health impacts

• Iron-deficiency anemia → reduced immune function, decreased exercise capacity
• Long-term impaired cognitive performance in iron-deficient children
• Iron deficiency in pregnant women can lead to maternal anemia,
  premature delivery, low birth weight, and increased risk of perinatal
  mortality

Interventions

• Iron-fortified pasta and cereal
• Health education: maximize absorption of iron by eating it with vit C;
  maximize absorption of non-heme iron by eating it with heme iron
• Iron supplementation for pregnant and breastfeeding women
• Because breast milk is low in iron and infants have iron stores that
  only last up to 6 months, the first complementary foods should be
  iron-rich

Question 14

Describe basic facts about polio

Organism, Reservoir, Mode of transmission

Incubation period, infectious period

Epidemiology

Presentation, Testing

Case management, Contact management

+/- Immunization

Answer 14

Poliomyelitis (all acute flaccid paralysis reportable)
- Organism: Poliovirus (RNA virus, Picornaviridae family, enterovirus subgroup)
- Wild poliovirus: Three types with different capsid proteins; immunity to one
serotype does not confer immunity to the other two types
- Type 1: Currently circulating
- Type 2: Last detected in 1999; declared eradicated globally in September
2015
- Type 3: Last detected in November 2012
- Vaccine-associated paralytic poliomyelitis (VAPP): OPV usually causes an
attenuated polio infection, but in rare cases, it causes paralysis; 2-4 cases/1
million doses of vaccine (polio from the vaccine, acquired via OPV)
- Circulating vaccine-derived poliovirus (cVDPV): In populations with large pools of
susceptibles, excreted, OPV vaccine-derived polioviruses can circulate in the
community; if circulation occurs for a prolonged period, the virus can mutate and
reacquire neurovirulence and cause paralysis (polio from the vaccine, acquired
via environment)
- Reservoir: Humans
- Mode of transmission: Fecal-oral (rarely, respiratory droplets)
- Epidemiology:
- Endemic in 3 countries: Afghanistan, Nigeria, Pakistan
- Last indigenous case of wild polio virus in Canada = 1977
- Canada declared polio-free = 1994
- Children < 5 years are most susceptible to polio infection
- 90-95% of infections are asymptomatic
- <1% of cases result in paralysis
- Case-fatality rate of paralytic polio = 2-5% (children), 15-30% (adults)
- Presentation: Usually asymptomatic; when symptomatic, fever, fatigue, headache. N/V →
severe muscle pain, neck and back stiffness → acute onset, symmetrical, flaccid
paralysis +/- aseptic meningitis
- Incubation period: 6-20 days (range: 3-35 days)
- Infectious period: Usually begins at the onset of illness and can last 3-6 weeks post
convalescence; shedding may occur for much longer time periods in
immunocompromised persons
- Case management: Contact precautions; supportive care
- Contact management: For susceptible household or daycare contacts, receive IPV as
per immunization schedule; exclude susceptible food handlers
- Vaccine:
Oral polio vaccine (OPV) - live attenuated, easy to administer, cheap, provides intestinal immunity, can cause VAPP, cVDPV

Inactivated polio vaccine (IPV) - inactivated, more expensive
- Canada switched from OPV to IPV in 1977
- IPV recommended for all infants and children, unimmunized adults, and
immunized adults at increased risk of contracting polio (single lifetime booster)
- As a result of the eradication of type 2 poliovirus, trivalent oral polio vaccine
(tOPV) was removed from global eradication programs in 2016 and replaced with
bOPV

Question 15

What is a case-crossover?

What is the ecological and atomistic fallacy?

Answer 15

• *Study designs**
• *Descriptive studies**: No comparison group; describe disease occurrence
• Case report
• Case series
• Description of rates (e.g., surveys, registries)
• *Analytic studies**: Comparison group; assess associations; test hypotheses
• Experimental/interventional studies: Investigator assigned the exposure
• Randomized trial: Randomization controls for unknown confounding, but at
  higher cost and reduced external validity
• Simple, two-arm RCT: Group A receives treatment and group B receives placebo
• Cross-over RCT: Group A receives treatment and group B receives
  placebo → washout period → Group A receives placebo and group B receives treatment
• Factorial: Group A receives treatment 1 + placebo, group B receives
  treatment 2 + placebo, group C receives treatment 1 + 2, group D
  receives placebo
• Non-randomized trial
• Quasi-experimental: Investigator does not assign the exposure, but conducts the
  research as if s/he did (e.g., before-after study/interrupted time series)
• Observational: Investigator did not assign the exposure; individual-level outcomes known
• Cohort: Identify all individuals in a group and follow them forward in time to
  assess outcome (temporal sequence known, but not feasible for rare outcomes)
• Prospective: No individual has developed the outcome of interest at the
  time of study enrollment
• Retrospective: Some individuals have developed the outcome of interest
  at the time of study enrollment and the investigator retrospectively
  determines whether or not the individual was exposed
• Case-control: Cases are matched with controls without the outcome of interest,
  and then each are assessed for the exposure (good for rare outcomes, but risk of
  recall bias)
• Cross-sectional: Data on exposure and outcome collected simultaneously
• Hybrid designs
• Nested case-control: Cohort with a case-control within in it; cases and
  controls are both drawn from a cohort
• Case-crossover: Case act as their own control; used for outcomes with
  rapid onset (e.g., MI, MVC)
• Ecological: Investigator did not assign the exposure; individual-level outcomes
  unknown
• *Beware the ecological fallacy: Drawing inferences at the individual level
  based on group-level data (the reverse is called the atomistic fallacy:
  drawing inferences at the group level based on individual-level data)

Question 16

Discuss the health impacts of fluoride and the benefits of water fluoridation

Answer 16

Fluoride (hot topic)
Guidelines
Optimal fluoride concentrations:
- Community water systems: 0.7 mg/L (=ppm)
- Toothpaste fluoride concentrations of 1000 ppm or higher have the greatest caries
prevention

• *Canadian Pediatric Society recommendations:**
• Community water fluoridation
• _Everyone older than 6 months: Fluoridated toothpaste 2x/day (minimal amount for
  children) _

Canadian Dental Association recommendations:
- Community water fluoridation
- Everyone older than 3 years: Fluoridated toothpaste 2x/day
- Infants and toddlers 3 years and less: Brush teeth and gums without toothpaste; if at
high risk of tooth decay, brush teeth and gums with a minimal amount of fluoridated
toothpaste

Epidemiology
- Introduction of fluoride into a water supply reduces the frequency of dental caries by
50%
- Approximately 45% of Canadians drink fluoridated water; lowest in Quebec, where
approximately 3% of population drinks fluoridated water (Quebec also has the highest
rate of dental caries)

Health impacts
Mechanism of action:
- Before age six, ingested fluoride is incorporated into the tooth and can contribute to
fluorosis
- Beneficial actions of fluoride are primarily topical: it inhibits plaque formation, inhibits
demineralization, and enhances remineralization of enamel

Fluorosis: Disease of the teeth and bones caused by excess consumption of fluoride
- Dental fluorosis: _Changes in the appearance of the tooth enamel when children < 6-8
years old are exposed to high levels of fluoride (_teeth cannot develop fluorosis after
eruption); “So few children [in Canada] have moderate or severe fluorosis that, even
combined, the prevalence is too low to permit reporting” (PHAC)
- Very mild: Barely noticeable scattered white flecks, occasional white spots, frosty
edges, or fine, lacy chalk-like lines on teeth
- Mild: Scattered white flecks, occasional white spots, frosty edges, or fine, lacy
chalk-like lines on teeth
- Moderate: Noticeable white spots on teeth
- Severe: Rough, pitted surfaces
- Skeletal fluorosis: Joint pain and stiffness, ligament calcification; typically reported in
areas with naturally high levels of fluoride in water (e.g., areas of Jordan, Sudan,
Thailand, India)
- Acute fluorosis: Abdominal pain, excessive saliva production, N/V, seizures, muscle
spasms

Common criticisms and counterarguments:

Fluoride is a poison: Like any chemical, the dose makes the poison (“To get
fluoride poisoning from tap water, you would have to drink a
couple thousand litres of water without peeing”)
Fluoride in water = 0.7 ppm
Fluoride in toothpaste = 1,500 ppm

Water fluoridation treats people without their consent
Cost-effective prevention of one of the most common diseases
ROI: $1 spent on fluoridation = $50 saved in dental treatment costs
Greatest beneficiaries are low-income children

Fluoride can be obtained elsewhere:
In Calgary, savings from cutting fluoridation moved to dental
treatment for low-income children; cost = $250/child (“and only
after they had cavities and were in pain”)

Scientific “controversy”

No scientific controversy about fluoride

Question 17

What are examples of passive immunization available in Canada?

Answer 17

Specific Ig available in Canada: Botulism antitoxin, botulism Ig, CMV Ig,
diphtheria antitoxin, HBIg, RabIg, RSV monoclonal antibody, tetanus Ig, VarIG

Question 18

Compare and contrast provincial jails and federal penitenciaries.

Describe common health conditions among prisoners in Canada.

Answer 18

Prisoners
Provincial jails
- Sentences of two years less a day are served in provincial jails; individuals who have yet
to be sentenced (i.e., remanded before or during trial) or detained on immigration issues
are also held in provincial custody
- In Ontario, there are approximately 8-9,000 individuals in custody on any given day and
approximately 50,000 unique individuals released from Ontario jails per year
- ⅔ of individuals in Ontario are on remand (i.e., not yet sentenced)
- 1 in 10 drug toxicity deaths in Ontario occur within one year of release from
provincial jail
- On any given day, 6-8% of the Ontario provincial jail population is in segregation
(colloquially known as solitary confinement)
- Life expectancy for individuals who had been incarcerated in provincial jails is 4.2
years less for men and 10.6 years less for women than the general population
*Local public health agencies do have jurisdiction in provincial jails
*Health services in provincial jails are provided by the provincial health agency in Nova Scotia
and Alberta, by the provincial correctional agency in Ontario, and by private companies in BC

Federal penitentiaries
- Sentences of two years or more are served in federal penitentiaries
- Statutory release: Inmates are released into the community on parole once ⅔ of
the sentence has been served, unless there is an extraordinary reason not to;
inmates can request earlier parole through the National Parole Board
- Warrant expiry: Date at which (correctional services of Canada) CSC no longer has control over the offender (inmates who did not receive stat release must be released from prison on their
warrant expiry; offenders on parole are released from parole)
- Indeterminate sentence: No warrant expiry (life sentence), although inmates can
still apply for parole
- Long-term supervision order: Requires offenders to report to CSC for ten years
after their warrant expiry date; for dangerous offenders only
- Approximately 15,000 inmates in 43 institutions (+ 8,700 offenders on parole)
- 95% men
- 22% Indigenous
- 15-20% of Indigenous inmates attended a residential school
- 54% have not completed high school (compare to 13% in general population)
- 22% report injection drug use prior to incarceration
- 17% report injection drug use while incarcerated
- 40% are smokers (smoking banned in federal penitentiaries since 2008)
- Most common health conditions identified in incoming inmates: head injuries (34% of
incoming inmates), mental illness, back pain (19%), asthma (15%), and HCV
- 25-30% of inmates are HCV+
- 1-2% of male and 1-9% of female inmates are HIV+
- Inmates are excluded from the Canada Health Act while incarcerated; instead, they are
provided health care under the Corrections and Conditional Release Act, which requires
penitentiaries to provide “essential health care” and “reasonable access to non-essential
mental health care”
*Local public health agencies do not have jurisdiction in federal penitentiaries

Question 19

Describe the timeline of health promotion documents related to the Ottawa Charter

Answer 19

• In November 1986, the first Global Conference on Health Promotion was convened in
  Ottawa by the WHO; the Ottawa Charter was adopted by the WHO, cosponsored by the
  CPHA and Health and Welfare Canada (now Health Canada)

Timeline of health promotion documents related to the Ottawa Charter
- 1974: A New Perspective on the Health of Canadians (aka LaLonde Report), released
by the Canadian Minister of National Health and Welfare, introduced “health fields”
concept (biology, environment, lifestyle, and health care); moves towards an
understanding of the social determinants of health and acknowledges that health care is
not the sole determinant of health, but still “blaming the victim” by not recognizing the
social, economic, and political drivers of lifestyle “choices”
- 1978: Declaration of Alma-Ata identified the primary care as essential to achieving
Health for All; identified economic and social development as a prerequisite to health
- 1986: The Ottawa Charter for Health Promotion
- 1986: Achieving Health for All: A Framework for Health Promotion (aka Epp Report)
released by the Canadian Minister of National Health and Welfare explicitly recognized
the social determinants of health and defined the three mechanisms of health promotion:
self-care, mutual aid, and healthy environments

• Other WHO statements flowing from the Ottawa Charter:
• 1988: Adelaide Recommendations on Healthy Public Policy
• 1991: Sundsvall Statement on Supportive Environments for Health
• 1997: Jakarta Declaration on Leading Health Promotion into the 21st Century
• 2000: Mexico Ministerial Statement for the Promotion of Health: From Ideas to
  Action
• 2005: Bangkok Charter for Health Promotion in a Globalized World
• 2009: Nairobi Call to Action
• Global Conferences on Health Promotion continue to occur every 3-5 years

Question 20

Contrast stochastic versus deterministic models when modelling a dose-response curve

Answer 20

Modelling a dose-response curve:
- Stochastic/random model: 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

• Non-stochastic/deterministic model: Dose vs. severity of outcome; assumes a threshold;
  increased dose increases severity of outcome of interest (higher dose results in bigger
  tumour) *Threshold relationship
• Consider: Additivity, synergy, linear vs. quadratic relationship, impacts (e.g., cellular)
  outside the observable range

Question 21

Explain situational leadership styles.

Answer 21

Question 22

What are the stages of team development?

Answer 22

Team development
Evaluating team performance through the lens of team development allows managers to
understand why a team may be performing at a certain level; development is not a linear
process: “changes, such as members coming or going or large-scale changes in the external
environment, can lead a team to cycle back to an earlier stage”;

Stages of team development include:
Forming
- Feelings: Excited, eager, anxious
- Behaviours: Many questions
- Tasks: Create a team with a clear structure, goals, direction, and roles; task
accomplishment may be low
Storming
- Feelings: Frustration and anger at being unable to meet expectations (mismatch
between individual expectations and team performance); team members observe how
others express these negative emotions
- Behaviours: Disagreement between team members; criticism of team’s goals;
behaviours may be less polite than during the forming stage
- Tasks: Redefinition of structure, goals, and roles
Norming
- Feelings: Increased sense of comfort as individual expectations and team performance
become increasingly aligned; increased comfort to share ideas and ask for help
- Behaviours: Effective communication, establishing ground rules
- Tasks: Increased productivity; evaluation of team processes
Performing
- Feelings: Satisfaction in team progress, confidence
- Behaviours: Share personal insights, increased self-awareness, problem solving
- Tasks: Progress towards goals, continuing team development, celebrate achievements
Ending/Adjourning
- Feelings: Anxiety, sadness, sense of loss, satisfaction leading to rises and falls in team
morale
- Behaviours: Decreased focus on tasks, resulting in decreased productivity vs. increased
focus on tasks and increased productivity, depending on the person
- Tasks: Complete deliverables, evaluate team process and products, closing celebration

Question 23

What are the incubation period and communicability periods for invasive meningitis?

Answer 23

Incubation: 2-10 days

Communicability: 7 days before onset of symptoms to 24 hours after initiation of abx

Question 24

Define and contrast:

quality control,

quality assurance

and quality improvement

Answer 24

- Quality control: Activities to test or inspect a product or service to identify problems before the product or service reaches the customer; “find it, fix it” (retrospective)

• Quality assurance: Activities to identify problems in a process that might lead to problems with a product or service; “looking further up the line” (prospective) using quality standards
• Quality improvement: Activities to continually monitor and improve all processes within a system (prospective and retrospective)

Question 25

Describe basic facts about the reportable disease chancroid

Organism, Reservoir, Mode of transmission

Incubation period, infectious period

Epidemiology

Presentation, Testing

Case management, Contact management

+/- Immunization

Answer 25

Chancroid (reportable)

• Organism: Haemophilus ducreyi (Gram-negative rod)
• Reservoir: Human
• Mode of transmission: Direct contact with ulcer (no asymptomatic transmission)

Epidemiology:
- Attack rate > 50%
- Eliminated in many parts of the world (not endemic in Canada); cases often
associated with travel, with clustering around index case
- Associated with sex work
- Risk of HIV infection increases 10-50x if concomitant H. ducreyi infection

Presentation: Papule (usually on external genitalia) → pustule → rupture to form painful,
purulent, shallow ulcers that bleed easily +/- lymphadenitis

Incubation period: 3-7 days
Testing: Culture for H. ducreyi with special transport media (r/o syphilis and HSV)
Case management: Ciprofloxacin, 500 mg po x 1 OR Erythromycin, 500 mg po tid x 7
days
Contact management: Notify, assess/test, and empirically treat all sexual contacts of the
case for whom contact occurred in the two weeks prior to symptom onset

Question 26

Describe the healthy immigrant effect in Canada.

Answer 26

• Healthy immigrant effect: Phenomenon where foreign-born status is associated with
  better health outcomes than Canadian-born status; attributed to an immigration process
  that selects for healthy, well-educated adults + healthier diets; effect declines with time in
  new country
• Effect stronger in adults than children and elderly; effect stronger for mortality
  than morbidity
• Convergence: Over time, morbidity and mortality of immigrants approach (or
  become worse than) those of the Canadian-born population due to adoption of
  the the same physical, social, cultural, and environmental risk factors, combined
  with socio-economic disadvantage
• Health status post-arrival declines most rapidly in refugees, low-income immigrants, and
  immigrants with low proficiency in English or French

Question 27

Regarding obesity,

what are recent epi trends,

risk factors

and available public health interventions?

Answer 27

Population interventions in summary:

Personal skills:

• social marketing (nutrition, PA)
• Canada Food Guide

Clinical services:

• behavioral interventions (CTFPHC, nutrition, PA, meds/surg)

Community action:

• school/work/facility-based policy (nutrition, PA)

Supportive environments:

• menu/food labeling
• voluntary industry improvement in food quality (low salt/sugar)
• urban design for active transport + walkability
• zoning against fast food near schools,

Health public policy:

• tax unhealthy food (SSB)
• subsidy healthy foods
• marketing restriction (esp. children)

Epidemiology

• *YOUTH**
• Prevalence of overweight+obesity in Canadian children and youth (ages 5 to 17) = 30%
• Prevalence of obesity in Canadian children and youth (ages 6 to 17) = 10.6%
• Prevalence of obesity in Canadian children has tripled since 1979
• *ADULTS**
• _Prevalence of overweight+obesity in Canadian adults = 62% (55% women, 69% men in 2018)
• Prevalence of obesity in Canadian adults = 26.9%_

Modifiable risk factors
- Low physical activity (strongest predictor of obesity at the population level)
- Poor diet (low fruit and vegetable intake; high total energy consumption; 60% of family
food purchases in Canada comprise processed foods)
- Alcohol consumption
- Screen time (sedentary behaviour + exposure to advertising)
- Inadequate sleep

- For childhood obesity: maternal smoking, high birthweight, rapid infant weight gain after low birth weight

• *Non-modifiable risk factors**
• SES (increased income results in decrease risk of obesity in women, but not men)
• Ethnicity (minority status)
• Immigration status
• Environmental factors
• Education (inverse relationship between years of education attained and obesity)
• Income
• Rural residence

Protective factors for childhood obesity: breastfeeding, breakfast consumption

• *Health impacts**
• ENDO: DMII, insulin resistance
• CV: _CVD, h_ypertension
• GI: Gallbladder disease
• MSK: Osteoarthritis, musculoskeletal disorders, Chronic back pain, reduced balance
• Resp: Obstructive sleep apnea, asthma, breathing difficulty
• Cancer: Colorectal, kidney, breast, endometrial, ovarian, pancreatic
• PSYCH: Depression, Low self-esteem, Feeling judged, Being teased or bullied

Interventions
Individual-level health services/clinical interventions (effective at promoting weight loss,
but less effective at preventing weight re-gain)
- Behaviour modification/therapy/coaching
- Behavioral interventions that reduce recreational sedentary screen time among children
- Reduced-energy diet
- Physical activity
- Bariatric surgery
- Prescription medication

• Community-level interventions that influence individual and group behaviours*
• Social marketing (varied impact)
• School-based interventions for children (insufficient evidence)
• Menu and shelf labelling
• Work-based programs for adults (e.g., education, increased access to health food, increased opportunities for physical activity)
• Public policies*
• Subsidy programs to support healthy eating and/or physical activity
• Urban planning that promote physical activity
• Regulation of food advertising to children: Since 1980, Quebec has banned advertising to children; children in Quebec have the lowest obesity rate in Canada
• Taxation on specific foods (e.g., sugar-sweetened beverages)
• Zoning that prevents unhealthy food establishments from school areas

The food industry can play a significant role in promoting healthy diets by: reducing the fat, sugar and salt content of processed foods;
ensuring that healthy and nutritious choices are available and affordable to all consumers; restricting marketing of foods high in sugars, salt and fats, especially those foods aimed at children and teenagers; and ensuring the availability of healthy food choices and supporting regular physical activity practice in the workplace.

Question 28

What are sources of ionizing radiation?

What is the annual radiation dose limit for workers in Canada?

Answer 28

Sources of radiation (and percentage of total ionizing radiation of the average US individual)

• *Background radiation**
• Space sources (e.g., cosmic rays, cosmic microwave background radiation); air travel increases exposure to cosmic radiation (typical cross-Canada flight = 0.02 mSv) (5%)
• Terrestrial radiation (from radioactive constituents of Earth’s crust) (3%)
• Internal radiation (from radioactive isotopes incorporated into the body, e.g., K-40, C-14) (5%)
• Radon and thoron (products of naturally occurring radioactive decay) (37%)
• *Man-made**
• Industrial sources (<0.1%) (nuclear power, weapons, waste)
• Occupational exposure (<0.1%) Annual radiation dose limit for nuclear energy workers in Canada = 50 mSv

- _Medical procedures_ (48%)
Conventional radiography (5%); typical CXR = 0.1 mSv
Interventional fluoroscopy (7%)
Nuclear medicine - isotopes (7%); average PET scan = 10 mSv
CT scan (24%); typical CT chest = 7 mSv

Question 29

What is a health needs assessment and how is it done?

What are data sources that can contribute to the situational assessment?

What are PEEST and SWOT analyses?

Answer 29

Health needs assessment

Definition: “systematic method of identifying unmet health and healthcare needs of a population and making changes to meet these unmet needs” (Wright et al., 1998)

• *Steps:**
  1. Identify the research questions
  a. What is the situation?
  b. What is making the situation better and what is making it worse?
  c. What possible actions can be taken to deal with the situation?

Stratify responses to the research questions according to intervention levels: Individuals, Networks, Organizations, Society

2. Develop a data-gathering plan
3. Gather the data (e.g., f_rom community health status indicators, research data, best practice guidelines, environmental scan, community surveys, community stories or testimonials_, etc.)
4. Analyze, synthesize, and summarize the data (see tables below)
5. Communicate the information
6. Consider how to proceed

Examples of data sources using example of mental health:

1. Sociodemographic profile - Develop a community profile (age, sex etc, pop #s) that is the focus of the HNA - statistics Canada
2. Epidemiology - Describe epidemiology of mental health of the relevant population - P/T mental health surveys, hospitalisation database, physician billing, prescription database
3. Comparative assessment - compare local provision against national norms - CCDSS
4. Service user views - patient surveys, satisfaction
5. Resources available - description of healthcare and allied health available for mental health (e.g. community psychologists, dedicated psychiatric facilities)
6. Healthcare utilization - emergency department visits, EMS call outs

PEEST analysis
What are the political, economic, environmental, social, or technological trends that might
impact the program your organization would like to develop?
Factor Example
Political Local politicians consider the issue important
Economic High unemployment rate and poverty
Environmental High levels of TRAP near your organization’s building limit outdoor activities
Social High turnover in the community (i.e., people regularly moving in and out of
the community)
Technological Low level of internet access in the target group

SWOT analysis
What are the strengths, weaknesses, opportunities, and threats for your organization related to
developing a program that addresses the situation of concern?

Internal:

• *Strength** Highly credible organization that is able to obtain funding
• *Weakness** Ongoing challenges working in partnership with community organizations

External:

• *Opportunity** New grant program available to fund programs addressing the situation of concern
• *Threat** Lack of interest in the situation of concern in the City Council

Question 30

Regarding refined sugars in excess,

what are health impacts

and available public health interventions?

Answer 30

Question 31

What are the principles of health impact assessments?

What are the process steps of health impact assessments?

Answer 31

Health impact assessment

Definition: An HIA is a “combination of methods whose aim is to assess the health consequences to a population of a policy, project, or programme that does not necessarily have health as its primary objective” (Lock, BMJ, 2000)

PRINCIPLES

Holistic approach
To inform a pending decision
For a non-health project or policy
Follows a standardized process (includes at least screening, scoping and appraisal)
Multidisciplinary approach (at least within the public health sector)
Concern for inequality (distribution of effects)
Based on an evidence search
Neutral, objective (without a priori solutions), transparent
Realistic recommendations

Process (SSARME)
- Screening: Could the proposed policy, program, or project impact health? Are these
impacts substantial enough to warrant an HIA?
- Scoping: What is the scope of the HIA? What information is required and who will
collect it? How much time is available?
- Appraising: What is the likely impact of the policy, program, or project on health, based
on the available evidence?
- Reporting: Are there modifications to the policy, program, or project based on the
findings of the evidence appraisal?
- Monitoring: What are the real impacts of the policy, program, or project on health?

- Evaluation: Was the HIA process successful?
Evaluation of the effectiveness of an HIA should examine:
- Context: Broader decision-making context; the values, purpose, and goals of the HIA;
HIA parameters (e.g., given the context, was it possible for the HIA to be effective?)
- Process: Transparency, organizational capacity and experience, adequacy of time and
resources
- Impacts: Proximal (e.g., informing or changing decisions or implementation) vs. distal
(e.g., development of partnerships, improved understanding of the SDOH outside the
health sector)

Question 32

Regarding prostate cancer,

what are recent epi trends?

risk factors?

CTFPHC screening recommendations?

Answer 32

Prostate cancer

• *Epidemiology**
• Most commonly diagnosed cancer in men, other than skin cancer
• Third-leading cause of cancer-related death in men (lifetime risk of death due to prostate cancer = 3.6%)
• 1 in 7 Canadian men will be diagnosed with prostate cancer in their lifetimes
• Prevalence of undiagnosed prostate cancer at autopsy in men ages 70-79 years is 70%
• Prostate cancer has the highest 10-year survival rate of any cancer in men (95%)

Risk factors
- Known risk factors: Older age, family history, African-American race
- Possible risk factors: Diet high in fat, dairy, red meat, or processed meat; overweight and
obesity; prostatitis; high levels of testosterone; tall adult height; pesticide exposure
(unknown which specific pesticides); occupational exposures to cadmium or chemicals
used for rubber manufacturing

Screening recommendations
- European Randomized Study of Screening for Prostate Cancer (ERSPC) found a small
absolute reduction in prostate cancer mortality in the group randomized to receive PSA
screening (13 lives saved per 10,000 men invited for screening)
- Overdiagnosis: Cancer correctly detected, but cancer would not have caused
symptoms or death; 40-56% of men screened who received a diagnosis of
prostate cancer in the ERSPC study were estimated to be overdiagnosed
- Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCO) found no effect
of screening on prostate cancer mortality (0 lives saved per 10,000 men invited for
screening)
- Neither study found that screening had an impact on all-cause mortality
- No trials have examined the impact of DRE alone on mortality
- Harms of prostate biopsy: hematuria, infection, hospital admission, overdiagnosis, and
death
- Benefits of prostate biopsy: Diagnosis

CTFPH recommendations (2014)
1. For men aged less than 55 years, we recommend NOT screening for prostate cancer with
the prostate-specific antigen test. (Strong recommendation; low quality evidence)
2. For men aged 55–69 years, we recommend NOT screening for prostate cancer with the
prostate-specific antigen test. (Weak recommendation; moderate quality evidence)
3. For men 70 years of age and older, we recommend NOT screening for prostate cancer
with the prostate-specific antigen test.(Strong recommendation; low quality evidence)

Question 33

Discuss homelessness in Canada

• Define it
• Recent epi trends
• Risk factors
• Impacts on health outcomes and health care utilization
• Available public health interventions

Answer 33

Persons experiencing homelessness

• *Homelessness:** Lack of stable, permanent, appropriate housing, or the immediate prospect, means, and ability of acquiring it
• Chronic homelessness: Individuals who are currently homeless and have been homeless for > 6 months in the last 12 months (i.e., 180 cumulative nights in a shelter or place not fit for human habitation)
• Episodic homelessness: Individuals who have experienced 3 or more episodes of homelessness in the last 12 months
• Transitional homelessness: Housed in supportive, but temporary, shelter
• Roofless: Homeless and living outside

Epidemiology:
- Timeline:
- Pre-1980s: Small number, mostly single men
- 1980s to 2000s: Increasing number of persons experiencing homelessness; attributed to closures of long-term psychiatric care facilities
- 2000s: Increased investments in shelters
- Now: Increasing system integration; Housing First
- 35,000 Canadians are homeless on a given night, of which 13,000-33,000 are chronically homeless
- 235,000 Canadians experience homelessness in a year, of which:
- 5,000 are unsheltered
- 180,000 are staying in emergency sheltered
- 50,000 are provisionally sheltered (e.g., motels, couch-surfing, jail, hospitals)

• Risk factors for homelessness (note that with appropriate structural supports, individual risk factors do not lead to homelessness):

Individual:

• Adverse childhood experiences
• Mental illness and substance use

- Indigenous (28-34% of the shelter pop is Indigenous)

• Criminal justice system experiences
• Marital breakdown / intimate partner violence

Community:

• Institutionalization (health care, child protection, jail)
• Housing unaffordability
• *Impact of homelessness on health care use**:
• Prioritizing seeking food and shelter above medical care
• Difficulty adhering to medication regimens (e.g., due to lack of storage space, unable to regularly take with food, limited access to clean water, limited access to toilets for GI side effects)
• Difficulty obtaining a health card without an address
• Difficulty accessing medical services without a health card
• Difficulty booking appointments (no address or return phone number)
• Difficulty receiving coordinated healthcare (medical records stored in several locations)
• Personal appearance and or personal hygiene that may be alarming to some working in or utilizing health care services
• _Difficulty paying for prescription_s and items not covered by the province
• Challenges to recuperation following treatment due to a lack of caregivers and space to recuperate
• *Health outcomes associated with homelessness:**
• Cardiovascular disease
• Mental illness and substance use
• Injuries, including traumatic brain injury (unintentional, intentional, and self-harm)
• Hypothermia / frostbite
• _Tuberculosis
• Hepatitis B and C
• HIV_
• _Scabies
• Body lice_
• Bartonella quintana (“urban trench fever”; documented in US and France)

Public health interventions:
- Monitoring and surveillance of health outcomes of individuals experiencing homelessness
- Case management (for psychiatric patients, assertive community treatment)
- Housing first: Strategy for addressing homelessness that provides housing without requiring individuals to engage with services or find a job first; improves health outcomes
and reduces involvement with justice and healthcare system
- Poverty reduction / income support
- Affordable housing
- Eviction prevention
- Institutional transition support (housing on discharge)
- Employment opportunities for low-skilled workers
- Primary prevention: Anti-violence interventions, early childhood interventions

Question 34

Define liberalism, communitarism, utilitarianism and postmodernism.

Contrast libertarianism and egalitarian liberalism.

Answer 34

Philosophical paradigms
Philosophical paradigms are used to justify the choice of an ethical framework and the choice of
a particular intervention.

Liberalism: States should intervene to protect individual rights
- Libertarianism: Negative rights (i.e., freedom from…) should be protected, but
otherwise, there should be no state intervention
- Egalitarian liberalism: Both negative and positive rights (i.e., freedom from and
freedom to…) should be protected, and resources should be distributed in a way that
allows freedom of choice (“the right to choice is meaningless without resources”)

Communitarianism: States should intervene in order to create or maintain a good society (i.e.,
the good of society is prioritized over the good of individuals)

**Utilitarianism**: _Decisions should be judged by their consequences; most common approach in
public health_ (e.g., contrasting two programs on the basis of _QALYs)_

Postmodernism: Rejects the idea that there is objective moral truth than exists, so there is no
deeper justification for state intervention

Question 35

Describe 5 waste water treatment steps

Answer 35

Wastewater treatment
Screening: Large pieces of debris (“chunks”) are removed and disposed of in a landfill
Settling: Solids settle to the bottom of a tank; supernatant is removed
Aeration: Supernatant is aerated (or filtered) to allow aerobic microorganisms to consume
organic material
Clarifier: Solids settle to the bottom of the tank (again) and are sent to sludge processing (sludge from settling tank and clarifier is digested by microorganisms)
Disinfection: Aerated supernatant is disinfected (usually with chlorine) and then returned back
to the water cycle
Sludge disposal: Processed sludge can be used in agriculture, incinerated, or sent to landfill
Waste-to-energy: Methane is produced by the sludge processing, which can be captured and
burned for energy

Question 36

List 3 categories of chlorine disinfection by-products.

What is the suspected cause of eye and respiratory tract irritation in swimmers?

Answer 36

• Health risks of swimming more likely to come from chlorination than microbiological
  contamination
• Disinfection by-products (DBPs): Produced when chlorine reacts with organic matter;
  divided into three major groups:
• Halogenic organics: E.g., Chloramines, trihalomethanes (including chloroform and bromodichloromethane), chloral hydrate
• Chloramines, rather than chlorine itself, are the suspected cause of eye and respiratory tract irritation of swimmers → may explain the increased risk of asthma, bronchial hyperreactivity, and airway inflammation in elite swimmers
• Two trihalomethanes (chloroform and bromodichloromethane) are IARC 2B
• Non-halogenic organics: E.g., aldehydes, benzene
• Inorganics: E.g., chlorate
• “at recommended swimming pool FAC (free available chlorine) levels (ranging from 0.8-5.0 ppm according to swimming pool guidelines and regulations across Canada), ingestion of pool water does not have adverse health effects on bathers” (NCCEH)

Question 37

What factors need to be considered when calculating a sample size?

How can statistical power be increased?

Answer 37

Sample size calculations
How many people do we need to detect a statistically significant difference between the null and
alternative hypothesis?

Sample size determined by:
1. Hypotheses
2. Type I error rate
3. Power (1 - type II error rate)
4. A particular alternative value
5. An estimate of population variance

How can statistical power be increased?

Increase sample size

Increase alpha

Increase effect size

Decrease random error

Conduct one-tailed test

Question 38

Describe the jurisprudence around HIV disclosure criminalization?

Answer 38

Criminalization (hot topic): In Canada, non-disclosure of HIV status prior to a sexual act may be punishable as a criminal offense (usually charged with aggravated sexual assault); neither intent to harm nor transmission are necessary for criminal charges; partner is not required to ask about status; although it has not been tested, people who might have HIV and ought to be aware of that possibility could be charged, even if they have not been tested; no evidence that criminalization reduces transmission or increases disclosure

• 1990s: Legal obligation to disclose HIV established by case law
• 2012: R. v. Mabior and R. v. DC established legal obligation to disclose HIV status if there is a “realistic possibility of transmission”; no duty to disclose from a criminal perspective when engaging in vaginal/oral sex with a condom and an undetectable viral load or when engaging in kissing or masturbation; rulings did not comment on anal sex
• 2014: Canadian consensus statement on HIV and its transmission in the context of criminal law

2019 update:

There is an obligation to disclose HIV-positive status to
a sexual partner before activity that poses a “realistic
possibility” of HIV transmission— and prosecutors and
courts effectively determine what this means.
• According to the Supreme Court of Canada, there
is no obligation in Canadian criminal law to disclose
HIV-positive status when having vaginal or anal sex if a
condom is used and the HIV-positive partner has a “low”
viral load (under 1500 copies/ml).
• Whether a person might be prosecuted and convicted
for not disclosing their HIV-positive status in other
circumstances is still evolving, and depends on court
decisions and on directives and guidelines governing
prosecutors (where they exist).
• A federal directive limits prosecutions in Canada’s
three territories. Formal policy for provincial Crown
prosecutors has been adopted in Ontario and British
Columbia. An advisory has been given to provincial
prosecutors in Alberta.

Question 39

Compare and contrast direct vs indirect standardization.

Answer 39

Standardization
Direct standardization
“The process where the rate of disease (or mortality) in a population is calculated on the
assumption that the population had a standard age-sex distribution. If this is done for several
different study populations then the resulting standardized incidence (mortality) rates can be
directed compared because any differences in age/sex between the populations have been
removed. Direct standardization is most commonly performed for age and sex but can be
performed for other characteristics such as race, socioeconomic status.”
Your question: How many deaths per year would you expect in your study population if your
study population had the same age distribution as a reference population?
You need:
1. The age-specific disease rates in your study population; and
2. The age distribution of the standard population
You get: A standardized mortality rate (expected deaths/100,000/year)

Indirect standardization
“The process where the observed number of events in a study population is compared to the
number of events that would have been expected to occur if the study population had the same
incidence/mortality rate as a reference population. Indirect standardization is most commonly
performed for age and sex but it can be performed for other characteristics, such as race,
socioeconomic status.”
Your question: How many times greater (or less) is the mortality rate in your study population
than in the reference population?
You need:
1. The age distribution of your study population; and
2. The age-specific disease rates in the standard population
You get: A standardized mortality ratio (SMR)
**Cannot compare one SMR to another SMR**

Question 40

Describe recent epi findings related to occupational illnesses.

Answer 40

• Workers are most likely to be injured within the first month of work than any other time
  (RR = 3)
• Younger workers are more likely to be injured than older workers
• Almost 40% of back pain worldwide is due to occupational ergonomic stressors
• Industries reporting the highest number of workplace injuries: #1. Healthcare, #2.
  Manufacturing, #3. Construction (2015 totals)
• Common occupational health issues:
• Sprains and strains (40% of Ontario WSIB claims)
• Traumatic injury (30% of Ontario WSIB claims)
• Probably under-reported:
• Noise-induced hearing loss: “Notch” in audiogram around 4000 Hz
• Silica-related lung disease
• Occupational dermatitis
  *Health outcomes very rarely pathognomonic for exposure, so it is often challenging to link
  disease to specific exposures

Question 41

What are the leading causes of death in Canada?

Answer 41

Source: Statistics Canada, year = 2019.

Leading causes of death, both sexes:

1. Cancer, 80k deaths
2. Heart diseases, 53k
3. Accidents, 14k
4. Cerebrovascular disease, 14k
5. Chronic lower respiratory diseass, 13k
6. Diabetes mellitus
7. Influenza and pneumonia
8. Alzheimer’s disease
9. Intentional self-harm (suicide)
10. Kidney Disease

2011 distribution by sex held true in 2019, see image

Disease burden in DALY (as per GBD tool)

Cancers combined
Ischemic heart disease
Back pain
Lung cancer
Diabetes
Stroke

By age group per Statistics Canada

1-14: cancer, accidents,

Question 42

What are potential health hazards of placentophagy?

Answer 42

Placentophagy (hot topic)
Consumption of the human placenta after birth is become increasingly common based on the
belief that it contains vitamins, minerals, or hormones that may help the mother recover after
birth.
Forms: Encapsulated, raw (e.g., in a smoothie), cooked (e.g., in pasta sauce)
Methods:
- Patient or her family prepares the placenta: Only eaten by patient or her family; or Sold
or given to other people
- Person hired by patient or her family prepares the placenta: Prepared in the patient’s
home; or Prepared in another location

Potential hazards:
- No case reports of communicable disease transmission as a result of placentophagy
- No conclusive evidence of risks or benefits
- The placenta is not sterile (its microbiome is similar to that of the human mouth) and it is
reasonable to consider it a potential vector for disease, including sexually transmitted
infections, yeasts, and bacterial contamination from the mother or the environment,
including hospital-acquired infections. Other hazards might include:
- Blood-borne diseases (e.g., through cross-contamination between one person’s
capsules and another person’s uncooked placenta);
- Prion diseases (note that iatrogenic Creutzfeldt-Jakob disease has only been
associated with “exposure to infectious brain, pituitary, or eye tissue”); and
- Organisms that reach high concentrations in placental tissues (e.g, Coxiella
burnetii, the causative agent of Q fever; “The organism has unusual stability, can
reach high concentrations in animal tissues, particularly the placenta, and is
highly resistant to many disinfectants.”).

Legal status
- Status of placenta capsules or placenta-preparation businesses in Ontario is unclear;
products may fit into one of three categories:
- Natural health product: If so, the manufacturer must comply with the licensing
requirements of the Natural Health Products Regulations (Health Canada),
including good manufacturing practices and evidence of safety and efficacy.
However, products compounded by a healthcare provider for an individual patient
are exempted from these regulations.
- Biomedical waste: Guideline C-4: The Management of Biomedical Waste in
Ontario recommends incinerating human anatomical waste. The Guideline also
recommends extensive special handling procedures.
- Food: If placenta-preparation businesses are considered food premises, then
they must comply with the Health Protection and Promotion Act, Regulation 562:
Food Premises.

Question 43

What are 10 types of risks for an organization?

What type of activity can risk management action plans contain?

Answer 43

Risk management
Basic concepts
- Risk: Chance of an occurrence that will have an impact on the achievement of
objectives (positive or negative)
- Residual risk: Level of risk remaining after mitigation strategy employed
- Risk increases as you move from project/operational decisions to program
decisions to strategic decision
- Risk management: Systematic approach to preparing for risk through identification,assessing, understanding, acting on, and communicating risk issues
- Examples of risks: Financial (e.g., fraud, funding), operational, organizational (e.g., staff morale, succession, retention, surge capacity), privacy, security, technology, equity, governance, environment, and legal issues
- Risk intelligence: Organizational ability to think about risk and uncertainty and
effectively use forward-looking risk concepts
- Risk oversight: Systematic approach to determining whether or not an organization has
a robust risk management process (risk oversight = what boards do; risk management =
what organization does)

• Risk management process:
• Objectives: What are the outcomes of interest?
• Identify: Use a structured approach to ensure that all risks threatening the
  objectives are identified and documented
• Assess: Consider probability, impact, and timing; build a HIRA of the identified
  risks (probability x impact)
• Plan and take action: For acceptable risk exposures, document rationale for
  acceptability; for unacceptable risk exposures, document and communicate
  action plans;

Action plan may be:
- Preventive: Reduce probability of risk
- Detective: Detect early, intervene early, and reduce impact
- Recovery: Improve response strategies to reduce impact
- Monitor and report: Monitor status of risks, effectiveness of action, and revise
assessments and action plans as required; share risk-related information via
regular reporting mechanisms

• Key risk indicators: Indicator of the probability that a risk will occur (e.g.,
  average time to fill vacant positions, audit findings, number of reporting
  deadlines missed)

Question 44

When is smallpox vaccine recommended?

What are possible adverse events related to smallpox vaccination?

What would be the PEP and type of precautions for smallpox?

Answer 44

Smallpox (Variola)
- Two strains of the smallpox virus, Variola major and Variola minor
- Eradicated in 1977
- Canadians born after 1972 have not been routinely immunized against smallpox;
individuals born in 1972 or earlier may have partial immunity
- PHAC maintains stockpiles of smallpox vaccine and VIG
- Remaining variola virus stocks are kept in 2 WHO reference labs

Route of exposure: Droplet or aerosol (i.e., airborne precautions required)
Incubation period: 10-14 days
Presentation:
- Prodrome (1-4 days): Fever, fatigue, malaise, headache
- Rash (weeks): Progression from macules → papules → umbilicated vesicles → scabs
(infectious while rash is present)
Fatality rate:
- Variola major: 25%
- Variola minor: 1%
Treatment: Supportive
Vaccination and PEP:
- Vaccine administered via scarification into the epidermis; results in the development of a
papule surrounded by erythema (if no papule or vesicle forms, individual should be
vaccinated again)
- Touching the vaccine site before the area heals can lead to auto-inoculation of other
sites or inoculation of other people
- Vaccination currently recommended only for laboratory workers working with
orthopoxviruses
- PEP (vaccination only, not VIG) given within 2-3 days of exposure protects against
development of smallpox and PEP given within 4-5 days reduces risk of death

• Adverse events related to vaccination include:
• Generalized vaccinia: Vaccine-associated viremia results in lesions developing in
  unimmunized skin; usually benign
• Progressive vaccinia: In individuals with immune defects (esp. T-cell
  deficiencies), progressive skin and organ necrosis develops; often fatal
• Eczema vaccinatum: Vaccinial skin lesions develop in eczematous areas; usually
  self-limited, but can be fatal
• Vaccinia keratitis
• Post-vaccinial encephalitis
• Acute myopericarditis
• Most adverse events (with the exception of vaccinia keratitis) can be treated with VIG

Question 45

Describe basic facts about lyme disease

Organism, Reservoir, Mode of transmission

Incubation period, infectious period

Epidemiology

Presentation, Testing

Case management, Contact management

+/- Immunization

Answer 45

Lyme disease (reportable)
- Organism: Borrelia burgdorferi sensu lato (“borrelia in the widest sense”): a spirochete
bacteria; this includes B. burgdorferi sensu stricto (“borrelia in the strictest sense”), B.
afzelii, B. bavariensis, B. garinii, and B. spielmanii; only the first occurs in North America;
the others occur in Europe and Asia
- Mode of transmission: Vector-borne; in eastern Canada, by Ixodes scapularis
(blacklegged ticks); in western Canada, by Ixodes pacificus and Ixodes angustus (the
latter two are less capable of carrying Borrelia); tick must be attached for > 24h (usually
> 36-48 h) to transfer the spirochete; Lyme disease cannot be transmitted directly from
an animal to a human or by person-to-person contact (although transmission via blood
transfusion is possible)
- Reservoir: Black-legged ticks are most commonly carried by white-footed mice and
white-tailed deer; other small mammals and birds can also carry ticks. Deer cannot be
infected with Lyme disease, but they can transport ticks that can then pick up B.
burgdorferi when they feed on small animals and birds
- Epidemiology: Incidence highest when nymphal ticks are most active (because they are
small and more likely to remain attached long enough to transmit disease); incidence
increasing in Canada due to warmer temperatures
- Presentation:
Stage Clinical presentation Incubation period
Early localized disease: Erythema migrans, or a “bull’s eye” rash, occurs in 60-80 percent of people; “bull’s eye” must be >5cm Flu-like symptoms (fatigue, headache, myalgias, fever) , inbuation of 1-2 weeks
Early disseminated disease:
Neurological: aseptic meningitis, cerebellar ataxia, seventh nerve palsies (in Lyme-endemic
areas, up to 1 in 4 patients presenting with seventh nerve palsy (Bell’s palsy) have Lyme
disease), incubation is weeks to months
CVS: Bradycardia, AV block, cardiomegaly
Derm: Multiple erythema migrans lesions
Late disease: Arthritis of the hips or knees, rare neurological problems, incubation is Months to years
Post-Lyme disease syndrome (PLDS):
Patients who have had well-documented Lyme disease who report subjective MSK pain, cognitive impairment, and fatigue despite appropriate treatment
- Testing: PHAC and CDC recommend a two-tiered approach, a_n enzyme immunoassay
(e.g., ELISA), then a Western blot test for IgM/IgG if the enzyme immunoassay is
positive or indeterminate_; early localized disease is a clinical diagnosis based on S/S
and exposure history (IgM ab do not develop for several weeks after infection)

• PEP: Single dose of doxycycline for patients > 8 years old if:
• Lyme-endemic area AND
• Patient has removed a tick within the last 72 h AND
• Tick is engorged or has been attached for > 24 hours AND
• Patient has no allergy to doxycycline and is not pregnant
  PEP is not recommended for children < 8 years because “the of absence of data on an
  effective short-course regimen for prophylaxis, the likely need for a multiday regimen
  (and its associated adverse effects) [14-day course of amoxicillin], the excellent efficacy
  of antibiotic treatment of Lyme disease if infection were to develop, and the extremely
  low risk that a person with a recognized bite will develop a serious complication of Lyme
  disease” (IDSA guidelines)
• Case management/treatment: First-line treatment in adults is amoxicillin, 500 mg PO TID
  x 14-21 days OR doxycycline, 100 mg PO BID x 14-21 days; first-line treatment for
  children is amoxicillin, 50 mg/kg/day divided q8h x 14-21 days
• Other: Integrated tick management: The use of several methods to reduce the number of
  ticks; includes personal protective measures (light-coloured, long-sleeved pants; closedtoed
  shoes; DEET; and performing a tick check after spending time in long grass or
  wooded areas) + landscaping methods (restrict use of ground cover plants; plant deer resistant
  plants; relocate high-use areas away from woodland edges; isolate high-use
  areas from woodland edges with wood chip, mulch, or gravel borders; discourage rodent
  activity, cut grasses short; remove leaf litter and brush)

Question 46

Compare and contrast the different E. Coli strains

Answer 46

E. coli consists of a diverse group of bacteria. Pathogenic E. coli strains are categorized into pathotypes. Six pathotypes are associated with diarrhea and collectively are referred to as diarrheagenic E. coli.

Shiga toxin-producing E. coli (STEC)—STEC may also be referred to as Verocytotoxin-producing E. coli (VTEC) or enterohemorrhagic E. coli (EHEC). This pathotype is the one most commonly heard about in the news in association with foodborne outbreaks (0157). TTP-HUS (e.g. O157); abx may
increase risk of HUS; HUS is leading cause of renal failure in children in Canada

Enterotoxigenic E. coli (ETEC) Common cause of travellers’ diarrhea and <5 mortality in LMICs

Enteropathogenic E. coli (EPEC) Most commonly occurs in nonbreastfed infants (rare in HICs)

Enteroaggregative E. coli (EAEC)

Enteroinvasive E. coli (EIEC) When you think someone has bacillary dysentery (bloody stool, fever), they probably actually have EIEC; endemic in LMICs

Diffusely adherent E. coli (DAEC)

Question 47

List determinants of health according to PHAC (12)

Answer 47

Determinants of health according to PHAC:

1. Income and social status: As income and social status increase, individual health status increases; as income and social inequality decrease, population health status increases (evidence: Whitehall study)
   a. Health gradients: At every income level, people in higher strata have better outcomes than people in lower strata
2. Social support networks: Increased social contact and emotional support reduces mortality; social networks influence risk factor exposure (e.g., physical activity, obesity)
3. Education and literacy: Education level predicts SES, improves job security, and increases job satisfaction; literacy allows individuals to access knowledge required for problem-solving
4. Employment/working conditions: Unemployment, unemployment, stressful work environments, and unsafe work environments are associated with poorer health outcomes
5. Social environment: Cohesive, diverse, and stable institutions, organizations, and informal networks reduce the risk of crime and violence
6. Physical environment: Air, water, soil, and food contaminants can adversely affect health; the built environment can influence both physical and psychological well-being
7. Personal health practices and coping skills: The actions individuals perform to selfcare, problem-solve, and cope can enhance or detract from health (e.g., smoking, alcohol use, drug use, unsafe sex, dietary choices)
8. Healthy child development: Health outcomes are affected by birth weight, parental attachment, childhood housing, family income, parental education, access to nutritious foods and physical recreation, and access to dental and medical care
9. Biology and genetic endowment
10. Health services
11. Gender: Culturally-determined values and roles ascribed to the sexes
12. Culture: Marginalization, stigmatization, and devaluation of language of minority cultures by the majority culture can lead to additional health risks (e.g., through lack of culturally appropriate
    health care services, through socio-economic exclusion)

Question 48

Define risk assessment, risk management and risk communication

Answer 48

• Hazard: A potential danger to health
• Risk: Probability of hazard x impact of hazard (see also: HIRA)
• Risk assessment: “A systematic process for describing and quantifying the risk
  associated with hazardous substances, processes, action, or events”; descriptive
• Risk management: Steps taken to alter (i.e., reduce) the levels of risk to which an
  individual or population is subject”; the active process of controlling hazards for which a
  risk assessment has indicated an unacceptably high level of risk
• Risk communication: Communicating the nature of the risk and the responses to the
  risk; two-way process
• Acceptable risk: Level of risk to which a target population considers acceptable; a
  social judgment, not a scientific one
• As low as reasonably achieveable (ALARA): When an acceptable risk level is unknown or
  cannot be achieved, regulations may use the ALARA limit based on the best available
  control technology

Question 49

Describe the air quality index and its limitations in communicating risks to at-risk populations

Answer 49

Air quality index:
- Scale 0-100 (very good to very poor air quality)
- Pollutants included CO, NO2, PM2.5, SO2, O3, TRS (but only the value for the highest
pollutant is used at any one time) NO2, PM2.5, O3 (weighted)
- Basis for scale Regulatory standards for air quality
- Standardized across provinces
- Results Primarily driven by ozone in the summer and PM2.5 in the winter

Criticism of using AQ indices to drive public health messaging:
- Most (2/3) of the effects of air pollution on health occur secondary to long-term exposure (i.e., annual AQ levels are more important to health than real-time indicators)
- Most people spend most of their time indoors, so most exposures to outdoor air pollutants occur indoors; this is particularly true of those at highest risk of harm from air pollutants (the elderly, those with pre-existing CV and resp conditions); i.e., the messaging associated with AQ indices (stay indoors, reduce strenuous exercise) is often
irrelevant to those at highest risk
- Messaging associated with AQ indices emphasizes that some days, everyone is at a higher risk of harm from air pollutants; the messaging does not acknowledge that on all days, some people are at higher risk (e.g., those who live near major traffic arteries)
- Not validated for non-urban areas
- Range of RR from study that the AQHI is based on = 1 to 1.1

Question 50

Describe basic facts about prion diseases

Agent, Reservoir, Mode of transmission

Incubation period, infectious period

Epidemiology

Presentation, Testing

Case management, Contact management

+/- Immunization

Answer 50

Prion diseases / transmissible spongiform encephalopathies
- Agent: Prion protein (abnormally-folded form of a host-encoded cellular protein)
- Sporadic Creutzfeldt-Jakob disease (85% of CJD cases): Sporadic development
of abnormal protein folding
- Iatrogenic CJD (<1% of CJD cases): Exogenously acquired due to an iatrogenic
exposure
- Familial CJD (15% of CJD cases): Inherited CJD, due to a mutation
- Variant CJD: Exogenously acquired; CJD caused by exposure to bovine
spongiform encephalopathy
- Gerstmann-Straussler-Scheinker disease: Inherited, due to a mutation
- Fatal familial insomnia: Inherited, due to a mutation
- Kuru: Exogenously acquired via funerary cannibalism

• Reservoir: Humans (except vCJD)
• Mode of transmission: All types of prion disease, even those that are inherited or
  spontaneously arise, are transmissible
• Epidemiology:
• Worldwide incidence of CJD is 1-2 cases/1 million persons; Canadian incidence
  is the same as worldwide incidence
• Usually affects the middle-aged and elderly, except vCJD (mean age = 28 years)
• 226 vCJD cases identified worldwide as of 2012; incidence decreasing as animal
  feeding practices improve
• Presentation: Progressive neurodegenerative disease (dementia, confusion, myoclonus)
  resulting from tissue deposition of prions; FFI results in intractable insomnia
• Incubation period: Decades (although may be months in vCJD)
• Testing: Clinical features + MRI + EEG + CSF +/- postmortem brain biopsy
• Case management: Supportive care
• Contact management:

IPC implications:

• Exposure routes for iatrogenic CJD: Growth hormone, gonadotropin, dura mater
  graft, corneal graft, instrument exposure (risk of transmission from asymptomatic
  patients is negligibly low)
• Institutions should track their reused equipment; otherwise, all equipment that
  may have come into contact with an infectious patient must be discarded
• Stainless steel can tolerate CJD decontamination; plastic and electronic devices
  cannot (decontamination requires NaOH or NaOCl + autoclaving)
• Instruments that may have contacted a CJD patient must be quarantined until the
  diagnosis is excluded

Question 51

Discuss the public health implications of supervised injections sites:

• its objectives?
• its public health impact?

What services are usually provided at SIS?

What are ETHICAL pros/cons values for SIS?

Answer 51

Case study: Supervised injection sites (hot topic)

• *Supervised injection sites**: “Legally sanctioned and supervised facilities designed to reduce the health and public order problems associated with illegal injection drug use”
• *- Objectives:**

1) Reduce public disorder, increase public safety,

2) reduce overdose morbidity and mortality,

3) increase access to health and social services

• *Impacts of SISs:**
• Reduction in harmful injection behaviour
• Reduction in the spread of bloodborne infections, resulting in savings to the health care system
• Reduction in violence, victimization/sexual assault, public disorder, and arrest while intoxicated
• Reduction in overdose fatalities
• Increased access to healthcare (e.g., for abscesses, psychosocial support, foot care, pregnancy tests) and social services (like housing, employment assistance and food banks)
• reduce public drug use and discarded drug equipment
• reduce strain on emergency medical services, so they can focus on other emergencies
• provides space for people to connect with staff and peers, which can help a person moderate their drug use and decide to pursue treatment

Services typically provided at SISs include sterile injecting equipment, emergency medical care, basic health services, BBSTI testing, needle exchange, counselling/MH, referrals to other agencies and supports, education on drugs and injection techniques, drug checks, treatment/referral for drug treatment

ETHICAL AGAINST

Beneficence, non-maleficence - injecting drugs is inherently dangerous

Duty to provide care, deontologic consideration - participating and witnessing inherently dangerous clinical process of injecting drugs

Resource stewardship

Trust - unintended consequences on community hosting site

ETHICAL FOR

Utilitarianism - practical approach to save lives

Solidarity

Respect for autonomy

Timeline:
- 2003: Insite opened in Vancouver, operated under an exemption from the Controlled Drugs and Substances Act
- 2011: Supreme Court of Canada required the federal government to maintain Insite’s exemption from the CDSA
- 2013: Federal government introduced the a bill that would become Respect for Communities Act; on the surface, it allows the creation of new SISs, in line with the 2011 Supreme Court decision, but in practice, creates multiple barriers to implementing new
SISs
- 2015: Respect for Communities Act receives royal assent, requiring extensive consultation before implementing SISs

Question 52

Describe basic facts about amebiasis

Organism, Reservoir, Mode of transmission

Incubation period, infectious period

Epidemiology

Presentation, Testing

Case management, Contact management

+/- Immunization

Answer 52

Amebiasis
Organism: Entameba histolytica
Reservoir: Humans
Transmission: Person-to-person or fecal-oral
Presentation: Usually asymptomatic, but can cause amebic dysentery
Case management: Cases require enteric precautions
Tx = Systemically-active amebicide + luminal amebicide
Public health measures: Personal hygiene, sanitation systems, water treatment, safer sex

Question 53

Compare and contrast treponemal and non-treponemal syphilis tests?

Answer 53

Testing: Blood test; test individuals with risk factors, symptoms, or contact with a case; perform routine prenatal screening (repeat at 28-32 weeks and at birth if high risk)

• Non-treponemal tests: Detect non-specific antibodies formed by host response to syphilis infection; may be falsely negative in early primary syphilis and late syphilis and may be f_alsely positive due to other infections_ (esp treponemal infections, yaws, bejel, pinta), lupus, and very high antibody levels (hook effect) (in Ontario, rapid plasma reagin (RPR), which detects anti-cardiolipin antibodies,
  and T. pallidum particle agglutination (TPPA) are used); will decline with treatment
• Treponemal tests: Detect anti-treponemal IgG and IgM, but may be falsely negative early primary infection; usually positive for life after infection (in Ontario, chemiluminescent immunoassay (CLIA) is the treponemal test +/- fluorescent treponemal antibody absorbance (FTA-Abs) if RPR and TPPA are non-reactive or indeterminate)

Question 54

What are notifiable diseases under IHR?

What are nationally notifiable diseases in Canada?

What are sections 22, 35 and 102 in Ontario?

Answer 54

Communicable disease legislations

Global:

Always Notifiable under IHR: Smallpox, Poliomyelitis due to wild-type poliovirus, Human influenza caused by a new subtype, Severe acute respiratory syndrome (SARS)

Other Potentially Notifiable Events may include cholera, pneumonic plague, yellow fever, viral hemorrhagic fever, and West Nile fever, as well as other biological, radiological, or chemical events that meet IHR criteria.

Federal:
- Nationally notifiable diseases: “Communicable disease that have been identified by the
federal government and all provinces and territories as priorities for monitoring and
control efforts”
- Criteria used to identify diseases that are nationally notifiable: International
regulations, incidence in Canada, severity, communicability, potential for
outbreaks, socioeconomic burden, preventability, risk perception, necessity for
public health response, changing incidence patterns
- P/Ts voluntarily submit notifiable disease data to PHAC on an annual basis
- Nationally notifiable diseases differ from provincially reportable diseases
https://en.wikipedia.org/wiki/Notifiable_diseases_in_Canada

Provincial (Ontario):
- Reportable diseases: Diseases for which public health agencies must be notified by
law; facilitates surveillance and disease control; all reportable diseases are infectious,
but not all reportable diseases are communicable (e.g., botulism, some types of
encephalitis and food poisoning, hantavirus, legionellosis, Lyme, malaria)
- Communicable diseases: Diseases that spread from person to person (general) or list
of diseases contained in O.Reg 558/91 (Ontario-specific); an MOH can issue a section
22 for a communicable disease listed under O.Reg 558/91; if an individual breaches a
section 22 order for a virulent disease, an MOH can apply to a judge for a section 102
order
- Virulent diseases: A sub-set of communicable diseases in the HPPA; the HPPA lists
cholera, diphtheria, Ebola, gonorrhea, hemorrhagic fevers, Lassa, leprosy, Marburg,
plague, syphilis, smallpox, tuberculosis, SARS as virulent; an MOH can issue a section
22 order for a virulent disease; if an individual breaches a section 22 order for a virulent
disease, an MOH can apply to a judge for a section 35 order

• Section 22 orders: Under the HPPA, an MOH may issue a section 22 order to an
  individual with a communicable disease if:
• “that a communicable disease exists or may exist or that there is an immediate
  risk of an outbreak of a communicable disease in the health unit served by the
  medical officer of health;
• “that the communicable disease presents a risk to the health of persons in the
  health unit served by the medical officer of health; and
• “that the requirements specified in the order are necessary in order to decrease
  or eliminate the risk to health presented by the communicable disease.”
• Discretionary power = MOH is not obliged to issue a s.22 order, but must
  consider issuing a s.22 order
  The section 22 orders may “require a person to take or to refrain from taking any action
  that is specified in the order in respect of a communicable disease”. Section 22 orders
  should follow the principle of minimal intrusion (i.e., you have followed a graduated
  approach to reducing the risk of disease spread prior to issuing the section 22).
  Individuals can be fined up to $5,000/day for contravening a section 22 order.
• Section 22 issues specific to TB: Strict interpretation of the HPPA would not allow
  an MOH to (a) order treatment after a person is no longer infectious (i.e., after 3-
  4 weeks of treatment; BUT if individual stops treatment, this increases the risk of
  resistant TB and risks relapse to infectious TB) and (b) order treatment if the
  person remains in a negative-pressure room, because the individual is not posing
  a risk to the community
• Section 35 orders: Under the HPPA and at the request of an MOH, a justice of the
  peace may issue a section 35 order to an individual with a virulent disease who has
  failed to comply with a section 22 order. A section 35 order requires an individual with a
  virulent disease to be treated.
• Section 102 orders: Under the HPPA and at the request of an MOH, a judge may issue
  a section 102 order to any individual who has failed to comply with any orders
  associated with the HPPA (e.g., section 13, 22, 35 orders, as well as SDWS directives);
  a section 102 order ratifies the previous order and allows additional enforcement
  mechanisms; Justice Archie Campbell says this is “unclear and confusing” (glad I’m not
  the only one)

Question 55

Describe acute exposure guideline levels

Answer 55

AEGL (acute exposure guideline levels): Threshold exposure limits for the general
public; applicable to emergency exposure periods; based on acute exposure data, not
chronic exposure data; AEGL-1, 2, and 3 values identified for exposure periods of 10
min, 30 min, 1h, 4h, and 8h
- AEGL-1: Exposure above this level could result in discomfort, but effects are
transient and not disabling
- AEGL-2: Exposure above this level could result in long-lasting health effects
- AEGL-3: Exposure above this level could result in death

Question 56

Regarding cervical cancer,

what are recent epi trends?

What are risk factors (5)?

what are the CTFPHC recommendations?

Answer 56

Cervical cancer

• *Epidemiology**
• Incidence of cervical cancer has declined substantially over the last 50 years, from 1.5% lifetime incidence to 0.7%; attributed to Pap screening
• 50% of cancers occurs in women who were never screened or were not recently screened
• 70% of cervical cancers are caused by HPV types 16 and 18
• *Risk factors**
• Known risk factors:

1) HPV, sexual activity

2) smoking (decreases HPV clearance),

3) multiparity,

4) immunosuppression,

5) maternal use of diethylstilbestrol

6) Possible risk factors: Family history, history of STIs

• *Screening recommendations**
• Screening reduces incidence of invasive disease and cervical cancer-specific mortality
• Prevalence of abnormal Paps is highest in young women, but incidence of cancer is highest in older women

CTFPHC recommends screening with cytology alone for sexually active women (2013):
- For women aged less than 20 years, we recommend not routinely screening for cervical
cancer. (Strong recommendation; high-quality evidence)
- For women aged 20–24 years, we recommend not routinely screening for cervical
cancer. (Weak recommendation; moderate-quality evidence)
- For women aged 25–29 years, we recommend routine screening for cervical cancer every 3 years. (Weak recommendation; moderate-quality evidence)
- For women aged 30–69 years, we recommend routine screening for cervical cancer every 3 years. (Strong recommendation; high-quality evidence)
- For women 70 years of age or older who have undergone adequate screening (i.e., 3 successive negative Pap test results in the last 10 yr), we recommend that routine screening may stop. For all other women 70 years of age or older, we recommend continued screening until 3 negative test results have been obtained. (Weak recommendation; low-quality evidence)
*CTFPHC does not recommend for or against HPV testing, citing a lack of evidence

SOGC recommends:

• Starting screening at 21, rather than 25 years of age
• Use of HPV testing in line with provincial guidelines; in Ontario, HPV DNA testing is recommended for women ages 30-65 years, with cytology if the result is positive (HPV testing is not covered by OHIP)

Question 57

What are examples of common distributions?

Answer 57

Question 58

Describe biological contaminants in pools and spas.

What is the most common infection associated with pools?

How are fecal incidents in pools managed?

Answer 58

Pool and spa microbiological contaminants
- Common microbiological contaminants of pools include Pseudomonas aeruginosa,
E. coli, Giardia intestinalis, Cryptosporidium spp., non-TB mycobacteria, and Legionella
- Fecal material can be introduced when washed off swimmers’ bodies, fecal leakage, or
formed stool (e.g., young children prior to toilet training).

• _Organisms that can survive in biofilms include P. aeruginosa, non-TB mycobacteria, and
  Legionella._Diseases associated with biofilms are more common in spas than pools because
  they are aerosolized by water jets in spas. Removing biofilms requires scrubbing, application of high heat, or chlorine residuals > 50 ppm (the latter may lead to corrosion). Prevent biofilms by backwashing and superchlorinating regularly

Crypto the most common pool-associated infection:

• Chlorine resistance: Cryptosporidium spp. are extremely resistant to chlorination;
  Giardia are somewhat resistant
• Children are more likely to ingest pool water and have the highest risk of infection
• Oocysts are resistant to chlorine disinfection - destroying crypto oocysts requires a contact time of 1 ppm x 10 days or 20 ppm x 12h
• Transmitted via fecal-oral route
• Released in high amounts in feces
• Low infectious dose
• Managing fecal incidents:
• Formed stool: Close pool for 1-2 h and increase chlorine residual to ~3 ppm
• Unformed stool: Assume crypto contamination; close pool overnight and
  superchlorinate

Question 59

Define food insecurity

How prevalent is it in Canada?

Answer 59

Nutrition
Definitions
Malnutrition: Any form of poor nutrition
- Undernutrition: Underweight for age, stunting, wasting, or deficient in micronutrients as
a result of dietary inadequacy; results in increased mortality due to gastroenteritis,
pneumonia, and malaria, especially in children, and impaired physical and mental
development; maternal and child undernutrition accounts for 10% of global burden of
disease
- Protein-energy undernutrition:
- Kwashiorkor: Severe protein deficiency (even in the setting of sufficient
calorie intake) resulting in edema, ulcers, and liver enlargement
- Marasmus: Severe energy deficiency, including protein, resulting in
severe emaciation
- Micronutrient undernutrition: Dietary deficiency of vitamins or minerals (aka
“hidden hunger”); globally, common deficiencies include iron, iodine, and vitamin A
- Noma: A polymicrobial infection of the mouth or genitals that occurs in severely
undernourished individuals that leads to a rapidly expanding necrotic ulcer that,
without treatment, is lethal in 80-90% of cases

• Overnutrition: Overweight or obesity as a result of dietary excess; results in increased
  mortality secondary to cancer, CVD, and diabetes

Food insecurity: Inability to access sufficient nutritious food (i.e., sufficient quantity and quality)
- Prevalence in Canada = 5% of children and 8% of adults
- Nunavut has the highest prevalence of food insecurity, 36.7%
- Food insecurity highest in low-income Canadian households, especially those that
received government benefits as their main source of income

Question 60

Name factors that support optimal early childhood development.

What is the early development instrument?

Answer 60

Early childhood development: The biological, psychological, and social development that occurs in the first 5 years of life; early neurocognitive development affects learning, behaviour,
and health throughout life

Early development instrument: 103-item questionnaire completed by kindergarten teachers in the second half of the school year; used across Canada; measures children’s ability to meet
developmental goals in five domains:
1. Physical health and well-being
2. Social competence
3. Emotional maturity
4. Language and cognitive development
5. Communication skills and general knowledge

Requirements for optimal early childhood development:

• *Foundational prerequisites:**
• Stable and responsive environment of relationships: Young children need consistent, nurturing interactions with adults in order to develop secure attachments
• Safe and supportive physical, chemical, and built environments: Young children need to actively explore their environment without significant risk of harm, including harms associated with toxic exposures (e.g., lead) and the built environment
• Sound and appropriate nutrition: Beginning with preconception nutrition and extending through early childhood
• *Caregiver and community capacities** to promote health and prevent disease and disability:
• Time and commitment: Both the quality and length of time spent with children is important
• Financial, psychological, and institutional resources: Includes both the individual and community capacity
• Skills and knowledge: For child-related professionals, high-quality training is essential to providing excellent childcare

Public and private sector policies and programs that support the later steps in the pathway to healthy development (e.g., child care, employment, housing, parental leave)

Question 61

What prompted the establishment of PHAC?

Answer 61

• May 24, 2003: A new cluster of SARS identified in Toronto, requiring more than
  5000 people to be quarantined
• October 2003: Learning from SARS (Naylor report) released; commented on
  public health in Canada; resulted in the establishment of PHAC in 2004
• April 2004: For the Public’s Health (Walker report) released; commented on IPAC
  in Ontario and resulted in the establishment of PHO and the PIDACs
• December 2006: Report of the SARS Commission (Campbell report) completed;
  commented on public health in Ontario; resulted to changes in the HPPA

Question 62

What are different types of public health organizational governance in Canada?

Answer 62

Public health governance in Canada

Types of public health organizational governance in Canada:
- Regional health authorities: Elected or appointed boards are responsible for the
provision of public and clinical health services for a defined geographical area (e.g., BC)
- Regional public health boards: Elected or appointed boards are responsible for the
provision of public health services, but NOT clinical health services, for a defined
geographical area (e.g., Newfoundland)
- Municipal/county boards: Primarily elected boards are responsible for the provision of
public health services +/- other community services for a defined geographical area that
aligns with one or more municipal borders (Ontario)
- Provincial/territorial: Public health services are delivered at the provincial/territorial
level (PEI, all the territories)

Structures of Boards of Health in Ontario
- Autonomous: Municipal council reps from multiple municipalities + provincial
appointees + citizen rep (22) (E.g., KFLA)
- Autonomous/integrated: Municipal council reps from one municipality + provincial
appointees + citizen rep (3) (E.g., Huron)
- Regional: All municipal councillors from multiple municipalities (7) (E.g., Peel, Halton,
Durham)
- Single-tier: All municipal councillors from one municipality (2) (Ottawa, Hamilton)
- Semi-autonomous: Some municipal councillors from one municipality + citizen rep (2)
(E.g., Toronto)

Question 63

What are stages of program implementation (6)?

What are different roles in program implementation (RASCI)?

Answer 63

Program implementation

Roles in program implementation (RASCI)
- Responsible: Person who is responsible for delivering on the task (e.g., AMOH is
responsible for managing an outbreak)
- Accountable: Person who is ultimately accountable for a task; may or not be the same
person who is responsible (e.g., MOH is accountable to the Board for AMOH’s
management of an outbreak)
- Supportive: Person(s) who perform the task (e.g., PHNs who investigate an outbreak)
- Consulted: Person(s) who must be consulted for the task to proceed (e.g., physician who
reported the initial case in the outbreak)
- Informed: Person(s) who should be notified of results, but are not involved in the
decision-making (e.g., PHO in the context of an influenza outbreak in LTC in a single
public health unit in Ontario)

• Every task must have a responsible and accountable individual
• Best practice is to have only one individual responsible for a task
• Consider formally drawing out a RASCI chart and assigning responsibility,
  accountability, support, consult, and informed roles for complex tasks

Stages of program implementation
Take one: Degrees of implementation
1. Paper implementation: New policies and procedures put in place without necessarily
resulting in changes in practice
2. Process implementation: New training processes put in place to support change in
practice (e.g., orientations) without necessarily changing organizational culture
3. Performance implementation: Paper and process implementation has successfully
occurred, along with organizational change and changes in practice that are resulting in
successful outputs

Take two: Stages of implementation
1. Exploration: Identify an issue that needs to be addressed or an improvement that could
be made (e.g.your health unit learns of an evidence-based program that could improve
outcomes in your community through “diffusion of innovation”); assess readiness for
implementation; identify resources required for the program
2. Program installation: Acquire resources for program (e.g., staff, funding, policies,
procedures, technology)
3. Initial implementation: First use of the program; staff need to learn new skills and new
ways of doing work → training sessions, orientation
a. Most sensitive stage of implementation: “the awkwardness associated with trying
new things and the difficulties associated with new ways of work are strong
motivations for giving up and going back to comfortable routines”
4. Full operation: Full implementation is considered to be reached when more than half of
the team is using the new methods with good outcomes; program becomes “the way we
do things”/”accepted practice”
5. Innovation: Full operation of the program provides opportunities for improvement (e.g.,
refinements, expansion); for evidence-based programs, innovations may be seen as
challenges to fidelity
6. Sustainability: Maintenance of the program through changes in staff, partnership,
external problems, etc.

Question 64

Describe the medical exam that immigrants undergo prior to to departure from their country of origin

Answer 64

Medical exam completed by an approved physician (usually in the country of origin prior to
departure); includes:
- Urinalysis for all persons 5 years of age and over

• Chest X-ray for all persons ≥ 11 years old and for some children (e.g. if indicated based
  on history or physical examination) (only the report, not the images, are provided);
• Active TB is treated prior to arrival in Canada
• Individuals with previously treated TB or inactive pulmonary TB are referred to
  local public health agencies for follow-up
• Syphilis test for all persons ≥15 years old and for some children
• Positive syphilis tests are treated prior to arrival in Canada and are not reported
  to public health
• HIV test for all persons ≥15 years old and for some children (e.g., born to infected
  mothers or received a blood transfusion)
• Individuals who are HIV + are referred to local public health agencies for followup

Question 65

Compare and contrast water treatment methods for their effectiveness in removing protozoa, bacteria, viruses and particulates

Answer 65

• *Boiling**: removes protozoa, bacteria and virus but NOT particulates
• *Iodine or chlorine**: removes protozoa (most), bacteria and virus but NOT particulates
• *Filtering**: removes protoza, bacteria (most), and particulates (NOT viruses)

Question 66

Describe basic facts about typhoid fever

Organism, Reservoir, Mode of transmission

Incubation period, infectious period

Epidemiology

Presentation, Testing

Case management, Contact management

+/- Immunization

Answer 66

Typhoid fever (reportable)
- Organism: Salmonella enterica, subspecies enterica, serovar Typhi (also sometimes
called S. typhi); encapsulated bacteria
- Reservoir: Humans
- Mode of transmission: Fecal-oral
- Epidemiology:
- 21 million cases of typhoid/year globally; most cases occur in children living in
South Asia
- 2-5% of untreated typhoid cases become chronic carriers (can shed bacteria for
years)
- Case fatality rate = 10% (untreated case in LMIC); <1% (treated case in HIC)
- Risk of contracting typhoid during travel to a typhoid-endemic country is low
- Most cases in Canada occur in returning VFR travellers
- Presentation: Ranges from low-grade fever to severe systemic disease
- Incubation period: 8-14 days (range, 3-60 days)
- Case management: Abx treatment, guided by sensitivity testing; exclude from food
handling, healthcare, and daycare until 3 consecutive negative stool samples + 48h
post-cipro tx OR 2 weeks post-ceftriaxone or azithromycin tx
- Contact management: No role for vaccination; exclude asymptomatic contacts who
travelled with a case and symptomatic contacts until 2 consecutive negative stool
samples
- Vaccines: Efficacy ~50%; adverse effects include abdo pain, N/V, diarrhea, headache,
rash; recommended for individuals travelling to South Asia
- Parenteral (Typh-I): Provides up to 3 years of protection
- Parenteral + Hepatitis A (HA-Typh-I): Provides up to 3 years of protection
- Oral (Typh-O): Live vaccine; provides up to 7 years of protection

Question 67

What are risk assessment considerations when preparing for mass gatherings?

Answer 67

Mass gatherings
Mass gatherings: Temporal and spatial concentration of people for a specific reason over a set
period of time; have the potential to strain the planning and response resources of the
community or country; “planned emergencies”
Examples of mass gatherings
- Hajj pilgrimage (Saudi Arabia): 3 million people annually
- Kumbh Mela pilgrimage (India): 40 million people every 12 years
- FIFA World Cup: 3 million people every 4 years
Types of mass gatherings

Risk assessment considerations

Type of event:
- Sporting event (e.g., may have increased risk of injury and violence)
- Religious event (e.g., may have more participants with preexisting medical conditions)
- Cultural/music event (e.g., may have increased risk of drug/alcohol use)
- Political event (e.g., may have increased risk of riots and injuries)
Duration:
- <1 week (participants and host location may not perceive themselves to be vulnerable to
health events so may not take precautions)
- > 1 month (increased risk of communicable disease; increased strain on healthcare
system)
Season:
- Summer (consider risk of heat-related illnesses)
- Winter (consider risk of cold-related illnesses)
- Wet (consider risk of waterborne diseases, flooding, drowning)
- Dry (consider risk of dehydration, fire, poor air quality)
Country of origin of participants:
- National (lower risk of disease importation)
- International (higher risk of disease importation)
Density of participants:
- Low density
- High density (higher risk of communicable disease spread and mass casualty event)
Venue characteristics:
- Outdoor (challenges to sanitation, food preparation)
- Fenced venue (risk of overcrowding)
- Uncontained venue (difficult to locate services)
- Rural (are health services accessible?)
- Temporary (challenges to sanitation, food preparation, onsite medical services)
- Permanent (does infrastructure need upgrading? Does it meet fire codes?)

Question 68

How does ricin work and what are its different presentation forms (3)?

Answer 68

Ricin
- Ricin is a tasteless, odorless, and stable toxin produced from the plant castor beans; unintentional
exposure is unlikely
- Ricin is a toxalbumin (i.e., it inhibits protein synthesis), resulting in cell death
- Presentation:
- Inhalation: Respiratory distress, fever, cough, nausea, pulmonary edema, hypotension
- Ingestion: Bloody vomiting and diarrhea, hypotension, seizures, liver, spleen, and kidney failure
- Skin and eye exposure: Redness, pain
- Treatment: Supportive (no antidote)

Question 69

Describe basic facts about HPV

Organism, Reservoir, Mode of transmission

Incubation period, infectious period

Epidemiology

Presentation, Testing

Case management, Contact management

+/- Immunization

Answer 69

Organism: Human papillomaviruses are a group of >100 viruses that cause warts (>40 types
infect the anogenital tract);
- Type 6, 11: Genital warts
- Type 1, 2, 4, 63: Plantar warts
- Type 2, 7, 22: Verrucal warts
- Type 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, and 59: Oncogenic
Reservoir: Humans
Mode of transmission: Direct contact (skin-to-skin); indirect contact via fomites (e.g., razors);
can be transmitted without visible lesions

Epidemiology:
- >75% of sexually active Canadians have been infected with a sexually-transmitted HPV
- >90% of anogenital warts are attributable to HPV-6 and 11
- Almost all cervical cancer is attributable to HPV infection (70% of cervical cancers are
caused by HPV-16 and 18)
- HPV also causes anal (80-90% of all cases), vaginal and vulvar (40%), and penile (40-
50%) cancers
- Modelling suggests that HPV causes 23-35% of oral cavity and oropharyngeal cancers,
but no evidence (yet?) that HPV vaccination will prevent oropharyngeal CA; most costeffectiveness
models include oropharyngeal CA
- Oncogenic effect of HPV synergistic with smoking

• *Presentation**: Most infections are asymptomatic
• *Incubation period**: 1-20 months (mean: 2-3 months)
• *Testing**: Diagnosis usually based on clinical exam

Case management/treatment:
- Genital warts will eventually resolve on their own, but treatment accelerates resolution
and can prevent recurrence
- Genital wart treatments include liquid nitrogen, podofilox, imiquimod, and surgery
Contact management: None
Other: Prevention: Most effective prevention strategy is to limit the number of sexual partners
(condoms and dental dams reduce, but do not eliminate, exposure, because skin-to-skin contact
occurs during protected sex)
Vaccination:
- HPV-2 (Cervarix): Type 16, 18; approved only for females, 9-45 years
- HPV-4 (Gardasil): Type 6, 11, 16, 18; approved for males and females, NACI
recommends for everyone between 9-26 years of age
- HPV-9 (Gardasil-9): Type 6, 11, 16, 18, 31, 33, 45, 52, 58; approved for males and
females, NACI recommends for everyone between 9-26 years of age (as of 2016, not
publicly funded in Ontario)
- Vaccination for males: Most provinces now have vaccination for boys; adding males to a
female-only program unlikely cost-effective; vaccine most effective when provided prior
to sexual debut; challenging to provide at most effective time for MSM if there is not a
universal program for boys
- Public acceptance is poor (lower coverage than other programs); initially refused in
some Catholic school boards in Ontario, but now accepted in all publicly-funded school
boards
- Two-dose v three-dose schedule: A 2-dose schedule is as effective as a 3-dose
schedule for immunocompetent individuals between 9-14 years of age, when the second
dose is given 6 months or more after the first dose
- Vaccine is most effective when received before becoming sexually active, but can be
given at any time; if recipient has already been sexually active, advise them that they
may have already been infected with HPV and that the vaccine will not affect the course
of pre-existing HPV infection

NACI recommendations (published 7/2016)

HPV2, HPV4 or HPV9 vaccine is recommended for routine vaccination of females aged 9 to 26 years and may be used in females over 26 years of age who have not been vaccinated previously or who have not completed the series.

HPV4 or HPV9 vaccine is recommended for routine vaccination of males aged 9 to 26 years, and may be used in males over 26 years of age who have not been vaccinated previously or who have not completed the series.

HPV2 (in immunocompetent females 9-14 years of age) or HPV4 (in immunocompetent females or males 9-14 years of age) vaccine may be administered using either a 2-dose or 3-dose schedule. For a two-dose schedule, two separate 0.5 mL doses should be administered at months 0 and 6-12. There is insufficient evidence at this time to recommend a 2-dose schedule for HPV9 vaccine. However, studies are ongoing and new evidence will be assessed as it becomes available.

Any immunocompromised individual, immunocompetent HIV infected individuals, and individuals who have not received any dose of HPV vaccine by 15 years of age should continue to receive three doses of HPV vaccine.

Efforts should be made to administer HPV vaccines at the recommended intervals. When an abbreviated schedule is required, minimum intervals between vaccine doses should be met. In a 3-dose schedule, the minimum interval between the first and second doses of vaccine is 4 weeks, the minimum interval between the second and third doses of vaccine is 12 weeks and the minimum interval between the first and last doses in either a 2-dose or 3-dose schedule is 24 weeks.

There is insufficient evidence at this time to recommend, at a population level, re-immunization with HPV9 vaccine in individuals who have completed an immunization series with another HPV vaccine.

Question 70

Name encapsulated bacterias preventable by vaccination

Answer 70

Strep pneumo, neisseria meningitidis, h. flu

Question 71

What is the purpose of accounting?

Name example of internal controls in accounting.

Define revenue, expense, deficit, assets and liabilities/obligations.

What are public accounts?

Answer 71

Accounting
Accounting: Process of keeping financial records or running tally of assets, liabilities, revenue,
expenses, and equity
- Cash accounting: T_ransactions are documented as they occur_; does not track events
that are not transactions (e.g., assets accruing interest; assets depreciating)
- Accrual accounting: Revenue and expenses are recorded as they are earned (as
opposed to when they are received)

Internal controls: Accounting processes, checks, and balances that safeguard assets; prevent
errors, duplications, omissions, and fraud
- Preventative controls: Limits access to business assets; examples:
- Segregation of duties: Asset custody, authorization of use of assets, and
recordkeeping are performed by different employees (this provides oversight and
prevents fraud)
- Payroll monitoring: Review timesheets, monitor for non-employees
- Detective controls: Identifies errors in accounting for assets
- E.g., Reconciling inventory counts

Glossary of public sector accounting terms
- Assets: Resources such as land and buildings, and financial property like cash and
loans receivable that are controlled by the government.
- Cost centre: Fixed budget; expenditure only (as opposed to a profit centre or
investment centre)
- Deficit: the amount by which government expenses exceed revenues in any given year.
- Expense: The decrease in economic resources in the period, typically through
expenditures or increases in liabilities.
- Expected Average Remaining Service Life: total number of years of future services
expected to be rendered by that group of employees divided by the number of
employees in the group.
- Financial Assets: Property used to discharge liabilities or finance future operations,
such as cash, accounts receivable and loans receivable.
- Liabilities: Future sacrifices of economic benefits that the entity is presently obliged to
make to other entities, typically paid for with cash in the future.
- Obligations: another term for Liabilities.
- Public Accounts: the Consolidated Financial Statements of the Province along with
supporting statements and schedules as required by the Financial Administration Act.
- Revenue: The increase in economic resources in the period, typically through the influx
of cash or other assets such as receivables (e.g. tax revenue) or decreases in liabilities.

Question 72

Name 3 vaccines contraindicated in pregnancy?

Answer 72

MMRV, OPV, BCG, +/-YF

Question 73

Regarding opioids, discuss the:

• recent epi,
• health effects and
• available population-level interventions

Answer 73

Prescription opioids

• *Epidemiology**
• 1 in 6 Canadians report using an opioid in the last year; of those, 5% report misuse
• Canada and the US have the highest levels of prescription opioid consumption in the world; use is continuing to rise
• The rate of dispensing high-dose prescription opioid formulations increased 23% between 2006 and 2011
• 4000 deaths due to opioid use in 2017
• *Health effects**
• Increased risk of fractures, road-trauma
• Reduced RR → Opioid-related mortality
• Constipation and nausea
• Tolerance, addiction, and withdrawal
• *Interventions**
• Harm reduction
• Naloxone
• Opioid substitution therapy
• Clinical practice guidelines (e.g., maximum daily dose): Per capita rate of high-dose opioid dispensing plateaued when guidelines were released
• Prescription monitoring programs
• Restricted reimbursement of opioids from publicly-funded drug plans: PEI, NFL, and BC restrict long-acting hydromorphone on their public drug formularies and have the lowest rates of dispensing in Canada
• Physician education/detailing

Question 74

Describe basic facts about TB

Organism, Reservoir, Mode of transmission

Incubation period, infectious period

Epidemiology

Presentation, Testing

Case management, Contact management

+/- Immunization

Answer 74

Organism: Mycobacterium tuberculosis complex
- M. tuberculosis complex includes: M. tuberculosis, M. bovis (causes TB via unpasteurized milk), M. africanum, and M. canettii (the latter two cause a small number of cases in Africa)
- Multi-drug resistant TB (MDR-TB): Resistance to at least INH + RMP
- Extensively drug-resistant TB (XDR-TB): Resistance to INH + RMP + any fluoroquinolone + one of the injectables (amikacin, kanamycin, capreomycin)
Reservoir: Primarily humans; rarely primates; cattle and some other animals are the reservoir
for M. bovis
Mode of transmission: Airborne; foodborne (milk and milk products; M. bovis)
Epidemiology:
- Estimated to infect almost one-third of the global population; highest rates per capita
occur in sub-Saharan Africa, but the majority of cases occur in Asia
- 4-5% of all active pulmonary TB is caused by MDR-TB
- <10% of individuals with latent TB will develop active TB; of those with latent TB who
develop active TB, 50% will develop active infection within 18 mos of infection
- Exception: 50% of children < 1 year will develop active disease
- Overall rate of TB in Canada is declining; foreign-born and Indigenous Canadians are
disproportionately affected by TB

4.9 per 100000, FN on reserve 30-40/100000, Inuit 150-300/100000

• TB isolates in N. Saskatchewan have very little genetic diversity→ attributed to spread in
  the residential school system
• TB isolates in Quebec have the most genetic diversity→ believed to be the source
  population for many TB strains in Canada (spread through Canada via fur trade)

Presentation: Primarily a pulmonary pathogen, but can cause disease anywhere in the body;
active TB commonly causes fever, night sweats, and weight loss
- Active pulmonary TB (contagious): Cough, hemoptysis; can be sub-clinical
- Active extra-pulmonary TB (not contagious)
- Latent TB (not contagious): Bacteria isolated within granulomas; asymptomatic

Incubation period: 2-10 weeks
Period of communicability: From first discharge of viable tubercle bacilli into sputum (active
pulmonary disease) until receipt of 2-4 weeks of antibiotics
- Extra-pulmonary TB is not usually contagious, except in the case of draining sinuses
- Laryngeal TB is highly contagious
Testing:
- Latent: TST or IGRA
- BCG vaccine may result in a false-positive TST; false positives are more
common in individuals who received BCG at an older age (false positives rare in
individuals who received the vaccine in the neonatal period)
- BCG vaccine does not result in false-positive IGRA
- TST ≥10 is considered positive in most people
- TST ≥5 mm of induration is considered positive if HIV+, if contact with active
contagious case, in children with suspected TB disease, or in
immunosuppressed individuals
- Active pulmonary TB: AFB on microscopy of 2+ sputum samples + CXR; culture for
drug-susceptibility testing; smear-negative but culture-positive TB is contagious

Case management:Treatment with RIPE (pyrazinamide, rifampin, isoniazid, ethambutol) until
susceptibility determined; if fully susceptible, then pyrazinamide + rifampin + isoniazid x 2
months, then rifampin + isoniazid x 4-9 months
Adverse events of first-line drugs
Drug Common adverse events Uncommon adverse events
INH Rash, hepatitis, neuropathy CNS toxicity, anemia
RMP Drug interactions, rash Hepatitis, flu-like illness, neutropenia, thrombocytopenia
PZA Hepatitis, rash, arthralgia Gout
EMB Eye toxicity Rash

Contact management:
- TST or IGRA to identify LTBI (two-step TST not recommended in contact tracing)
- Household and high-risk contacts: TST at initial exposure, second TST 8 weeks
after the end of exposure
- Non-household contacts: TST 8 weeks after the end of exposure
- LTC contacts: TST not reliable in the elderly and benefits LTBI tx may not
outweigh risks; LTC contact tracing should focus on early detection of secondary
cases
- Considerations for homeless contacts: Testing that can be carried out in a single
session (sputum collection, portable CXR, IGRA) may be more successful than
TST; improving shelter ventilation and UV air disinfection may prevent further
transmission
- If latent infection suspected, rule out active disease before providing treatment for latent
infection (treating active disease with a 1- or 2-drug regimen risks drug resistance)
- Contacts at high risk of developing active disease (HIV+, < 5 years old) should receive
presumptive treatment until 8+ week post-exposure TST or IGRA has been completed
- Treatment for latent TB is most commonly INH x 9 months, but INH x 6 months or INH +
RMP x 3-4 months are acceptable alternatives
Other:
- Bacillus Calmette-Guerin (BCG) vaccine: Developed from a strain from WWII army
recruits → strain evolution reduces efficacy? Protective against extrapulmonary disease
in children < 5 years, but not against initial infection; only recommended in high incidence
areas
- Medical surveillance: “Most foreign-born groups undergo a mandatory medical
examination prior to arrival in Canada, which includes chest radiography to detect active
TB. Those found to have active TB must be treated prior to arrival to ensure that they
are no longer infectious. Citizenship and Immigration Canada (CIC) requires that
individuals with previously treated TB and those with abnormal chest radiographs but
without active TB detected in this program undergo TB surveillance after arrival” (TB
Standards); universal screening is highly inefficient and could be improved by surveilling
only individuals from high-incidence countries

Question 75

Describe the precautionay principle.

What are 4 principles underlying it?

Answer 75

Competing definitions
- “In order to protect the environment, the precautionary approach shall be widely applied by States according to their capabilities. Where there are threats of serious or irreversible damage, lack of full scientific certainty shall not be used as a reason for postponing cost-effective measures to prevent environmental degradation” (Rio
Declaration, 1992)

• When an activity raises threats of harm to human health or the environment, precautionary measures should be taken even if some cause and effect relationships are not fully established scientifically (duty to prevent harm). In this context, the proponent of an activity, rather than the public, should bear the burden of proof. The process of applying the
  Precautionary Principle must be open/transparent, informed, and democratic, and must include potentially affected parties. It must also involve an examination of the full range of alternatives, including no action. (Wingspread Statement on the Precautionary Principle, 1998)

Beloin and Gagnon framework:

• *1. Alleged risk is sufficiently severe
  2. Relationship between cause and effect is somewhat likely
  3. Precautionary measures are acceptable**

Weir, Schabas, Wilson, and Mackie framework:

1. Is there sufficient evidence to support a reasonable suspicion that the exposure of interest causes the proposed harm? (Apply the Bradford-Hill criteria)
2. Is the harm associated with the suspected exposure serious?
3. Is the suspected exposure widespread?
4. Is there an observed increase in the incidence of the suspected harm that is temporally associated with increased exposure?
5. Is the harm associated with the suspected exposure difficult to treat or reverse?
6. What are the economic and non-economic costs and benefits of action and non-action?
7. Are the proposed control measures proportional to the level of risk? Are the economic costs of removing the exposure minimal? Are the health and societal costs of removing the exposure minimal?
8. Are comparable situations being treated similarly according to a standard of practice?
9. Is the level of the protective measures consistent with equivalent areas in which scientific data are available?
10. If precautionary measures are adopted, is there any new ev

Question 76

What is Employee performance management?

What are the steps/cycle to employee performance management?

What are SMART objectives?

Describe different coaching strategies based on stages of employee development.

What are 5 categories of performance problems?

When assessing an employee’s performance, what are potential sources of bias?

Answer 76

Managing employee performance
Employee performance management = Process for establishing a shared understanding about what is to be achieved and how it is to be achieved (align individual goals with organizational goals), and an a_pproach to managing people that increases the probability of
achieving success_
- Formal = Goal setting, development planning, mid-year review, end-of-year appraisal

Formal performance evaluation types:
- Objective: Employee assessed based on previously-agreed upon objectives/targets
- Narrative: Written description of performance
- Competency: Employee assessed based on list of competencies associated with a particular position/type of work
- Multi-rater: Employee assessed by multiple individuals (e.g., 360 evaluation)
- Should also occur informally throughout the year
- Understand the employee’s strengths and weaknesses; capitalize on the strengths (no
employee is perfectly well-rounded)
- “What was the best day you’ve had at work in the past three months? What was
the worst day?”

Employee performance management cycle =

In summary:

Set goals - SMART
Coaching
Check in - feedback, adjust goals
Performance assessment
Coaching
Set new goals

Performance planning (set performance and development goals) → coaching → check-in (feedback on performance, adjust goals) →
performance assessment (formal documentation, recognition, improvement planning) → coaching → performance planning
- Coaching = Helping people find the way forward on their own
- Performance goals = What are the results or outputs I want to accomplish? (Not routine parts of a job that must be accomplished, not the activities that produce results);
should be SMART:
- Specific (e.g., deliver educational sessions)
- Measureable (e.g., increase by 10%)
- Attainable
- Realistic
- Time-bound (e.g., by the end of Q1)
- Development goals = What are the skills or knowledge I want to acquire?

Coaching strategies based on stages of employee development
“Disillusioned learner” → Motivating, explaining, two-way dialogue
“Capable but cautious performer” → Supporting, encouraging, empowering
“Enthusiastic beginner” → Directing, highly structured, incremental, frequent instructions
“Self-reliant achiever” → Delegating

• *Coaching based on where an employee values recognition from:**
• Peers: Public praise
• Manager: Private praise
• Others with similar expertise: Professional/technical award
• Customers: Photo posted of employee and best customer

Coaching based on an employee’s learning style:
- Analyzer: Classroom-style teaching, role play, time for preparation
- Doer: Assign simple tasks so employee can learn by trial and error; gradually increase
complexity
- Watcher: Allow for employee to shadow top performers

Engaging high performers:
- Providing feedback: High performers may not be used to constructive criticism, but you
should still look for opportunities for them to improve; recognize them for their hard work,
focus on future performance
- Is the high performer happy in their current role ( → set challenging goals that will
continue to engage), or do they aspire to advancement ( → set development goals that
will build leadership potential)?

Most poor performance problems fit into 5 categories; identify the category in order to identify
potential improvement approaches:
1. Knowledge or skills gap (e.g., poor communication skills)
2. Workplace constraints (e.g., lack of necessary resources to complete job) *Important to
consider organizational explanations for an employee’s poor performance that may be
beyond their control
3. Interpersonal/behaviour issues (e.g., low emotional intelligence, lack of confidence)
4. Personal challenges (e.g., ill family member)
5. Serious issues (e.g., violence, theft, fraud)

When assessing an employee’s performance, consider potential sources of bias:
- Personal bias (e.g., assessment influenced by ethnicity or accent)
- Halo effect (i.e., employee’s strong performance in one domain falsely increases
impression of overall performance; or the reverse, with weak performance)
- Recency effect (i.e., most recent performance influences entire assessment)
- High performer bias (e.g., highly rating a person who shows great potential, but has not
yet met many of his/her goals)
- Past performance bias (i.e., outcomes of previous assessment influence current
assessment)
- Status effect (i.e., rating a person based on their status within an organization, rather
than their performance)

Question 77

What are benefits of immunization registries?

Answer 77

Benefits

• Automated reminders
• Provides proof of immunization
• Decreased repeat immunization (with concomitant reduction in immunization costs)
• Identify unimmunized individuals in the event of an outbreak
• Easy transfer of records to other regions
• Manage vaccine inventories more effectively
• Identify at-risk populations and develop targeted education programs

Question 78

What are different random sampling methods?

Answer 78

Random sampling methods
- Simple random sample: Each individual in the population has an equal chance of being
selected
- Stratified sample: Population first divided into strata, then simple random sampling is
performed within each strata (allows you to say something about smaller strata)
- Cluster sampling: Each group or cluster has an equal chance of being selected;
examine all units within the chosen cluster (done because it’s easier and simpler; e.g.,
we don’t have a list of all students in Canada, but we do have a list of all schools)
- Multi-stage sampling: Each group or cluster has an equal chance of being selected,
then each individual within the selected clusters has an equal chance of being selected

Question 79

What are the steps of a Root Cause Analysis?

What is a pareto chart?

What is a fishbone diagram?

Name 7 QI tools.

Answer 79

Quality improvement tools

• *Fishbone diagram (cause and effect,** Ishikawa diagram)
• Definition: Visual diagram of a problem and its root causes
• Components:
• Backbone: The problem you would like to address
• Ribs: The major inputs into the process that contribute to the problem (e.g., staff, computer programs, budget)
• Branches: The “causes of causes”; the reasons the “ribs” contribute to the problem

Root-cause analysis
Definition: “A structured method used to analyze serious adverse events”
- Why? For every adverse event, “There are underlying organizational causes that are
more difficult to see, however, they may contribute significantly to the undesired
outcome and, if not corrected, they will continue to create similar types of problems”
RCA divides causes of serious adverse events into:
- Proximate causes: The events or conditions that existed immediately before the
undesired outcome; if eliminated, the adverse event would not have occurred
- Root causes: One of multiple factors that contributed to or created the proximate
causes; if eliminated, the adverse event would not have occurred
- Organizational factors: Any operational or management system that results in root causes
Steps:
1. Clearly define the adverse event
2. Gather data: When and where did the adverse event occur? What were the conditions present and what controls could have prevented the adverse occurrence but did not?
3. Create an event and causal factor tree: Like a fishbone diagram that includes all possible causes and conditions that could have lead to the adverse event
4. Review each potential cause: Eliminate causes and conditions from the tree only when you have sufficient information to confirm they did not contribute to the event or it is not logically possible for the cause/condition to have contributed
5. Generate recommendations: Propose corrective actions that will eliminate the proximate causes and will eliminate or mitigate the root causes

Pareto chart
Definition: A graph that shows the proximate causes of a problem along the x-axis and the frequency at which those proximate causes lead to the problem along the y-axis; used to focus quality improvement efforts on the most commonly occurring proximate causes
- Concept that a few proximate causes are responsible the majority of the problem is based on the Pareto principle (20% of inputs result in 80% of outputs)

Other tools:

1. Flow Chart
2. Histogram
3. Scatter Plot
4. Check Sheet
5. Control Chart

Question 80

What are volatile organic compounds and 3 different categories of VOCs?

What are common sources and health effects for benzene?

What are common sources and health effects for TCE?

Answer 80

Volatile organic compounds
Definitions
- WHO definition: Melting point below room temperature and a boiling point between 50 and 260 C
- US EPA definition: C_arbon-containing compound that participates in atmospheric photochemical reactions_

Types of VOCs

• Chlorinated hydrocarbons (e.g., methylene chloride, a solvent used in industrial processes, TRI/TETRAchloroethylene)
• Fluorinated hydrocarbons
• Aromatic hydrocarbons (e.g., toluene, xylene, benzene)

Benzene (aromatic hydrocarbon)
Common sources:

• Used extensively to make other chemical and products (e.g., Styrofoam, nylon, synthetic fibres, glues, paints, wax, detergents, solvents),

- volcanoes, forest fires,

- crude oil, gasoline combustion, industry emissions,

- cigarette smoke → inhalation,

- attached garages

Short-term effects: At very high levels, death; at lower levels, drowsiness, dizziness, tachycardia, headaches, LOC

Long-term effects: Bone marrow suppression → Anemia, thrombocytopenia, Acute myeloid leukemia (IARC, group 1)

Trichloroethylene (chlorinated hydrocarbon)
Common sources: Metal degreaser, dry cleaning

Long-term effects: IARC, class 1 for non-Hodgkin’s, kidney; ?fetal heart malformations; ?immune effects

*water contamination events in Canada - Valcartier

Tetrachloroethylene (aka perchlorethylene, PERC, ECE) (chlorinated hydrocarbon)
Common sources: Dry cleaning ( → air), _metal degrease_r (water, soil → usually evaporates quickly into air)

Short-term effects: Dizziness, fatigue, headaches, unconsciousness, death

Long-term effects: Neurotoxic effects (changes in mood, memory, attention, reaction time); teratogenicity; ?bladder CA, multiple myeloma, non-Hodgkin’s lymphoma (IARC, group 2A)

Question 81

What is vaccine efficacy and how is it calculated?

Answer 81

Vaccine efficacy: Percent reduction in disease incidence in a vaccinated group
compared to an unvaccinated group under optimal conditions
- Efficacy = (Attack rate in unvaccinated - attack rate in vaccinated) / Attack rate in
unvaccinated

Question 82

Describe integrated tick management steps to reduce exposure to Lyme disease

Answer 82

Integrated tick management: The use of several methods to reduce the number of ticks;

• personal protective measures (light-coloured, long-sleeved pants; closed toed shoes; DEET; and performing a tick check after spending time in long grass or wooded areas)
• landscaping methods (restrict use of ground cover plants; plant deer resistant plants; relocate high-use areas away from woodland edges; isolate high-use areas from woodland edges with wood chip, mulch, or gravel borders; discourage rodent activity, cut grasses short; remove leaf litter and brush)

Question 83

Describe chronic disease screening recommendations for immigrants arriving to Canada

Answer 83

Question 84

Describe the demographic transition using population pyramids,

from youthful, transitional and mature distribution.

Expain the concepts of rectangularization of mortality and the compression of morbidity.

What is the epidemiologic transition?

Answer 84

Age, morbidity, and mortality distributions
- Population pyramid: Visual representation of age and sex structure of a country’s
population, with population along the x-axis divided into 5-year age groups and male
population on the left and female population of the right

• Youthful distribution: Pyramid-shaped pyramid, with a broad base and narrow
  peak (high fertility, high mortality, low life expectancy, high population growth)
• Transitional distribution: Barrel-shaped pyramid, with a larger working-aged
  population and smaller child and elderly population (declining fertility and
  mortality rates, increasing life expectancy, slowing population growth)
• Mature distribution: Inverted pyramid-shaped pyramid, with a larger elderly
  population and smaller children and working-aged populations (low fertility, low
  mortality, high life expectancy)
• Rectangularization of mortality: Increasingly rectangular shape of a population
  survival curve due to decreases in health inequities (i.e., everyone dies at approximately
  the same age)
• Compression of morbidity: “if the age of onset of the first chronic infirmity can be
  postponed more rapidly than the age of death, then the lifetime illness burden may be
  compression into a shorter period of time nearer to the age of death” (Swartz, 2008,
  summarizing James Fries’ hypothesis)
• Demographic transition: Increasing development → increased standards of living →
  fewer children and longer life expectancy; shift from “triangle” distribution of populations
  to “rectangle” age distributions of populations
• Epidemiological transition: Shift from mortality primarily caused by infectious disease
  to mortality primarily caused by chronic disease

Question 85

Define cases, carriers, contacts

Answer 85

• Case: A person who meets the case definition for a given disease or syndrome - Index case: First individual identified in an outbreak; usually not the first case
• Carrier: A person or animal without apparent disease who harbours a specific infectious agent and serves as a potential source of infection; types:
• Colonisation: Individual carries an organism without mounting an immune response (e.g., staph) - Inapparent infection: Individual carries an organism and mounts a sub-clinical immune response (e.g. polio, HAV)
• Incubatory: Individual is infectious during the incubation period (e.g., measles, varicella)
• Convalescent: Individual has recovered from clinical disease, but is still infectious for a short period (e.g., diphtheria)
• Chronic: Individual has recovered from clinical disease, but is infectious for a long period (e.g., typhoid, HBV)
• Contact: A person who has been exposed to a communicable disease in such a way there is the potential for transmission

Question 86

Describe the IARC classification system.

What are the 3 types of data considered?

Answer 86

IARC classification system
- IARC = International Agency for Research on Cancer; cancer agency of the WHO
- Weight-of-evidence approach: Used by the IARC Monographs Programme, which
evaluates environmental causes of cancer in humans
- 3 types of data: Situations in which people are exposed to the agent;

1 ) scientific evidence of carcinogenicity in humans (epi);

2) scientific evidence of carcinogenicity in animals (lab);
3) scientific evidence on cancer mechanisms

• Resulting classification indicates the weight of the evidence as to whether an
  agent is capable of causing cancer (i.e., indicates the hazard)
• Does not indicate risk (i.e., does not indicate the probability that cancer will
  occur)
• Group 1: Carcinogenic to humans (e.g., air pollution, tobacco smoke, formaldehyde, diethylstilbestrol, benzene, alcoholic beverages, asbestos, cadmium, deli meat, EBV virus)

[sufficient evidence of carcinogenecity in humans]

• Group 2A: Probably carcinogenic to humans (e.g., DDT, chloramphenicol, anabolic steroids, hot beverages [>65C], red meat, night shift work)

[limited evidence of carcinogenicity in humans + sufficient evidence of carcinogenicity in animals + strong mechanistic evidence in human cells or tissues]

• Group 2B: Possibly carcinogenic to humans (e.g., digoxin, EMF, aloe vera, occupational exposure to dry cleaning; note that coffee was previously classified as a 2B, but
  reclassified as a 3 in 2016)

[only one of those 3: limited evidence of carcinogenicity in humans • sufficient evidence of carcinogenicity in experimental animals • strong mechanistic evidence, showing that the agent exhibits key characteristics of human carcinogens]

• Group 3: Not classifiable (e.g., spironolactone, coffee, acetaminophen)

[inadequate evidence of carcinogenicity in humans + inadequate/limited evidence of carcinogenicity in animals]

• Group 4: Probably not carcinogenic to humans (caprolactam)

[lack of carcinogenicity in humans and in experimental animals]

Question 87

What are possible stages of a collective bargaining?

Answer 87

Labour relations and collective agreements

In summary collective bargaining: (mnemonic N C MAL)

Negotiation - Conciliation (MoLabour) - (+/- strike/lockout) - Mediation (non-binding) - Arbitration (binding) - Back-to-work legislation

• Collective agreement: Contract between a group of employees represented by a trade union and an employer; outlines the rights, privileges, and duties of the employees, union, and employer
• Grievance: Written complaint alleging a contravention of the collective agreement; grievance process is defined by the collective agreement

Collective bargaining: Process through which the collective agreement is negotiated;
bargaining processes often focus on wages, working conditions, grievances, and
benefits; generally moves through the following list

• Negotiation: Dialogue between the union and employer representatives to reach
  a new collective agreement; consider BATNA/WATNA/MLATNA to decide
  whether to continue negotiating or move to another stage
• Best alternative to a negotiated agreement (BATNA)
• Worst alternative to a negotiated agreement (WATNA)
• Most likely alternative to a negotiated agreement (MLATNA)
• Conciliation: In Ontario, a conciliation process is one in which a Ministry of
  Labour conciliation officer assists the union and employer in reaching a collective
  agreement; conciliation is required before the parties proceed to a strike or lockout
• Mediation: Process through which a neutral third party assists the union and
  employer in reaching a collective agreement, usually by developing
  recommendations that either party may accept or reject
• Arbitration: Quasi-judicial process in which an arbitrator or arbitration board
  hears from the union and employer and then makes a binding decision
• Rights arbitration: Arbitration about grievances (the interpretation and
  application of an existing collective agreement)
• Interest arbitration: Arbitration to renew an existing or establish a new
  collective agreement
• Strike: Collective action by employees to stop or curtail work (cessation, refusal, or
  slow-down in work) during a labour dispute; strikes are legal in Ontario if the collective
  agreement has expired + a strike vote has been held + conciliation was not successful;
  employees of hospitals, nursing homes, and the TTC, and firefighters and police do not
  have the right to strike (see also: strike contingency planning in COOP)
• Note that a strong strike contingency plan demonstrates that an organization is
  able to manage work stoppage and is unwilling/unable to meet the union’s
  requests; this reduces the probability of a strike
• Lock-out: Employer closes a workplace or suspends work during a labour dispute; a
  lock-out is legal in Ontario if the collective agreement has expired + conciliation was not
  successful; firefighters and police cannot be locked out
• Essential services: Service that is necessary for the safety and security of the public;
  cannot strike or be locked out
• Federal essential services include border security, correctional services, food
  inspection, accident safety investigations, income and social security, marine
  security, law enforcement, and search and rescue
• Ontario essential services include hospital and nursing home workers, TTC,
  firefighters, and police
• Back-to-work legislation: Law passed that ends a strike or lock-out by imposing
  binding arbitration or by defining a new collective agreement; usually used to end a
  strike or lock-out in an industry that the government determines is essential to the
  economy

Question 88

Describe basic facts about HSV

Organism, Reservoir, Mode of transmission

Incubation period, infectious period

Epidemiology

Presentation, Testing

Case management, Contact management

+/- Immunization

Answer 88

Mode of transmission: Direct contact with saliva, skin, or mucous membranes
- HSV-1: Mainly transmitted by oral-to-oral contact; can also be transmitted via oral-genital
contact
- HSV-2: Almost exclusively via sexual contact; 70% of cases are attributed to
asymptomatic transmission
- Risk of transmission of both is greatest when lesion is present, but either can be
transmitted asymptomatically

Epidemiology: Not reportable, so epidemiology in Canada is poorly described
- HSV-1: Usually acquired in childhood; infection is lifelong; globally, prevalence of 67%;
prevalence of HSV-1 genital infection increasing
- HSV-2: Canadian prevalence approximately 17-19% (increases with age)

Presentation: Tingling or burning sensation followed by the development of painful blisters or
ulcers at the site of infection
- HSV-1: Usually asymptomatic; when symptomatic, primarily causes oral lesions, “cold
sores” (although can also cause genital herpes, which typically recurs less frequently
than HSV-2 genital herpes)
- HSV-2: 60% of cases are asymptomatic; when symptomatic, primarily causes genital
lesions (can also cause genital pain, aseptic meningitis, and cervicitis without lesions)
- Complications: Encephalitis, keratitis, neonatal herpes
Incubation period: 6 days

Testing: Viral culture is most common, but PCR is more sensitive and specific (although often
unavailable in most labs); serology (type-specific)
- IgM: Presence is an indirect indication of recent (< few months) infection, although may
inconsistently increase in recurrent outbreaks
- Seroconversion indicates a primary infection (no HSV antibody in acute-phase sample
and HSV antibody in convalescent sample)

Case management: Antivirals (acyclovir, famciclovir, valacyclovir) can reduce severity of
symptoms and frequency of recurrence, but will not cure the disease; treatment is
recommended for clinically important symptoms
- Abstain from sex when sores are present
- Condom use will decrease, but not entirely prevent, HSV transmission
- Children with severe, first episodes of HSV-1 who cannot control oral secretions should
be excluded from daycare until lesions crust over

Contact management: Reportable in some provinces (not Ontario); cases should inform their
sex partners from the previous 60 days, although partner notification is not required as a public
health measure; consider testing partners to determine if they are serodiscordant and counsel
accordingly
- Risk of neonatal herpes is greatest in women late in pregnancy with newly-acquired
infections

Question 89

Define disability and recent epi trends in Canada.

Provide examples of how public health program can accomodate disabilities

Answer 89

Persons with disabilities
Definition of disability
- Abridged AODA, 2005 definition: Any degree of physical disability, infirmity,
malformation, or disfigurement; mental impairment of developmental disability; learning
disability; or mental disorder (*broad definition that would include most illnesses)
- WHO International Classification of Functioning, Disability and Health
definition:“an interaction between features of the person and features of the overall
context in which the person lives”
- I.e., Disability is, in part, extrinsic to a person (e.g., in a building that
accommodates wheelchairs, a person using a wheelchair is no longer disabled;
i.e., he/she is able to do all of the same activities as anyone else in that building)

Epidemiology
- Prevalence of disability in Canada increases with age, but Canada’s elderly population is
increasingly active and has good access to health care, so prevalence in the elderly
population is expected to decrease
- Canadians with disabilities make, on average, $10,000 less per year than Canadians
without disabilities
- About a third of Canadians with disabilities rely on non-employment income.
- People with disabilities have poorer health outcomes and are more likely to be obese,
smoke, and be physically inactive than people without disabilities

- Disability prevalence: average 10%, ranges about 4 to 43% in age groups.

Public health interventions
- Traditionally, public health has viewed disability as a morbidity to be reduced
- Campaigns based on this view signals that the lives of people with disabilities are
undesirable
- Public health, for the most part, has moved from trying to prevent disability to trying to
improve health-related quality of life for people with disabilities
- Accommodating disabilities within public health programs can enhance accessibility, for
example:
- Providing telephone teletype lines for individuals who are Deaf or hard-of-hearing
- Ensuring space is physically accessible (e.g., ramps, snow removal, curb cuts)
- Waiving fees for support persons
- Following web accessibility guidelines
- Posting disruptions to elevator service as far in advance as possible

Question 90

Describe the different presentations for syphilis

Answer 90

Presentation:
- Primary syphilis (infectious): Chancre, regional lymphadenopathy

• Secondary syphilis (infectious): Rash, fever, malaise, lymphadenopathy, mucous
  lesions, condyloma lata, alopecia, neurological involvement, uveitis, retinitis
• Early latent syphilis (infectious): Asymptomatic, <1 year; considered infectious
  due to risk of relapse to secondary state
• Late latent syphilis (non-infectious): Asymptomatic, >1 year
• Tertiary syphilis (non-infectious): CV syphilis (AA, aortic regurg), neurosyphilis
  (dementia, Argyll Robertson pupil, headache), gummatous disease
• Congenital syphilis: Disseminated infection, hepatosplenomegaly,
  lymphadenopathy, Hutchinson’s teeth

Question 91

What are 3 tools to monitor organizational performance?

What are the performance indicators on balanced scorecard?

How can public health agencies demonstrate accountability to stakeholders?

Answer 91

• Organizational/system performance management: Basically, quality improvement for organizations and systems, often based on performance indicators
• PH agenices can demonstrate accountability to stakeholders with: Accountability agreements, Organizational standards, Reporting indicators & targets, Annual reports, Accreditation
• Performance indicators: “a single measure that is reported on regularly and that provides _relevant and actionable informatio_n about population health and/or health system performance and characteristics. An indicator can provide comparable information, as well as track progress and performance over time” (from CIHI); see also: Population health indicators
• Dashboard: A summary of performance indicators presented to the Board; usually colour-coded to indicate performance against an outcome metric (e.g., red means below the standard) and includes trends (improving, diminishing)
• Balanced scorecard:

MNEMONIC= “FLIC” financial - learning - internal - customer

An alternative method for presenting performance indicators to the Board; a measurement framework that includes performance indicators in 4 quadrants; initially developed for the private sector to ensure corporations considered non-financial performance; used for organizational performance management; quadrants for public health include (according to ICES):
F. Health determinants and status (financial)

L. Integration and responsiveness (learning)

I. Resources and services (internal)

C. Community engagement (customers)

Quadrants according to Robert Kaplan and David Norton (the Harvard Business School guys who originally came up with the term): How do we look re outcomes? What can we improve? What do we excel at? What do customers think?

• *1. Financial stewardship and performance (financial)
  2. Efficiency (internal)
  3. Organizational capacity (learning)
  4. Customer or stakeholder satisfaction (customer)**
• Results-based accountability: “A disciplined way of thinking and taking action that can
  be used to improve the quality of life in communities and the performance of programs,
  agencies, and service systems”; made up of population accountability (cannot be
  assigned to any one individual organization) and performance accountability
  (accountability of the organization to its clients for the performance of the program); uses
  the desired community endpoints as the starting point for making decisions
  1. Define success at the population
  2. Define performance indicators for success:

How much did we do? (reach/scope)

How well did we do it? (quality/efficiency)

Is anyone better off? (effectiveness)

(Note that “we must use measures we do not completely control”)

3. Describe the baseline performance indicators and the reasons for the current performance
4. Compare performance to baseline and determine what works to improve performance

• Accountability agreement: Outlines the performance obligations an organization is
  responsible for achieving
• In Ontario, the MOHLTC currently uses 34 indicators as part of its public health
  accountability agreement (as of 2016); the indicators are divided into two groups,
  population health indicators (e.g., breastfeeding duration, chlamydia incidence,
  hep B immunization coverage) and governance and accountability indicators
  (e.g., staff length of service, board member orientation, strategic plan)
• Accreditation: Obtaining a certification or credentials from a third-party body (e.g.,
  Accreditation Canada) that demonstrates key processes are in practice; common for
  LHINs and hospitals to attain, and mandatory for CHCs; not mandatory for PH in
  Ontario; obtaining and maintaining accreditation often supports continuous quality
  improvement, but requires significant time and effort to comply and may duplicate or
  take resources away from meeting other performance targets or accountability
  agreements

Question 92

What are population-level interventions to increase physical activity?

Compare and contrast physical activity and physical fitness.

What are recommended amounts of physical activity?

Answer 92

Population-level interventions

• *Neighborhood/society:**
  1) Community-wide campaigns (e.g., advertising campaigns); moderately effective

2) Active transportation

3) U__rban planning to increase walkability

School/organizations:

1) Point-of-decision prompts (e.g., signs that recommend using stairs); moderately effective

2) School interventions
3) Classroom-based health education; insufficient evidence
4) School-based PE; effective

• *Individual;**
  1) Health behaviour change programs; effective

Physical activity comprises:
- Leisure-time physical activity: Recreational exercise; usually what is measured as
physical activity
- Aerobic activity is the most beneficial form of physical activity in terms of impact
on health outcomes
- Non-exercise activity thermogenesis (NEAT): Energy expended during activities of
daily living

Physical fitness: Measure of body composition, BMI, or aerobic capacity
- Different from the ability to engage in physical activity; both physical fitness and physical
activity independently result in health benefits

Sedentary behaviour: Time spent watching screens, reading, sitting, or participating in
sedentary hobbies; sedentary behaviour is a risk factor for poor health outcomes, even in
individuals who are physically fit

Physical literacy: Ability to move with competence and confidence in a wide variety of physical
activities in multiple environments that benefit the healthy development of the whole person
(PHE Canada)

Daily physical activity recommendations (Canadian Society for Exercise Physiology)
- Children and youth: 60 minutes of moderate- to vigorous-intensity physical activity/day,
including muscle- and bone-strengthening activities 3 days/week and <2 h/day of
recreational screen time
- Adults: 150 minutes of moderate- to vigorous-intensity physical activity/week (equivalent
to 10,000 steps/day), including muscle- and bone-strengthening activities 2 days/week

Epidemiology
- 7% of Canadian children and youth accumulate at least 60 minutes of moderate- to
vigorous-intensity physical activity at least 6 days a week
- Girls are significantly less active than boys
- 15% of Canadian adults accumulate 150 minutes of moderate- to vigorous-intensity
physical activity/week

Question 93

What is social marketing?

What are the 4Ps of marketing?

Compare and contrast commercial and social marketing.

Answer 93

Social marketing
Definition: “The application of commercial marketing technologies to the analysis, planning,
execution, and evaluation of programs designed to influence voluntary behaviour of target
audiences in order to improve their personal welfare and that of society”

Appeals to the target audience through the 4Ps:
- Product: Physical product, service, practice, or idea
- Price: What the consumer must do to obtain the product (e.g., financial cost, risk of
embarrassment, time)
- Place: The way in which the product reaches the consumer (e.g., mass media, physician
office)
- Promotion: Integrated use of advertising, public relations, advocacy, personal selling,
and entertainment

Types of social marketing:

Upstream v. midstream v. downstream;

community-based v. largescale

Social marketing position statement: “We want [target audience] to see [desired behaviour]
as [descriptive phrase] as more beneficial than [competing behaviour].”

Question 94

What are the canadian structures for monitoring and surveillance of adverse events following immunizations?

Answer 94

• Immunization Monitoring Program ACTive (IMPACT): Pediatric hospital-based
  national, active surveillance system for AEFIs, vaccine failures, and VPDs; includes 12
  Canadian pediatric hospitals
• Canadian Adverse Events Following Immunization Surveillance System
  (CAEFISS): Post-market vaccine safety monitoring system; in most cases, the pathway
  occurs event → nurse, physician, pharmacist → local public health → P/T public health
  authorities (IMPACT, DND, and FNIHB report directly to CAEFISS; pharmaceutical
  companies report to Health Canada)
• Brighton Collaboration: Group that establishes international case definitions for AEFIs

Question 95

Describe the hierarchy of controls

Answer 95

Hierarchy of controls
Definition: Mechanisms of controlling occupational hazards, listed from most to least effective

Elimination: Physically remove the hazard; most difficult to implement once a process has
been implemented
Substitution: Replace the hazard; easiest to implement during the design or development
stage of a process (e.g., switch to a non-toxic cleaner)
Engineering controls: Isolate people from the hazard; usually highly effective and provide
protection independent of worker behaviour; usually initially higher cost than administrative
controls of PPE, but may cost less in the long term (e.g., improve ventilation system to reduce
amount of hazard exposure)
Administrative or work place controls: Change the way people work; relatively inexpensive to
establish, but less effective and requires significant effort on the part of workers (e.g., reduce
number of hours spent in loud environments)
Personal protective equipment: Also relatively inexpensive to establish, but may be relatively
costly over the long-term; least-effective measure (e.g., respirators)

Question 96

Define climate change and describe its expected health impact and the role of public health.

What are 4 greenhouse gases?

Answer 96

In summary, health impacts are:

Temperature related morbidity and mortality (heat waves, fire, drought)
Weather related natural hazards (hurricanes)

Sea-level rise (flooding)
Vector borne and zoonotic diseases

Water and food borne contamination

Climate migration, food insecurity, unequal impact on vulnerable

Air quality (pollen, ozone, fires)

• *Public health roles in climate change**:
• Mitigation: Actions that stabilize or reduce the production of GHGs (e.g., cap and trade, carbon tax)
• Advocacy (e.g., for active transportation, for energy efficiency)
• Adaptation: Systems-level changes in response to observed or expected impacts of climate change
• Education and capacity building
• Research and surveillance (e.g., vector-borne diseases, identification of vulnerable populations)
• Empowering or protecting vulnerable populations (e.g., vaccination, case management for individuals experiencing homelessness)
• Emergency preparation and management

Climate change: Significant, long-term variations in temperature, precipitation, extreme weather events, snow cover, or sea level; caused by humans release of greenhouse gases, which absorb solar radiation and trap heat in the lower atmosphere

• key GHGs include CO2,methane, nitrous oxide, and fluorinated compounds
• Over the last 50 years, the mean global temperature has increased by 0.7 C; it is expected to increase an additional 1.8-4 C by 2100
• Canada contributes 2% of total global CO2 emissions, but Canada is the third-highest country in terms of per capita greenhouse gas emissions
• Don’t blame climate and geography: per capita emissions in Finland, Russia, and Sweden are lower than Canada’s
• Impacts in many Canadian cities will be:
• Increased number of tornadoes, wildfires, and thunderstorms
• Increased mixed precipitation in winter
• Increased number of freeze-thaw cycles
• Increased number of days > 30 C in summer (increased AC and electricity demand)
• Increased CO2 levels (resulting, for example, decreased concrete lifespan)
• Most infrastructure is built based on average of extremes that have occurred over the last 30-50 years; past extremes are not predictive of the future extremes that will occur with climate change
• *Health impacts of climate change** (verbatim from IPCC):
• Greater risk of injury, disease, and death due to more intense heat waves and fires (very high confidence) (note: some parts of the world already exceed the international standard for safe work activity during the hottest months of the year)
• Increased risk of undernutrition resulting from diminished food production in poor regions (high confidence)
• Consequences for health of lost work capacity and reduced labor productivity in vulnerable populations (high confidence)
• Increased risks of food- and water-borne diseases (very high confidence) and vectorborne diseases (medium confidence)
• Modest reductions in cold-related mortality and morbidity in some areas due to fewer cold extremes (low confidence), geographical shifts in food production, and reduced capacity of disease-carrying vectors due to exceedance of thermal thresholds (medium
  confidence) . These positive effects will be increasingly outweighed, worldwide, by the magnitude and severity of the negative effects of climate change (high confidence).

Question 97

What are adverse childhood events?

How do they lead to poor health outcomes?

Answer 97

Adverse childhood experiences (ACE)
- Adverse childhood experiences are linked to poor health outcomes in adults; graded,
dose-response relationship between ACE and poor health outcomes, including
increased risk of smoking, BMI > 35, suicide attempts, drug use, STIs, and COPD, early
mortality

• ACE include:
• Abuse: Emotional, physical, sexual
• Household challenges: Intimate partner violence, household substance abuse,
  mental illness in the household, parental separation or divorce, criminal
  household member, incarceration, homelessness
• Neglect: Emotional, physical
• Mechanisms through which ACEs impact health: Nutritional deficiencies, epigenetics,
  prolonged HPA activation, low level of language exposure, maladaptive neurocognitive
  development
  Image: CDC-Kaiser ACE study

Child protective services: In Canada, allegations of maltreatment are substantiated in 36% of
child maltreatment investigations; after investigation, 92% of children remain in their previous
residence; the remaining 8% of children move to informal placement with a relative, group
homes or residential treatment programs, or formal foster care/kinship placements

Question 98

Describe basic facts about pertussis

Organism, Reservoir, Mode of transmission

Incubation period, infectious period

Epidemiology

Presentation, Testing

Case management, Contact management

+/- Immunization

Answer 98

Pertussis (reportable)
- Organism: Bordetella pertussis (note that Bordetella parapertussis and Bordetella
holmesii can cause similar disease, but are not reportable)
- Reservoir: Humans
- Mode of transmission: Respiratory droplets
- Epidemiology:
- Infants who are too young to have completed their vaccine series are at highest
risk of infection and complications (<4 months)
- Source of infection is most often the parents
- Mortality rate in Canada = 1% in hospitalized infants (1-3 deaths in Canada/year)
- Duration of protection from natural disease is unknown
- Correlation of disease protection with titres is unknown; no correlate of protection
- Presentation: Infants present with atypical symptoms (apnea, seizures, sneezing,
gagging, choking, vomiting)
- Catarrhal stage: Rhinorrhea, sneezing, low-grade fever, mild cough x 1-2 weeks
- Paroxysmal stage: Severe cough, inspiratory whoop +/- posttussive vomiting x 1-
10 weeks
- Convalescence stage: Gradual recovery
- Incubation period: 9-10 days (range, 6-42 days)
- Infectious period: Infectious until day 5 of appropriate abx
- Testing: NPS for PCR
- Case management: Abx therapy + education about respiratory etiquette; avoid contact
with high-risk groups until 5 days of abx have been completed
- Contact management: Chemoprophylaxis (macrolide) for household contacts or high-risk contacts
(may protect contact, but does not change outbreak course); immunoprophylaxis is
recommended for susceptible adults and children, and all pregnant women > 26 weeks GA
- Vaccine:
- Recommended for routine immunization of infants, children, and adolescents;
also recommended for susceptible adults
- Vaccination in pregnancy: Vaccination in pregnancy provides passive immunity in
newborns
- ACIP recommendations: Tdap in every pregnancy
- NACI recommendations: Tdap in pregnancy as of 2018
- Acellular pertussis vaccine effectiveness declines rapidly over time and is likely
not effective 7 years post-vaccination
- Individuals who were primed with whole-cell vaccine receive better protection
from acellular product
- Vaccine may be less protective against protectin-deficient strains of pertussis
Timeline of pertussis vaccine in Ontario:
- 1943: Whole cell fluid vaccine
- 1984: Absorbed whole cell vaccine (caused large local reactions; Canadian whole call
vaccine product had a lower effectiveness than products used in other countries)
- 1997: Acellular vaccine
- 2003: Adolescent Tdap booster program introduced (14-16 years)
- 2011: Adult Tdap booster program introduced (1 dose any time as an adult)

Question 99

List 5 potential components of a vaccine.

Discuss concerns around thimerosal, aluminium and formaldehyde in vaccines.

Answer 99

Antigens: Components derived from a disease-causing organism that trigger an immune response

Stabilizers: Components that maintain vaccine stability (e.g., maintain the correct pH, prevent protein or carbohydrate aggregation, or prevent hydrolysis) (e.g., MgS04)

Adjuvants: Components that stimulate the production of antibodies; improve immune response; most commonly used in inactivated vaccines; “adjuvants are a highly heterogeneous group of compounds with only one thing in common: their ability to
enhance the immune response” (e.g., aluminum hydroxide); usually the cause of localized reactions
- Vaccines containing adjuvants should be injected IM to reduce localized side effects

Antibiotics: Used in the manufacturing process to prevent bacterial contamination of culture cells; usually only trace amounts end up in vaccines (e.g., neomycin)

• *Preservatives**: Added to multidose vaccine vials to prevent bacterial and fungal growth (not required for individual-dose vaccines, although used in some countries to reduce storage costs); added in response to deaths secondary to pyogenic bacteria (e.g., thimerosal, formaldehyde)
• Thimerosal: Ethyl-mercury compound; multi-dose influenza vaccine and Hep B are the only Canadian products that still contains thimerosal

Formaldehyde (preservative)

Formaldehyde is used in some vaccines, such as the hepatitis A vaccine. It’s used during the vaccine development process to kill or disable the viruses or bacteria.

The human body naturally produces formaldehyde. For instance, an infant’s body contains about 10 times the amount of formaldehyde found in 1 dose of a vaccine. The tiny traces that may be found in the vaccine are safe.

Thimerosal (preservative)

Sometimes many doses of vaccine can be taken from the same vial. Thimerosal stops harmful bacteria and fungi from growing inside these multi-dose vaccine vials. Even though each new dose uses a new needle and syringe, thimerosal adds another layer of protection. It prevents the vaccine from becoming accidentally contaminated, which could cause serious infections in the people getting the vaccine.

Thimerosal isn’t used in single dose vaccine vials. Routine vaccines in Canada come in single dose vials and are therefore thimerosal free.

Thimerosal breaks down into ethylmercury in the body and quickly leaves the body in the feces. It doesn’t build up in the body and doesn’t cause health concerns.

Many well-conducted studies have explored Thimerosal. During its long history of use in preventing contamination of vaccines, thimerosal has never been found to cause any harm.

Aluminum (adjuvant)

Some vaccines include aluminum salts to strengthen the body’s immune response to the antigens. This is known as an adjuvant.

Aluminum is one of the most common metals found in nature and is present in:

air

food

water

T_here’s less aluminum in vaccines than the amount found in breast milk or infant formula_.

Question 100

What is public health advocacy

and what are examples of public health advocacy activities?

Answer 100

Policy advocacy

Public health advocacy: “Advocacy is a critical population health strategy that emphasizes
collective action to effect systemic change. It focuses on changing upstream factors related to
the social determinants of health, and explicitly recognizes the importance of engaging in
political processes to effect desired policy changes at organizational and system levels.”
(NCCDH)
- “As the most political of public health strategies, advocacy is risky to both practitioners
and agencies. Many government-funded public health workers see advocacy as strictly
off-limits since influencing government policy is often the object of advocacy.” (NCCDH)

• *Advocacy roles for public health:**
  1. Framing the issue
  2. Gathering and disseminating data
  3. Working in collaboration and developing alliances
  4. Using the legal and regulatory system
• *Essential elements of effective advocacy:**
• Clear, specific goals
• Solid research and science base
• Values linked to fairness, equity, and social justice
• Broad-based support through coalitions
• Mass media used to set public agenda and frame issues
• Use of political and legislative processes for change

Types of advocacy:
1. Community activism: Enable communities to address the causes of poor health at a
policy level
2. Social policy reform: Champion legislative reform that redresses health inequities
3. Community development: Enable individuals to identify and address their own needs
4. Representational/client advocacy: Representing the rights and interests of those
unable to represent themselves

Question 101

Describe basic facts about arsenic

Answer 101

Arsenic (*)
Testing: Assess levels in humans with speciated urinary arsenic; inorganic As bad; organic As less bad

Common sources:

_Contaminated food (esp seafood and rice_)
Contaminated water (uncommon in Canada, more common in SE Asia, Mexico)
Other uses: Wood preservative, agriculture, medicines (African trypanosomiasis tx), incineration

Short-term effects: N/V, abdo pain, muscle cramps, paresthesia, cardiotoxicity

Long-term effects:

Cancer: Lung, bladder, SCC (organic As is IARC 2B; inorganic As is IARC 1)
Arsenicosis: Colour changes and thickening of skin due to long-term exposures to high levels of arsenic in drinking water

Question 102

Describe what a business case is and when it should be used.

Answer 102

Business case
Definition: Structured argument as to why a particular project should or should not proceed;

• *Steps:**
• Assess: Assess strengths and limitations of the project across six elements,

Project design (logic model),

Evidence base,

Implementation roles (RASCI; see below),

Resources and budget,

Work plan

Stakeholder roles and expectations

• Analyze: Based on the strengths identified in the previous step, list the potential benefits of the project. Based on the limitations identified in the previous step, list the potential risks of the project. Identify the areas that will be impacted by these benefits and risks
  (e. g., population health, access to services). Describe how likely and how significant each risk and benefit is. Consider strategies that will maximize benefits and minimize risks.
• Advise: Examine the overall patterns of strengths, limitations, risks and benefits in the context of your minimization and maximization strategies. Rate each of the six project elements. Draw conclusions about the overall project.

Examples of decisions that requires business cases: rent vs. buy, build software vs. buy software, provide services in-house vs. contract out services

Question 103

How are social network analyses used in public health?

Answer 103

Social network analysis

Definition: A structural approach to examining the linkages between actors, using mathematical
and computational models

Data analysis
- Network visualization: Visual representation of the social network
- Descriptive analyses: Description of the role of individual actors in the network (e.g.,
highly connected individuals, bridge individuals), description of subgroups, and
description of the type of network (e.g., hierarchical, dense)
- Statistical analysis: Descriptive statistics (e.g., distance, density) and inferential
statistics (usually using stochastic or longitudinal models)

• Distance: The length of the shortest path between actors
• Density = Total number of relational ties divided by the total possible number of
  relational ties
• *Uses in public health**
• Disease transmission networks
• Outbreak investigation
• Disease modelling
• Information transmission networks (e.g., who should we target with our messaging?)
• Social support networks (e.g., how does social capital flow?)
• Organizational networks (e.g., how are health organizations related to one another?)

Question 104

What are 3 biases associated with screening?

What are necessary criteria to establishing a screening program?

Answer 104

In summary, screening program criteria:

• Condition (4):
  1) burden, 2) latent state, 3) natural history, 4) accepted treatment
• Test (2):
  1) suitable, 2) acceptable
• Program (4):
  1) who pts are, 2) economically balanced for society, 3) continuous process, 4) facilities for dx+tx

Disease screening

Definitions
- Screening: S_ystematic process to identify individuals with a disease still in the asymptomatic phase_
- Universal screening: Screening program is offered to an entire population (where that population is defined by demographics, e.g., age and sex)
- Systematic screening: Systematic recall of patients to participate in a
universal screening program
- Opportunistic screening: Offering an opportunity to participate in a
universal screening program when the patient is present for another
reason
- Case-finding: “Screening” program offered to a specific population based on risk factors other than demographics (e.g., screening offered to family members of a patients with cancer); note that public health people get in long and heated arguments as to whether
case-finding is screening or not

• *Biases associated with screening**
• Selection bias: Healthy people who are more likely to have better outcomes are more likely to get screened
• Lead-time bias: Apparent improvement in length of survival in screened populations, due to earlier diagnosis rather than more effective follow-up
• Length bias: Apparent improvement in length of survival in screened populations, because screening is more likely to detect slowly progressing disease
• Overdiagnosis bias: “Screen-detected cases include non-progressive or slowlyprogressive disease that would not present clinically before death due to other causes” (i.e., not truly cases)

Screening program criteria

Emily’s alphabetic acronym:
- Acceptable screening test (safe, simple, low opportunity cost)
- Better outcomes with intervention in pre-symptomatic phase (natural history of disease
understood)
- Characteristics of screening test: PPV, NPV, cost
- Defined target population
- Equitable
- EFfective intervention
- Good evidence supporting screening program
- Harms of participation (e.g., overdiagnosis, overtreatment, false positives, false
reassurance) are outweighed by benefits (e.g., early diagnosis, more effective treatment)
- Important health problem (frequency or severity)

John’s 3-bucket approach

• *Condition (4)**
  1. The condition should be an important health problem.
  2. There should be a recognisable latent or early symptomatic stage.
  3. The natural history of the condition, including development from latent to declared disease should be adequately understood.
  4. There should be an accepted treatment for patients with recognised disease.
• *Test (2)**
  5. There should be a suitable test or examination.
  6. The test should be acceptable to the population.
• *Screening Program (4)**
  7. There should be an agreed policy on whom to treat as patients.
  8. Facilities for diagnosis and treatment should be available.
  9. The cost of case-findings (including diagnosis and treatment of patients diagnosed) should be economically balanced in relation to possible expenditure on medical care as a whole.
  10. Case-findings should be a continuing process and not a ‘once and for all’ project.

Question 105

Describe basic facts about Haemophilus influenzae

Organism, Reservoir, Mode of transmission

Incubation period, infectious period

Epidemiology

Presentation, Testing

Case management, Contact management

+/- Immunization

Answer 105

Haemophilus influenzae (Hib is reportable)

• Organism: Haemophilus influenzae (gram-negative coccobacillus)
• Typable: Encapsulated, designated a-f; serotype b (Hib) is the most pathogenic
• Non-typable: Not encapsulated
• Reservoir: Humans
• Mode of transmission: Respiratory droplets
• Epidemiology:
• Hib causes 95% of H. influenzae invasive disease
• In Canada, Hib incidence is highest in: 1. Infants < 1 year and 2. Children
  between 1-4 years of age
• Hib case-fatality rate = 5%
• Before the introduction of the Hib vaccine, Hib was the most common cause of
  bacterial meningitis and epiglottitis in children
• Non-b H. influenzae now the most common cause of invasive H. influenzae
  disease in Canada
• Presentation: Bacterial meningitis, epiglottitis, cellulitis, septic arthritis, bacteremia, otitis
  media, pneumonia; sequelae include permanent neurological impairment (10-15% of
  survivors) and deafness (15-20% of survivors)
• Incubation period: 2-4 days
• Infectious period: Up to 24-48 h post-abx
• Case management: Droplet precautions x 24 h post-abx; antibiotic treatment and
  supportive care; if cefotaxime or ceftriaxone were not used for treatment, provide a dose
  of rifampin chemoprophylaxis prior to discharge to eliminate carriage + vaccine if
  unvaccinated
• Contact management: Chemoprophylaxis (rifampin) for all unimmunized or incompletely
  immunized household and child care contacts + vaccination at age-appropriate intervals
• Vaccine:
• Recommended for: All children < 5 years of age and anyone > 5 years of age
  who also has a primary immunodeficiency, malignant hematologic disorder, HIV,
  asplenia (including sickle cell disease), transplant, or cochlear implant
• Primary series at 2, 4, and 6 months + additional dose at or after 12 months (the
  latter is necessary for sustained protection)
• Hib conjugate vaccines uses tetanus protein carriers; this does not immunize
  against tetanus

Question 106

Describe the behavior change model: Health belief model

Answer 106

Health belief model

• Whether or not an individual’s behaviour will change is based on:
• The threat posed by a health problem;
• The benefits of avoiding the threat; and
• Factors influencing the decision to act
• Perceived susceptibility: Belief that a behaviour, exposure, or event is a threat
• Perceived severity: Beliefs about the seriousness of a condition and its
  consequences
• Perceived benefits: Beliefs about the effectiveness of taking action
• Perceived barriers: Beliefs about the costs of taking action
• Cues to action: Factors that activate “readiness to change”
• Self-efficacy: Confidence in one’s ability to take action and overcome barriers
• Most effective at explaining simple behaviours (e.g., uptake of screening, immunization)
  than complex behaviours (diet, smoking)

Question 107

What is the Erickson De Wals framework?

Answer 107

In summary, Erickson De Wals vaccine program criteria:

Appropriate disease (1) - burden of disease

Good vaccine (5) - safety, immunogenicity, effectiveness, cost-effective, ease of administration

Good program (10) - feasible, acceptable, delivery strategy, sufficiently researched implementation, can be evaluated, comparable to others, legal/political/ethical/equity considerations

The final framework includes 53 items, grouped into 13 categories/questions. The 13 questions

(paraphrased) include:
1. Disease characteristics and burden Does the burden of disease justify a control program?
2. Vaccine characteristics Is the vaccine safe and effective?
3. Immunization strategies What is the goal of the program? What is the delivery strategy (e.g., schools vs. public clinics)? Will the delivery strategy achieve the goal of the program?
4. Social and economic costs and benefits Is the program cost-effective?
5. Acceptability Is the program acceptable to the public? Is there public demand for the program?
6. Feasability the program feasible given existing resources?
7. Ability to evaluate Can the program be evaluated?
8. Research questions Have important research questions affecting implementation of the program been adequately addressed?
9. Equity Is the program equitable?
10. Ethical considerations Are there ethical concerns?
11. Legal considerations Are there legal concerns (i.e., off-label use)?
12. Similarity to other programs Is the program the same as those planned or implemented elsewhere?
13. Political considerations Will the proposed program be free of controversy and/or produce some immediate political benefits?

Dr. Gemmill proposes that the most important characteristics to consider when introducing a
new vaccine are:

Immunogenicity, cost, safety, ease of administration, and effectiveness

Question 108

What are the principles of the Canada Health Act (1984)?

Answer 108

Canada Health Act (1984)
- Description: Federal law passed by Pierre Trudeau’s Liberal government to ensure that
all residents of Canada have access to necessary hospital and physician services
without regard to their ability to pay
- Principles (UPPAC) that the P/Ts must meet to be eligible for federal transfer payments
(Canada Health and Social Transfer):

(acronym = UPPAC)
- Universality: All eligible residents are entitled to uniform health insurance coverage
- Public administration: Health insurance plan must be administered by a nonprofit,
public authority
- Portability: Coverage for insured services must be maintained when an insured
person moves within Canada
- Accessibility: Insured persons must have reasonable access to necessary
hospital and physician services and may not be impeded by financial or other
barriers
- Comprehensiveness: All medically necessary services provided by hospitals and
doctors must be insured

• The CHA also forbids extra billing (billing for insured services) and user charges (out-ofpocket
  payments from insured individuals)

Question 109

How to choose which parametric statistical test to use?

Answer 109

Question 110

In the epidemiologic triangle, what are relevant characteristics of the agent for disease transmission?

Answer 110

• Infectiousness (I): Ability of an organism to establish itself in a susceptible host; I = infected / exposed
• Attack rate: number of new cases / number of persons at risk
• Secondary attack rate = Number of secondary cases / number of primary contacts
• Pathogenicity: Probability of an organism to cause disease (e.g., TB is not very pathogenic)
• Virulence: Severity of disease caused by organism (e.g., Zika is low-virulence; TB is highly virulent)
• Basic reproductive number: Theoretical number; the mean number of individuals directly infected by an infectious case through the total infectious period, when introduced to a susceptible population
• R = p x c x d (probability of transmission/contact x duration of infectiousness x contacts/time) - R < 1 → Infection will disappear; R = 1 → Infection is endemic; R > 1 → Infection can become an epidemic

Question 111

What are historically important adverse events following immunization?

Answer 111

Historically important AEFIs and specific AEFI syndromes
- Whole-cell pertussis vaccine (no longer used in Canada): Reversible encephalopathy;
hypotonic-hyporesponsive events
- Rubella component of MMR vaccine: Arthropathy (usually occurs in post-pubertal
women who are not yet immune)
- Measles component of MMR vaccine: Immune thrombocytopenic purpura (1
case/40,000 vaccinated children)
- Live-attenuated oral polio vaccine: Polio
- MMR vaccine: Severe allergic reactions to porcine gelatin
- Influenza vaccine: Oculo-respiratory syndrome (red eyes, cough, wheeze, chest
tightness, sore throat, facial swelling); occurs within 2-24 h of vaccination and resolves
within 48 hours
- Monovalent, adjuvanted 2009 H1N1 vaccine (used in some European countries only):
Narcolepsy
- MMR-V: Febrile seizures (4/10,000 12-23 month-olds will have febrile seizures when the
vaccines are given separately; 8/10,000 12-23 month-olds will have febrile seizures with
MMR-V)
- BCG: Osteitis
- RotaShield (never used in Canada; licensed in the US for <1 yr in 1998):
Intussusception

Question 112

What interventions could lower the burden of preventable cancer?

Answer 112

Preventable cancer burden
Epidemiology
At least 1 in 3 cancers are preventable

• Tobacco: 22% of cancer deaths worldwide are attributable to tobacco
• Infections: 22% of cancer deaths in LMICs and 6% of cancer deaths in HICs are
  attributable to infections (hep B and C, HPV, H. pylori, schistosomiasis, liver fluke);
  worldwide, 15 percent of all human cancers may attributed to viruses:
  ○ DNA viruses: Epstein-Barr virus, human papilloma virus, hepatitis B virus, and
  human herpesvirus-8
  ○ RNA viruses: Human T lymphotropic virus type 1 and hepatitis C
• Environmental pollution: 1-4% of cancers worldwide are attributable to environmental
  pollutants (e.g., arsenic, aflatoxins, dioxins, indoor air pollution)
• Occupational exposures: 10% of cancers in workers worldwide are attributable to
  occupational exposures

Interventions to reduce the preventable cancer burden
- Avoid smoking: Tobacco is the greatest avoidable risk factor for cancer
- Healthy lifestyle: Healthy eating + physical activity + maintenance of a healthy body
weight can prevent 1 in 3 of the 12 major cancers worldwide
- Healthy eating: Increase consumption of vegetables, fruits, and fibres; reduce
consumption of red and processed meats
- Reduce alcohol consumption
- Reduce UV exposure
- Avoid carcinogens: E.g., by receiving the HPV or hep B vaccine, by reducing radon
exposure, by wearing PPE when exposed to occupational carcinogens

Question 113

What are population level interventions that promote mental health?

What are CTFPHC recs for depression (2013)?

What are protective factors against suicide?

Answer 113

• *Population-level interventions** (categorized by Ottawa Charter actions; insufficient evidence available regarding outcomes with the exception of screening)
• Build health public policy: Trauma-informed policy, peace, social justice, human rights
• Create supportive environments: Safe environment, good housing, early childhood attachment, good prenatal care, economic participation, r_educe access to tobacco and alcohol_, good childhood nutrition
• Strengthen community actions: Reduce stigma and discrimination; strengthen sense of community
• Develop personal skills: Positive educational experiences, ability to manage conflict, physical activity
• Reorient health services: Improve capacity amongst health professionals to promote mental health
• Screening: The CTFPHC recommends against screening for depression in adults (no demonstrated benefit, potential for harm), both in those at average risk of depression and those at increased risk of depression (including post-partum)

Definitions

• Positive mental health (PHAC): The capacity to feel, think, and act in ways that enhance the ability to enjoy life and deal with challenges
• Mental health promotion (WHO): Creating conditions that support mental health and allow people to adopt and maintain healthy lifestyles
• Mental illness: Alterations in thinking, mood, or behaviour resulting in distress and impaired functioning
• *Epidemiology of mental illness**
• In any given year, 1 in 5 Canadians have a mental illness or addiction
• Addiction is more common in men than in women
• By age 40, 1 in 2 Canadians are experiencing or have experienced mental illness
• 1 in 7 Canadians access health services for mental illness
• Mental illness is the most common cause of short- and long-term disability in Canada
• *Suicide**
• Men are 4 times more likely to complete suicide than women, but women are 4 times more likely to attempt suicide than men
• Suicide in 5-6x more common in First Nations youth and 11x more common in Inuit youth than in non-Indigenous youth

- Protective factors: Socio-economic situation › Loving parent-child relationship › Having reasons for living › Social connectedness › Sense of belonging › Religion

- Suicide rate 11/100,000 in gen pop, 30/100,000 in first nations, >100/100,000 among Inuit.

The decision to recommend against screening was based on the lack of evidence on the benefits and harms of routinely screening asymptomatic adults. Despite the lack of evidence, the CTFPHC had concerns about the potential harms of screening (e.g. false positive, unnecessary treatment, labelling and stigma) and appropriate use of limited resources.
In the absence of a demonstrated benefit of screening, and considering potential harms, the CTFPHC recommends not routinely screening asymptomatic adults from average- and increased-risk groups.
Physicians who believe their patients, or a subset of their patients, place a high value on the potential benefits and are less concerned with potential harms would likely implement screening for these
patients.

Question 114

Describe different types of indoor air pollutants

What are the symptoms, possible cause and risk factor for sick building syndrome?

Answer 114

In summary:

Biological: allergens, endotoxin, mold

Chemical: combustion (cigs, indoor fuel, CO), off-gassing (VOC, formaldehyde), outdoor air pollution

Physical: radon, asbestos

• We spend almost 90% of our time indoors, so exposure to airborne pollutants is more common in indoor air than outdoor air
• Tight seals and air conditioners reduce the concentration of outdoor air pollutants indoors → lower income individuals are less likely to live in high-quality housing and therefore more likely to be exposed to outdoor air pollutants indoors (in addition to living
  closer to roadways and industry)
• Sick building syndrome: Symptoms (headaches, dizziness, rhinitis, nausea, lethargy) that improve when individual leaves the building, but no cause can be identified.

Possible causes are: air pollutants, poor ventilation, noise, vibration, poor lighting.

Risk factors include: female, atopy, overcrowding, job stress

• Building-related illness: Signs and symptoms that are attributable to an identifiable, building-related cause (e.g., Legionnaire’s disease, occupational asthma, hypersensitivity pneumonitis)

Biological contaminants

• *Allergens**:
• Sources: Pets, dust mites, cockroaches, fungus
• Health effects: Exacerbation of pre-existing asthma, increased risk of allergy, decreased risk of allergy (unclear which it is)
• *Endotoxins**:
• Sources: Lipopolysaccharide components of outer membranes of gram-negative bacteria; associated with contaminated humidifiers, food waste, lower ventilation rates, farms
• Health effects: Exacerbation of pre-existing asthma, decreased risk of future allergies and asthma
• *Mold**:
• Sources: Leaks in building structure or plumbing, condensation, and household mould (e.g., hidden food spills, defrost pans)
• Health effects: May result in upper respiratory symptoms (via exacerbation of environmental allergies or asthma), but symptoms may also be explained by dampness (uncommon health effects of mould include mycotic infections and, in low-income countries, hepatocellular carcinoma from aflatoxin exposure)

Combustion-related contaminants

• *Second-hand smoke**
• Sources: Cigarettes
• Health impacts: Upper respiratory symptoms, respiratory illness requring hospital admission, sudden infant death syndrome
• *Indoor fuel smoke**
• Sources: Biomass burning for cooking or heating (common in LMICs), results in CO, NO2, SOx, PMs, PAHs, Pb, chromium
• Health impacts: Lung cancer, childhood asthma, 2.7% of global DALYs (2 million deaths/year)
• *Carbon monoxide**:
• Sources: Attached garages, gas stoves, furnaces, woodstoves, fireplaces, cigarettes
• Health effects: Headache, nausea, fatigue, death

Contaminants from off-gassing
See also: Volatile organic compounds
Formaldehyde
- Sources: Paint, varnish, new furniture (esp pressed wood)
- Health effects: Increased bronchial responsiveness, respiratory tract irritations; IARC, group 1 (nasopharyngeal CA, leukemia)

Question 115

How should public health officials investigate and respond to infection control breaches?

Answer 115

Infection control lapse: Deviation from infection and prevention standards of care; has or may
result in infectious disease transmission to the premises’ clients, attendees, or staff

1. Identification of an infection control lapse (in Ontario, an initial and final report must be
   posted online)
2. Institute corrective action ASAP
3. Gather data
   a. What is the type of premise?
   b. What was the procedure, device, or practice that resulted in the lapse?
   c. What was the degree of the breach (e.g., was reprocessing omitted or just
   performed improperly?)
   d. What body fluids, tissues, or other biologic substances may patients have been
   exposed to?
   e. Which body surfaces or spaces (e.g., mucous membranes, solid organs, skin)
   were exposed?
   f. Lapse time frame (e.g., ongoing, one-time)
   g. Staff involved and their dates of employment
   h. Number of patients exposed (and individual-level BBI status, if available)
   i. Conduct literature review and consult experts
4. Involve key stakeholders: IPAC professionals, appropriate public health agencies,
   affected healthcare providers, licensing agencies
5. Risk assessment
6. Develop communications and logistics plans
7. Patient notification and testing
   a. High-risk breach (high probability of blood exposure): Notify and test all exposed
   patients
   b. Low-risk breach (lower probability of blood exposure): Decide whether
   notification and testing is warranted based on risk, public concern, and balance
   of duty to warn with harm of notification

Question 116

What are measures of central tendency (3) and central dispersion (3).

What is skew and kurtosis?

Answer 116

Descriptive statistics

Measures of central tendency
- Mean: Most commonly used measure of central tendency
- Median: The value in the middle of a distribution; less sensitive to extreme scores, more robust and may be more informative for skewed data
- Mode: The most commonly observed value in a distribution; meaning is obvious, but
greatly subject to sample fluctuations

Measures of dispersion
- Range: The difference between the largest and smallest values; simplest measure; very
sensitive to extreme values
- Variance: Average squared difference between the mean and each value
- Standard deviation: Square root of the variance; the usual difference between
observations and mean; most intuitively appealing
- Standard error: The standard deviation of the sampling distribution of a statistic;
estimate of the variability between the sample mean you measured and the sample
means you might’ve measured from other samples of the population

Measures of symmetry
- Skew: Measure of the lack of symmetry of a distribution around its mean; can be
symmetrical, right-skewed (tail to the right), or left-skewed (tail to the left),

Measures of tailedness
- Kurtosis: Measure of how “heavy” the “tail” of the distribution is; i.e., data sets with high
kurtosis have a lot of outliers; data sets with low kurtosis don’t have a lot of outliers

• *Depicting data**
• Frequency tables: Lists categories along with how often each occurred, numbers: frequency/cumulative frequency (#), relative frequency/cumulative relative frequency (%).
• Histogram: Graphical summary of a univariate data set; the data range is split into bins
  listed along the x-axis and then the frequency counts for each bin are listed along the yaxis
• Stem-and-leaf plot: Data are sorted in ascending order, stems (e.g., tens places) are
  listed in one column, then the leaves (e.g., ones places) are listed beside the appropriate
  tens place
• Box-and-whisker plot: A variety of ways to draw these plots; commonly, the end of the
  whiskers represent the upper and lower extremes, the box represents the upper and
  lower quartile, and the line within the box represents the median

Question 117

What are basic facts about trichomoniasis?

Organism, Reservoir, Mode of transmission

Incubation time, infectious time

Epidemiology

Presentation, testing

Case management

Contact management

Answer 117

Trichomoniasis
- Organism: Trichomonas vaginalis (protozoa)
- Reservoir: Humans
- Mode of transmission: Direct contact (sexually transmitted; note that other common
infectious causes of vaginal discharge–bacterial vaginosis and vulvovaginal candidiasis-
-are not usually considered sexually transmitted)
- Epidemiology: Not well-characterized, but thought to be one of the most common nonviral
STIs; associated with an increased risk of HIV acquisition and transmission in
women; associated with PROM, preterm birth, and low birth weight (unclear if tx
improves outcomes)
- Presentation: 10-50% of women are asymptomatic; if symptomatic, vaginal discharge,
itch, dysuria, “strawberry cervix”; most men are asymptomatic
- Incubation period: 3-28 days (mean: 7 days)
- Testing: On wet mount, motile flagellated protozoa; on Gram stain, PMNs and
trichomonads; vaginal d/c culture (most sensitive)
- Case management: Metronidazole (single dose or 1-week course po); do not treat
asymptomatic pregnant women
- Contact management: Metronidazole for current partners (single dose or 1-week course
po) (no testing required)
*Abstain from etoh x 24 hours post-tx (metronidazole causes Antabuse reaction)

Question 118

What are the benefits of a no fault system following adverse events following immunizations?

Answer 118

No-fault compensation following adverse events attributed to vaccinations
- “Regardless of proper design, manufacture, and delivery, adverse events occur following vaccination…. At the population level, it is considered that these small risks are balanced by the benefits of widespread population immunization. However, this means
that an individual occasionally bears a significant burden for the benefit provided to the rest of the population.”
- Traditional legal mechanisms of compensation usually require evidence of negligence; most vaccine-related adverse events do not occur during negligence

Benefits:
For the people injured:

1) No-fault compensation programs provide a mechanism for individuals who bear the harms of vaccination to receive compensation without the requiring proof of negligence;
2) it also removes the negative equity impacts of using the tort liability system on injured parties (litigation is expensive and inaccessible to many people)

For the companies and vaccine programs:

1) No-fault compensation programs also protect vaccine manufacturers from lawsuits, which reduces vaccine prices and vaccine shortages, and increases vaccine research.
2) No-fault compensation programs reduce negative media coverage of vaccine manufacturers

Applicable ethical principles:

• Fairness (helps equalize the cost borne by the injured and uninjured)
• Equity (removes economic barriers to receiving compensation)
• Solidarity (no member of the community bears the risk of vaccination alone)
• Within Canada, only Quebec has no-fault compensation program

Question 119

What is the rationale for newborn screening tests?

What are some diseases that are screened at birth?

Answer 119

Rationale for newborn screening:
- Disease usually inapparent at birth
- Treatment prevents severe, costly, often irreversible sequelae (e.g., mental retardation,
seizures, failure to thrive, death)
- In most cases, treatment must be implemented soon after birth
- Collectively, prevalence of any one of these conditions at birth is 1 in 800 (200 affected
infants/year in Ontario)

Question 120

Describe basic facts about rotavirus

Organism, Reservoir, Mode of transmission

Incubation period, infectious period

Epidemiology

Presentation, Testing

Case management, Contact management

+/- Immunization

Answer 120

Rotavirus
- Organism: Rotavirus (Reoviridae family); numerous strains
- Reservoir: Humans
- Mode of transmission: Fecal-oral (some evidence that it can also be transmitted through
the respiratory route); stable in the environment
- Epidemiology:
- Rotavirus accounts for 10-40% of all childhood gastroenteritis; 1/62-1/312
children < 5 years require hospitalization with rotavirus
- Small infectious dose
- Most unimmunized children are infected by 5 years of age, but infection does not
usually lead to permanent immunity
- Higher rates of disease in Indigenous children
- Serotype G1P[8] is the most common serotype in HICs
- Disease is more severe in children 3 to 24 mos than < 3 mos, probably due to
passive immunization through maternal antibodies
- Presentation: Spectrum from asymptomatic, to mild disease, to severe dehydration, to
death; typically acute onset of fever and vomiting +/- diarrhea x 5-7 days
- Incubation period: 18h to 3 days
- Infectious period: A few days prior to symptoms up to 21 days afterwards
- Case management: Supportive care, esp hydration; exclude from childcare until diarrhea
has resolved
- Contact management: None
- Vaccine: Monovalent Rot-1 (Rotarix) requires 2 doses; pentavalent Rot-5 (RotaTeq)
requires 3 doses
- Recommended for all immunocompetent infants without a pmhx of
intussusception starting at 6 weeks of age
- Intussusception: Small increase in the risk of intussusception in the 7 days
following vaccination with RotaTeq and RotaShield (no evidence of risk with
Rotarix); RotaShield was never used in Canada and was licensed in the US for
<1 yr in 1998
- 10/13 P/Ts have publicly-funded rotavirus vaccine
- Incredibly effective vaccine (both in terms of hospitalization rates and cost);
vaccinating kids also creates a herd effect (prevents illness in the elderly);
introduction of the vaccine reduces infant and child rotavirus-specific ED visits
and hospitalization by 85%

Question 121

What are 3 types of source water

What are basic principles of well water maintenance?

What are 3 water disinfection techniques and pros/cons?

Answer 121

Source water types:

• Ground water, surface water, ground water under the direct influence of surface water (GUDI)
• *Well water treatment**
• Groundwater is usually filtered by soil and so is safe for consumption
• Well maintenance: Ensure well cap is watertight, surface water does not collect near the well, and well is upstream of any source of pollution
• New wells should be disinfected before use to ensure any bacteria introduced during drilling are removed
• If an existing well becomes contaminated, it can be disinfected (“shocked”) with household bleach
• If shocking does not eliminate the source of contamination, a disinfection device must be installed
• Household drinking water disinfection devices:

Filtration (removes particulate matter and parasites, but cannot remove some bacteria and viruses)

Chlorination (does not kill parasites, does note remove particulate, leaves residual)

Distillation (can remove chemicals)

Boiling (does not remove particulate)

UV (can remove chemicals)

Ozonation (can remove chemicals)

Ceramic candle filter (does not kill viruses)

Activated charcoal (can remove chemicals)

reverse osmosis (can remove chemicals)

• *Water treatment for individual backcountry and travel use**
• Boiling x 1 min (x 3 min at altitudes > 2000 m)
• Filtration (preferably with a chemical disinfectant matrix, because this will also remove some viruses)
• Disinfection: Iodine, chlorine, oxidants; not appropriate for long-term use due to potential effects of excess iodine or chlorine by-products

Question 122

What is the public health importance of giant hogweed?

Answer 122

Wild parsnip and giant hogweed: Phototoxic; produce furocoumarins, which, when exposed to
sun, produce a phyto-photodermatitis; sap absorbed by skin + light exposure → furocoumarin
energized → burn

Heracleum mantegazzianum, commonly known as giant hogweed, is a monocarpic perennial herbaceous flowering plant in the carrot family Apiaceae. H. mantegazzianum is also known as cartwheel-flower, giant cow parsley, giant cow parsnip, or hogsbane.

Also in the same family, Apiaceae – the carrot family, is wild parsnip (Pastinaca sativa), another invasive species to avoid.

Question 123

What are short-term and long-term health effects of air pollution?

Answer 123

Short-term effects
- Primary effect: Exacerbations of preexisting conditions; risk greatest in vulnerable
groups (elderly, children, individuals with cardiac or respiratory disease)
- Outcomes: MI, CVA, CHF/COPD/asthma exacerbation, adverse birth outcomes (IUGR, pre-term labour)

• *Long-term effects**
• Primary effect: Incident cases of chronic disease; risk proportionate to exposure
• Outcomes: Chronic lung conditions (asthma, COPD), impaired lung development, increased susceptibility to infection, l_ung cancer_, dementia

Question 124

Describe basic facts about CADmium

Answer 124

Cadmium (*)

Common sources:

• Fertilizer production;
• Agricultural soil → food;
• Smoking

Short-term effects:

• Toxic pneumonitis;
• Itai-itai disease (ouch-ouch in Japanese), severe joint/spine pain

Long-term effects:

• Progressive palmar fibrosis;
• Kidney dysfunction → decreased vit D → osteoporosis;
• Lung cancer (IARC 1)

Question 125

What can be done to improve recruitment and retention of health professionals?

in human resources, what is succession planning?

What are terms of reference?

Answer 125

Human resources

Improving recruitment and retention of health professionals
1. Offer educational opportunities: CPD, research, training, and job growth opportunities
2. Expand scope: Allow health practitioners to take the most extended roles possible (most applicable to nursing)
3. Professional and personal support: Enact specific measures that support employees with young children and older employees (e.g., child care); implement activities, along with protected time to participate, that support physical and emotional wellbeing
Note that financial incentives are rarely sufficient on their own.
Measures of retention include: employment status, staff stability index, staff turnover rates, job vacancy rates, and job satisfaction levels

• *Succession planning** (APIE model):
  1. Assess: Identify critical roles within your organization
  2. Plan: Identify key competencies required to perform the critical roles and choose workforce development strategies that will develop these key competencies
  3. Implement: Implement the planned workforce development strategies
  4. Evaluate: Monitor, evaluate, and adjust the succession plan

Hiring:
- Hire the person best suited for the job (i.e., “Don’t hire the ‘best’ person for the job”; in
competitive job markets, it is easy to hire over-qualified individuals who will become
bored and frustrated, leading to poor morale, turnover, and absenteeism); minimizing
formal educational qualifications expands the talent pool
- Behaviour is generally predictable; interview questions should focus on past behaviours;
ask questions that can get concrete responses
- Panel should include a variety of individuals (e.g., different personalities who would
appreciate different features of the interviewee)

Promotion:
- Peter principle: Individuals are continually promoted within an organization until the
reach a level at which they are no longer competent (i.e., people “rise to their level of
incompetence”)
- Being too slow to promote can lead to the best talent leaving the organization
- Do not assume all employees wish to advance within the organization

Terms of reference
- Terms of reference: Clear description of the roles and functions of a position or
committee that the individual or group agrees to accept; standard by which performance
will be judged
- Considerations:
- TOR should be re-visited regularly, especially when the project has changed
substantially
- Maintain document control (e.g., version number, sign-off dates)
- To include:
- Background: Context in which the individual or committee will work
- Function of the committee/position: Describe the responsibilities
- Role of the committee/position: List the tasks that the committee or individual will
complete
- (Role of individual committee members)
- (General: For committees, describe the membership, the chair, agenda process,
minute process, frequency of meetings, whether or not delegation is permitted,
quorum requirements)
- General: Timetable, dispute resolution

Question 126

Name 7 health behavior change models

Answer 126

Health behaviour change models
Health belief model
Social cognitive theory
Transtheoretical/Stages of Change model
Theory of reasoned action and planned behaviour
Precaution-adoption process model
Diffusion of innovation theory
Community development

COM-B /behavior change wheel

Health Belief Model

Perceived susceptibility
Perceived severity
Perceived benefits
Perceived barriers
Cues to action
Self-efficacy

Stages of Change

Precontemplation
Contemplation
Preparation
Action
Maintenance
Relapse

Social cognitive theory

Reciprocal determinism
Behavioral capability
Expectations
Self-efficacy
Observational learning/modelling
Reinforcement

Planned behavior and Reasoned action
Behavioral intention/behavior depend on: (mnemonic PAS)

• *- Perceived behavioral control**
• Attitude toward the behaviour
• Subjective norms
• *Precaution-adoption**
  1. Unaware of issue
  2. Unengaged by issue
  3. Deciding whether or not to act
  4. Acting
  5. Maintenance

COM-B / Behavior change

Capability

Opportunity

Motivation

Question 127

Describe a Gantt chart.

Answer 127

Gantt charts
- Definition: Chart used to track project or program schedules; visually depicts how tasks
relate to one another, how far each task has progressed, and who is responsible for
each task

Question 128

How would the inhalation of intentionally-released Francisella tularensis present

and what could be done about it?

Answer 128

Tularemia
- Francisella tularensis is a gram-negative bacillus that is transmitted from contaminated
animals or through tick bites; could be deliberately released, resulting in pneumonic
tularemia
- Incubation period: 3-5 days

• Presentation:
• Ulceroglandular tularemia: Skin ulcer + regional lymphadenopathy
• Pneumonic tularemia: Initially presents like nonspecific pneumonia, but can
  progress to septic shock, ARDS, and respiratory failure (no pathognomonic
  signs)
• Other presentations: Glandular (no ulcers), oropharyngeal (pharyngitis with
  ulcers and cervical lymphadenopathy), conjunctivitis, typhoidal tularemia (no
  localizing symptoms)
• Treatment: Gentamicin or streptomycin x 10 days
• PEP: Doxy or cipro x 7 days

Question 129

What are the pros and cons of culture-independent diagnostic tests

Answer 129

Pros and cons of culture-independent diagnostic tests
Pros
- Faster results
- Can rule in or out multiple pathogens at once
- Usually more sensitive than culture

Cons

• Dead microbes still produce positive results
• Single test can identify multiple microbes and not all may be causing illness
• Does not characterize antimicrobial susceptibility, cannot establish link between source and case

Solution: Reflexive testing with culture if CIDP positive

Question 130

Describe the steps of a cancer cluster investigation and challenges with this type of investigation.

What sources of data can help assign outcome and exposure status in a cluster investigation study?

Answer 130

Cancer cluster = a greater than expected number of cancer cases that occurs within a group ofpeople in a geographic area over a defined period of time
- Comparator = Incidence of cancer cases normally seen in the community or a similar community
- Cancers should be the same type, with the exception of different types of cancer that share the same, known risk factor (i.e., case definitions that include different cancers are usually not useful)
- Choose the geographic area and time period carefully so that a cluster is not created or obscured
In addition to shared etiology, cancer clusters may occur because:
- Cancer is common; communities may perceive the normal frequency of cancer to be a cluster
- Statistically significant excesses of cancer can occur due to chance
**Most cancer cluster investigations do not find a cause**
Challenges to cancer cluster investigation:
- Small number of cases resulting in lack of statistical power to detect an association even if one exists
- Large number of cases (cancer is common!) resulting in spurious association
- Long latency periods, coupled with mobility, limit ability to identify past environmental exposures

Steps: Stop at any step if there is no evidence to proceed to the next step
1. Initial contact and response: Is there evidence that the situation presented f_its the definition of a cluster_ and is it biologically plausible that the cancers share a common etiology? Use risk communication tools to communicate the response to the community member, who may be distressed

2. Assessment: Determine whether the suspected cancer cluster is a statistically significant excess; c_alculating the standardized incidence ratio is recommended (observed/expected)_; develop a communications plan
3. Determine the feasibility of conducting an epidemiologic study:

Identify hypotheses; involve partners; consider whether an expert advisory panel is required; if a study is feasible, propose a study design; continue the communications plan

4. Conduct an epidemiologic study to assess the association between cancers and environmental causes: Correlation does not imply causation; determination of causation should also rely on clinical and laboratory studies

What are data sources for outcome and exposure determinations in cluster investigations?

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 131

Describe the canadian Foodborne Illness Outbreak Response Protocol and the role of its different actors

What are FIORP process steps?

Answer 131

Canada FIORP (Foodborne Illness Outbreak Response Protocol):
- Protocol developed by PHAC (Public Health Agency of Canada), HC (Health Canada), and CFIA (Canadian Food Inspection Agency) to enhance collaboration in the response to
multi-jurisdictional foodborne illness outbreaks

• Outbreak Investigation Coordination Committee (OICC): Forum for information sharing and interpretation, establishing response priorities, and developing communication strategies
• Local/regional health units: Investigate outbreaks occurring within their boundaries; report outbreaks to P/T officials
• P/Ts: Investigate outbreaks that involve >1 local/regional health units and outbreaks that occur in First Nation communities north of 60 degrees; conduct provincial surveillance for enteric illnesses
• PHAC:

1) Coordinate outbreak investigations that involve >1 P/Ts;

2) conduct national surveillance for enteric illnesses;

3) provide consultation through the NML (National Microbiology Laboratory) and CFEP; (Canadian Field Epidemiology Program)

4) notify the WHO if the outbreak is a PHEIC

• Health Canada:

1) Regulate safety and nutritional quality of food, regulate pesticides, and evaluate the safety of veterinary drugs;

2) investigate outbreaks that occur in FN communities south of 60 degrees or on cruise ships (north of 60 = territorial governments), airplanes, and trains;

3) Other roles: risk assessment, communication, consultation
- CFIA (canadian food inspection agency):

1) Inspect food, seed, livestock feed, fertilizers, plants, and animals;

2) trace food item through the food distribution system;

3) food safety investigation;

4) food recall

• RCMP (Royal Canadian Mounted Police): Investigate potential criminal activity (e.g., tampering, terrorism)

STEPS

Identification of Hazards
Notification of Partners
Review Information
OICC Assessment Call - may go back to step 1
OICC Activation
Epi, food, lab Investigations
Central Integrated Analysis
Health Risk Assessment
Public Health and Food Safety Actions
Communication with Public
OICC Deactivation
Post Outbreak Debrief

ON-FIORP: (Ontario)

• Similar structure to Canada’s FIORP; key difference = OICC can be created when a food-related hazard has been identified, even without any reported illness
• LPHAs (local public health agencies): Investigate outbreaks occurring within their boundaries; conduct food safety investigations at retail premises
• MOHLTC (Ontario MoH and Lont term care): Investigate outbreaks that involve >1 health units
• OMAFRA (Ontario Mo Agriculture, Food and Rural Affairs): Conduct food safety investigations in provincially licensed plants
• CFIA: Conduct food safety investigations in federally registered establishments; food recall (even if outbreak is within a single health unit)

Question 132

Provide examples of health inequities for indigenous peoples in Canada

Answer 132

Question 133

What are the pros and cons of an infant vs adolescent hepatitis B immunization program?

Answer 133

Infant program
- 90% of infants who are infected with HBV go on to develop cirrhosis
(compared to only 1-5% of adults)
- Despite targeted immunization for infants born to HBV+ mothers, some
infants are missed and acquire HBV; a universal infant program would
prevent these cases
- Most effective at reducing the number of chronic carriers

Adolescent program
- Most reported acute HBV infections occur in adolescents and adults; there
is a rapid drop in antibodies following immunization, so individuals have
maximum protection at time of greatest risk (caveat: 90% of 18-year-olds
will mount an anamnestic response after a primary infant series)

• Most effective at reducing the number of acute infections

Question 134

What are 4 factors contributing to vaccine hesitancy?

Answer 134

Vaccine hesitancy: “Delay in acceptance or refusal of vaccines despite availability of vaccination services” (WHO definition)

Factors contributing to vaccine hesitancy (4Cs *Extra C)

• *Complacency**
• Lack of experience with vaccine-preventable diseases (see graph below)
• *Convenience**
• Geographic barriers
• Cost barriers
• *Confidence**
• Fear of being injected with a substance derived from disease-causing organisms
• Past adverse experiences
• Feeling intimidated
• Perceived risk/benefit
• Actual risk/benefit (technical concerns over probability of side effects)
• *Culture**
• Religious beliefs (see below)
• Social context and media personalities
• Distrust of the medical system or pharmaceutical industry
• Distrust in government

Question 135

Describe 6 types of viral encephalitis, their reservoirs and vectors

Answer 135

Viral encephalitides (aka arboviral encephalitides) (reportable)
In general,
S/S = meningitis, encephalitis, or myelitis (acute flaccid paralysis) with fever, headache, neck
stiffness, altered mental status; up to 50% of survivors may have permanent neuro or
neuropsych defects
Diagnosis = CSF IgM (preferred); serum or CSF PCR (false-negatives common)

• West Nile: Reservoir = birds; transmitted by culex mosquitoes; 80% of cases are
  asymptomatic; symptomatic cases may have flu-like symptoms +/- rash +/-
  meningoencephalitis +/- flaccid paralysis; infection usually leads to lifelong immunity
• Eastern Equine: Reservoir = birds; transmitted by multiple mosquito spp.; cases of EE
  in Canada occur in the spring, related to bird migration from the US; CFR = 50-75%
• Western Equine: Reservoir = birds; transmitted by multiple mosquito spp.; affects
  Western Canada; CFR = 3-7%
• La Crosse: Reservoir = small mammals; transmitted by Ae. triseriatus and albopictus;
  no cases reported in Canada yet, but could occur here if Aedes range expands due to
  climate change; CFR < 1%
• Powassan: Reservoir = medium-sized mammals; transmitted by Ixodes ticks; CFR =
  0.3-60%
• Japanese encephalitis: Reservoir = water birds; transmitted by Culex spp. and Aedes
  spp.; occurs in Western Pacific, East Asia, and parts of Southeast Asia; CFR 5-40%
  Other arboviral encephalitides present (but rare) in Canada: Snowshoe hare virus, Jamestown
  Canyon virus, California virus, Cache Valley virus

Question 136

Name 3 species of ticks and examples of diseases they carry

Answer 136

Ixodes species (deer ticks)

• Lyme disease (Asia, Europe, US, and parts of Canada)
• Tick-borne encephalitis (Europe and northeast Asia)
• Anaplasmosis, babesiosis, Powassan fever

Dermacentor variabilis (dog tick)

• Tularemia (also transmitted by deer flies, lone star tick and wood tick)
• Rocky Mountain spotted fever

Amblyomma americanum (Lone Star tick)

• Ehrlichiosis, tularemia

Question 137

Describe basic facts about giardiasis

Organism, Reservoir, Mode of transmission

Incubation period, infectious period

Epidemiology

Presentation, Testing

Case management, Contact management

+/- Immunization

Answer 137

Giardiasis (reportable)
- Organism: Giardia lamblia (aka Giardia intestinalis or Giardia duodenalis; three names
for the same thing), protozoan parasite
- Trophozoite: Motile, vegetative form that causes symptoms
- Cyst: Infectious form; can survive for months in cold water; <10 cysts required for
infection
- Reservoir: Humans, other mammals (cats, dogs, cattle, beaver)
- Mode of transmission: Fecal-oral (drinking water, swimming, contaminated food,
institutions, daycare centres), anal intercourse
- Epidemiology:
- Worldwide occurrence
- In temperate climates, incidence peaks in the late summer and fall
- Prevalence in temperate countries = 2-10% in adults and 25% in children
- Risk factors: Daycare attendance, hiking, anal sex, immunocompromise
- Presentation: Usually asymptomatic; if symptomatic, most commonly acute, self-limited
diarrhea x 2-4 weeks; may be followed by chronic infection with diarrhea, steatorrhea,
malabsorption, and weight loss x months
- Incubation period: Median 7-10 days (range 3-25+ days)
- Infectious period: Duration of infection
- Testing: Stool for O&P x 3 (Giardia dx’ed via identification of cysts or trophozoites in
feces)
- Case management: Education, re: hand hygiene, safer sex, feces disposal, swimming;
drug tx with metronidazole, tinidazole, or nitazoxanide can be used to reduce the
duration of symptoms
- Contact management: None
- Other: Can be transmitted via recreational waters; concentrations of chlorine used in
pools do not routinely kill Giardia

Question 138

What are interventions that can decrease vaccine hesitancy?

Answer 138

Enhancing access to vaccination:

• *Improve the offer of vaccination (convenience and access)**
• Geographical: Home visits, vaccination programs in schools and childcare centres
• Cost: Reduce client out-of-pocket costs
• *Increasing community demand for vaccinations**
• Engagement of religious or other influential leaders to promote vaccination in the community
• Social mobilisation and mass media:
• “Play the issue, not the opponent”; adversarial approaches to anti-vax advocates can create the false impression that vaccination is a contested intervention
• Employing patient reminder and follow-up (recall systems)
• Non-financial incentives
• Mandating vaccinations / sanctions for non-vaccination
• 2 Canadian provinces (Ontario, New Brunswick) and all US states require children to be vaccinated prior to attending school, but allow for medical, religious, and philosophical exemptions
• Some other provinces (e.g., Alberta) do not require immunization, but will exclude a child from school if there is a VPD outbreak
• WHO has no official stance on mandatory immunization
• Other approaches: Vaccination is not mandatory in Australia, but it provides nontaxable payments to parents for each child who meets immunization requirements between 18-24 months and again between 4-5 years of age; immunization is mandatory in Latvia, and philosophical or religious exemptions are not permitted
• *Enhancing provision of vaccines:**
• Reducing pain associated with vaccination (3P approach)
• Pharmacologic:Use least-painful brand when possible; topical anesthetics
• Physical: Breastfeeding or providing sweet-tasting solution during vaccination for infants < 12 mos; do not vaccinate children in the supine position; do not aspirate; inject the most painful vaccine last; provide tactile distraction at the time of injection (e.g., Buzzy Helps, Shotblocker)
• Psychological: Distraction techniques, deep breathing

Provider admin measures:

• Electronic immunization records
• Standing orders
• Provider reminders
• HCW communications training: Focus on building a trusting relationship; “overselling” vaccines increases hesitance; aim to increase patient knowledge and awareness about vaccination

Question 139

What are the federal food safety legislations?

Answer 139

Food safety legislation

• *Federal:**
• Food and Drugs Act: Sets standards (e.g., alteration, colouring, bacterial counts, manufacturing) for all foods produced and stored in Canada
• Food-specific acts (e.g., Health of Animals Act, Safe Foods for Canadians Act)
• The Safe Food for Canadians Act replaced the Canada Agricultural Products Act, Fish Inspection Act, Meat Inspection Act, and Consumer Packaging and Labelling Act in 2012
• The SFCA was developed in response to the 2009 Weatherill Report
  (investigation into the 2008 Maple Leaf Foods listeriosis outbreak that resulted in 22 deaths) to improve food safety
• Enforced by the CFIA, which is made up of food inspectors from Health Canada, Agriculture and Agri-Food Canada, and the Department of Fisheries and Oceans

1) Increase safety oversight

2) increase legislative authority

3) increase international marketing

• *Provincial (Ontario)**:
• HPPA: Mandate for regulations, programs, and protocols that govern food premises
• Enforced by the LPHAs (specifically, either the MOH or PHIs)
• *Municipalities within Ontario:**
• Bylaws may address issues around garbage, sewage, and zoning that are not covered by federal or provincial laws
• Enforced by municipal bylaw officers

Question 140

Contrast target population, study population and sample.

Contrast study design error, sampling error and measurement error.

In the context of inferential statistics, contrast a parameter and a statistic.

Answer 140

Inferential statistics
Definitions
- Target population (theoretical): The population about whom we wish to draw
conclusions
- Study population: The accessible population that we can identify and contact; access
this population through the sampling frame; if this is systematically different than the
target population, this introduces bias
- Sample: The subset of the study population from whom we actually get data from; if this
is again systematically different than the target population, this introduces bias
- Parameter: Characteristic of interest in the target population
- Statistic: Numerical estimate of the parameter

• Study design error/bias: Systematic difference between sample and population of interest due to study design; can be reduced by random sampling
• Sampling error: Differences between sample and population of interest introduced by sampling;
  due to “noise”/sampling variability; can be reduced by increasing sample size

Question 141

Describe basic facts about Q fever

Organism, Reservoir, Mode of transmission

Incubation period, infectious period

Epidemiology

Presentation, Testing

Case management, Contact management

+/- Immunization

Answer 141

Q Fever (reportable)
- Organism: Coxiella burnetii (obligate intracellular coccobacillus)
- Reservoir: Farm animals (cattle, goats, sheep), pets (cats, rabbits, dogs), wild animals
(mice, birds, coyotes)
- Mode of transmission: Exposure to biological fluids (amniotic fluid, urine, feces, milk)
and placenta of infected animals via direct contact or aerosolization of contaminated
dust; bite of infected ticks (rare)
- Airborne particles may be carried downwind up to 1km, so lack of contact with
animals or ticks does not exclude Q fever
- Can survive on fomites for years (soil, contaminated animal bedding)
- Epidemiology:
- Worldwide occurrence
- CFR (untreated) = <1% (except Q fever endocarditis, which is fatal if untreated)
- Risk factors for acquisition: Veterinarians, farmers, abattoir workers, butchers
- Risk factors for chronic infection: Valvular heart disease, pregnancy, immunocompromise
- Presentation: Wide range of presentations (the lupus of infectious disease? The syphilis
of non-STI infectious disease? The next Lyme disease?)
- Asymptomatic in 60% of cases;
- Acute Q fever: Fever, flu-like symptoms, nonspecific pneumonitis/atypical
pneumonia; usually self-limiting
- Pneumonia (due to aerosol inhalation)
- Hepatitis: Abnormal liver function +/- granulomatous hepatitis
- Chronic Q fever: Endocarditis, neurological syndromes (incl stroke), chronic
hepatitis, vasculitis, pulmonary amyloidosis, and a bunch of other weird stuff
- Post-Q fever fatigue syndrome
- Incubation period: 3-30 days (depends on infectious dose)
- Testing: Serology, PCR
- Case management: Doxycycline (+ hydroxychloroquine for chronic Q fever); TMP-SMX
in kids
- Contact management: Disinfection, PPE, adequate animal disposal, milk pasteurization
- Other: Q-vax vaccine available only in Australia for high-risk individuals

Question 142

What failure rates of different contraception methods?

Answer 142

Question 143

What are the 8 core competencies for governmental public health?

Answer 143

Core competencies for public health
- In business, a core competency is the collective learning of an organization delineating
how to organize work to deliver value; what the organization is good at (e.g., H&M’s core
competency is delivery cheap, fast fashion)
- In public health, a core competency is a skill an individual should have to do a particular
job; what an individual should be good at

In 2009, the MOH Competencies Working Group of the Public Health Physicians of Canada
defined the 51 minimum competencies for MOHs in Canada, clustered into 8 domains
(verbatim):
- Foundational Clinical Competencies: MOHs need to draw upon their clinical
knowledge, skills and experience to assess issues and communicate decisions affecting
the health of the public.
- Monitoring and Assessing the Health of the Public: MOHs play a central role in
assessing the health of the public to inform priority setting, program planning, delivery
and evaluation.
- Public Health Consultant: MOHs must exhibit sound evidence-based decision-making
and analytical abilities based on the health needs of the public as a whole, and be able
to make decisions in critical situations in the absence of complete information.
- Investigating and Mitigating Immediate Risks to Human Health: MOHs are
responsible for assessing potential risks to the health of the public and taking whatever
possible steps are necessary to reduce or eliminate that risk.
- Policy, Planning and Program Development: MOHs develop, recommend and
implement public policies in support of improved health, including contributing to the
planning and delivery of public health programs and services.
- Communication, Collaboration and Advocacy for the Public’s Health: MOHs are a
primary source of information on public health matters to a range of audiences and
utilize their knowledge of communities to develop and shape strategies with partners to
mobilize action to identify inequities in health and build healthy public policy to reduce
them.
- Leadership and Management: MOHs champion action to improve and protect the
health of the public in inter-sectoral and organizational settings. Internally, the MOH
promotes a shared vision and purpose to drive action and is able to link today’s work
with long range plans.
- Professional Practice: MOHs fulfill a number of professional roles including educator,
the development and translation of public health knowledge, the maintenance and
improvement of their own expertise in public health practice, and ethical conduct.

The CPSO requires non-PH physicians who are transitioning to a public health role to meet the
PHPC minimum competencies; the Joint Task Group on Public Health Human Resources
highlights MOHs without public health training as a risk to public health

Question 144

Name 2 consensus-forming techniques.

Answer 144

Making decisions
Steps in group decision-making: Discuss, Debate, Decide, Do:
- Discuss: Propose options
- Debate: Identify preferred options and evaluate them
- Decide: Choose one option
- Do: Implement the option (note: implementation prevents those who oppose the plan
from circling back to “discuss”)

Participation models (from least to most participatory):
- Team leader decides and informs the team
- Team leader gathers input from team and then decides
- Consensus with fallback (team leader chooses a course of action that is pursued if the
team is unable to make a decision)
- Consensus; formal consensus techniques include:
- Nominal group technique:
1. Generate ideas: Moderator defines the problem. Participants
independently write down their proposed solutions.
2. Record ideas: Participants read their proposed solutions and moderator
records them.
3. Discuss ideas: One by one, each proposed solution is discussed.
4. Vote: Moderator establishes criteria for determining which solution is
preferred. Each participant votes for a solution via rank-order ballot.
- Delphi method: Repeated rounds of anonymous questionnaires sent to a panel
of experts; anonymous results of the previous questionnaire are provided to the
panel between each round; individuals can change their answers in light of this
new information
- Team leader delegates decision to team members

Four frame model: Describes the frames through which different people view the organization;
understanding how other people view problems/solutions allows for more productive decisionmaking
- Structural: The organization is a machine governed by policies (e.g., people use
evidence to determine what the best solution is); conflict is resolved by authority
- Human resources: The organization is a family governed by relationships (e.g., people
use the best outcomes for employees to determine what the best solution is); conflict
resolved through relationships
- Political: The organization is a cut-throat environment governed by power struggles
(e.g., people use the best outcomes for their ascension up the organizational hierarchy
to determine what the best solution is); conflict resolved through bargaining or
manipulation
- Symbolic: The organization is a theatre governed by rituals (e.g., people use what will
best fit the narrative of the organization to determine what the best solution is); conflict
resolved by negotiating shared meanings

Question 145

Define community engagement.

What are levels of public engagement?

What are principles of public engagement?

What are steps in the process of public engagement?

Answer 145

Definition: Process of developing relationship between a community and an organization to identify a shared vision; wide spectrum of community engagement, but the goal is to collaboratively develop solutions acceptable to the community for community-identified needs

Planned two-way discussions with individuals, organizations, or groups, external to the Government of Canada, designed to:

• gather input,

- clarify information and

- foster understanding among those interested and affected by an issue, decision or action and to

- better inform HC and PHAC’s decision-making.

Levels of community engagement:

• Information giving (INFORM)
• Community consultation (LISTEN)
• Community involvement (DISCUSS)
• Devolved responsibility (DIALOGUE)

Principles of public engagement: mnemonic OI-TT-RR

• Open and Inclusive
• Timely and Transparent
• Relevant and Responsive

Steps:

Step 1 Planning
Step 2 Developing Products
Step 3 Implementing
Step 4 Analysis & Reporting
Step 5 Evaluating

Question 146

Define critical theory and constructivism.

Name 3 qualitative analytic approaches.

What are some qualitative sampling strategies (6)?

What are some qualitative data collection strategies (4)?

What are criteria on which to appraise qualitative methods (4)?

Answer 146

Qualitative methods

Philosophical paradigms

• Critical theory: “Multiple truths exist, and they are influenced by power relations among people”
• Constructivism: “Multiple truths are constructed by and between people”

(Some) analytical approaches
Phenomenology
- Origins: European philosophy
- Truth: Subjective, knowable only through experience
- Central question: How do people make meaning of their lived experience?
- Product: A description of themes of experiences of the phenomenon of interest
- Prostate cancer screening example: How do primary care providers experience
uncertainty in clinical decision-making related to prostate cancer screening within the
larger context of the doctor-patient relationship?

Discourse analysis
- Origins: Linguistics
- Truth: Structured by shared language
- Central question: How is language used to achieve particular personal, social, or political
ends?
- Product: Description of how language is used to shape and negotiate identities and
relationships
- Prostate cancer screening example: How are primary care providers roles constructed
and negotiated in interactions with patients regarding prostate cancer screening?

Grounded theory
- Origin: Sociology
- Truth: Negotiated through social interactions
- Central question: How can we explain a particular social process?
- Product: An explanatory theory* that captures the range of participant experiences of a
phenomenon
- Prostate cancer screening example: What circumstances lead to prostate cancer
screening discussions in primary care settings?

Thematic analysis

Content analysis

Ethnography

• *Qualitative sampling strategies**
• “Typical case” sampling: Sampling the usual cases of a phenomenon
• “Deviant case” sampling: Sampling the most extreme cases of a phenomenon
• Critical case sampling: Sampling cases that are predicted to be particularly illuminating, based on theory or previous research
• Maximum-variation sampling: Sampling as wide a range of perspectives as possible to capture the broadest set of experiences
• Confirming-disconfirming sampling: Sampling cases whose perspectives are likely to confirm or challenge the researcher’s understanding of the phenomenon
• Theoretical sampling: Sampling cases whom the researchers predict would add new perspectives to those already represented in the sample
• Snowballing, convenience
• *Data collection strategies**
• Individual interviews: Structured, unstructured, semi-structured, in-depth
• Group interviews: Focus groups, consensus panel, natural group, community interview
• Observation: Participant observation, non-participant observation
• Documents: Text (media articles, research articles, diaries, etc.), photographs, videos

Question 147

Describe basic facts about tetanus

Organism, Reservoir, Mode of transmission

Incubation period, infectious period

Epidemiology

Presentation, Testing

Case management, Contact management

+/- Immunization

Answer 147

Tetanus (reportable)
- Organism: Clostridium tetani spore neurotoxins
- Reservoir: Soil
- Mode of transmission: Wound contaminated with soil, feces, or dust; *noncommunicable
- Epidemiology:
- Exists worldwide in soil and animal intestinal tracts
- Case-fatality rate = 10-80% (highest in the elderly and infants)
- Maternal and neonatal tetanus still occurs in 18 countries; eliminated in Canada
- Approximately 4 cases/year of tetanus in Canada
- Presentation: Muscle spasms, usually beginning in the jaw and then descending
- Pathophys: Spores → wound → germination (requires an anaerobic environment,
like a necrotic wound) → neurotoxin production
- Maternal tetanus: Tetanus occurring during pregnancy or within 6 weeks of the
end of pregnancy
- Neonatal tetanus: Tetanus occurring within the first 28 days of life
- Incubation period: 3-21 days
- Testing: Clinical diagnosis
- Case management: IM injections of TIg (neutralizes circulating toxin but has no effect on
toxin already fixed to nerves), aggressive wound care, antibiotics, antispasmodics,
tetanus vaccination
- Contact management (wound PEP):
- For clean, minor wounds: Vaccine for unimmunized, underimmunized, unknown
immunization status, or last booster > 10 years age (no vaccine if fully immunized
and last vaccine < 10 years ago)
- For other wounds: Vaccine + TIg for unimmunized, underimmunized, unknown
immunization status; vaccine alone if last booster > 5 years ago (no vaccine if
fully immunized and last vaccine < 5 years ago)
- Vaccine: Childhood series (4 doses) + adult boosters q 10 years

Question 148

What entities make the decision to implement vaccination programs in Canada?

Answer 148

Decision to implement a program: Made by P/T health ministries,

Question 149

Describe 10 Canadian data sources for surveillance or population health assessments.

Answer 149

Examples of data sources for surveillance or population health assessment:

• Canadian Health Measures Survey (CHMS): National cross-sectional survey of 3-79
  year olds that collects information through household interview and physical health
  measures (e.g., spirometry, audiometry, height, weight, muscle strength, blood and urine
  testing) in a mobile clinic (similar to NHANES)
• Excludes the territories, persons living on reserves, full-time Canadian Forces
  members, institutionalized persons, and persons in some remote areas
• Questionnaire administered via computer-assisted personal interviewing (CAPI)
• Canadian Community Health Survey (CCHS): National cross-sectional survey of those
  12 years and older that collects self-reported health status, healthcare utilization, and
  health determinants data
• Excludes persons living on reserves, full-time Canadian Forces members,
  institutionalized persons, and persons living in certain Quebec health regions
• Questionnaire administered via computer-assisted personal interviewing (CAPI)
• Core questions remain stable, but each cycle has a different Rapid Response
  module that is developed to answer specific questions about an emerging issues;
  provinces and territories may also choose to add content collected only in their
  region
• Easier and cheaper to administer than the CHMS, but tends to underestimate
  prevalence of obesity
• Canadian Tobacco, Alcohol, and Drugs Survey (CTADS): National cross-sectional
  survey of 15-24 year-olds that collects self-reported data on tobacco, alcohol, and drug
  use and related behaviours and harms
• Excludes the territories and institutionalized persons
• Questionnaire administered via computer-assisted telephone interviewing (CATI)
• CTADS replaced the Canadian Tobacco Use Monitoring Survey (CTUMS) and
  Canadian Alcohol and Drug Use Monitoring Survey (CADUMS) in 2013
• Canadian Student Tobacco, Alcohol, and Drugs Survey: Survey of students in grade
  6-12 (grades 6 to secondary V in Quebec) about tobacco, alcohol, and drug use
• Previously called the Youth Smoking Survey
• Census: Mandatory collection of demographic data from all Canadian households once
  every five years (with the disappointing exception of 2011, when the voluntary National
  Household Survey replaced the Long-form Census for a single data collection period)
• Discharge Abstract Database (DAD): CIHI database containing administrative, clinical,
  and demographic information on individuals discharged from all acute care hospitals in
  Canada, excluding Quebec (deaths, sign-outs, and transfers; excludes stillbirths and
  cadaveric donors)
• Hospital Morbidity Database (HMDB): DAD + data received by CIHI (Canadian Institute for Health Information) from the Quebec ministere de la santé et des services sociaux
• First Nations Regional Health Survey (RHS): Administered by First Nations
  Information Governance Centre; survey of First Nations persons on reserve and in
  northern regions
• National Ambulatory Care Reporting System: CIHI database containing presenting
  complaint and discharge diagnosis information on day surgery, outpatient, and
  emergency department visits from participating hospitals (data collected varies
  depending on facility)
• Vital statistics: Administrative survey that collects all birth, stillbirth, death information
  once per year from all P/T registries; the Canadian Vital Statistics system operates
  under an agreement between that Government of Canada and the P/Ts
• Other health-related Statistics Canada surveys:

Canadian Cancer Registry,

Canadian Coroner and Medical Examiner Database,

Community Noise and Health Study,

Canadian Survey on Disability,

Longitudinal and International Study of Adults.

Question 150

Describe the epidemiology of chicken-associated illnesses in Canada and available public health interventions

Answer 150

Chicken and egg (and general bird) hygiene
What?
- Salmonella and Campylobacter are commensal bacteria in chickens
- Salmonella enteritidis can infect chicken’s ovaries, leading to yolk contamination (i.e.,
not all eggs have sterile yolks)
- Cooking eggs until the yolk is firm destroys bacteria

Epidemiology
- National prevalence of Salmonella in broiler chickens in Canada = 25.6% (most common
in Ontario)
- National prevalence of Campylobacter in broiler chickens in Canada = 24.1% (most
common in BC)
- National prevalence of Salmonella in fecal and eggbelt samples of commercial eggproducing
chickens in Canada = 52.9%
Interventions
- Vaccinate laying flocks against Salmonella; this approach is used in most of Europe; if
applied in Canada, it would reduce egg-associated illnesses to 4% of baseline
- Test flocks for Salmonella and divert eggs from contaminated flocks
- Use pasteurized egg products (the US CSC recommends that pasteurized egg products
be used for allrecipes requiring raw or lightly cooked eggs, like hollandaise sauce,
Caesar salad dressing, tiramisu, and egg nog)
- Wash egg shells (this is what Canada, the US, Japan, Australia, and the Scandinavian
countries do now, unlike the rest of the world) → this reduces egg shell contamination,
but washing removes a natural egg coating, making the egg shell more porous, requiring
continuous refrigeration for its entire shelf life (unwashed eggs can be stored at room
temperature)
- But don’t wash your chicken
- Cook unpasteurized eggs until the egg white and yolk are both firm (public health ruins
everyone’s fun)

Question 151

How to choose which non-parametric statitistical tests to use?

Answer 151

Question 152

Describe key food preparation and storage instructions to prevent foodborne illnesses

Answer 152

Food preparation and storage

• 4 elements of safe food handling: cook, chill, separate, clean
• “Danger zone” = 4 C to 60 C
• Keep foods out of the danger zone while preparing dishes by preparing food in small batches, using pre-chilled ingredients, or putting ice packs on food
• Cool cooked foods to less than 20 C within 2 hours and to less than 4 C within 4 hours
  - Cooling food too slowly is one of the leading causes of foodborne illness
• Frozen = - Refrigerator and cold holding = <4 C (slows most microbial growth, although refrigeration provides the optimum growth temperature for L. monocytogenes and Y. enterocolitica)
• Cooked = > 74 C (lower for whole cuts of red meat and fish)
• _Hot holding = > 60 C (room temperature holding is acceptable if displayed for < 2h)
• *Cannot re-heat food in a hot holding unit_
• Food preservation methods: dehydration, temperatures, preservatives, canning, fermantation, irradiation

Blanching: Heats food prior to preservation to reduce microbial population on the surface of the food

• Canning: Seal in a container after sterilization; preservation to prevent microbial growth
• Water bath vs. high pressure canning
• Unlike most pathogenic bacteria, C. botulinum grows best in higher pHs, so highly acidic foods (e.g., tomatoes) are preferred for canning
• Drying, low acidity, high sugar, nitrates, high sodium can reduce microbial growth (consider risk vs. benefit, e.g., nitrates reduce botulism but is a carcinogen; sodium reduces listeria growth but increases hypertension)
• Most pathogenic bacteria reproduce best in a pH between 2 to 7 (most foods fall in that range)
• Bacteria cannot grow in dry foods, but they can survive (sodium, freezing, dehydrating, sugar reduce the amount of water available to bacteria)
• High-protein foods (e.g., meat, dairy) are highly nutritious for bacteria and support high levels of growth
• Irradiation: Application of ionizing radiation to food to prevent microbial growth; low doses do not affect taste or texture (currently only applied to onions, potatoes, wheat, flour, spices, dehydrated seasonings in Canada)
• Sanitization:
• Always clean before sanitizing
• Triple sink: Wash, rinse, sanitize
• Double sink: Wash and rinse, sanitize (only acceptable in establishments that prepare small amounts of food or usually use a mechanical dishwasher)
• Mechanical dishwasher
  - Sanitize food contact surfaces with hot water (>77 C), quaternary ammonia, iodophors, or chlorine for at least 45 s
• Other considerations:
  - Hand hygiene
• Garbage disposal
• Pest control (e.g., cockroaches, flies, rodents)
• Ventilation
• Water source
• Food storage

Question 153

Describe steps in the development of a health public policy?

Answer 153

Policy development
PHO rational health public policy development model similar to the APIE model for program development.

ASSESS
1. Describe the problem: Cause, impact, perception (who else thinks this is a problem?),
possible solutions
2. Assess readiness for policy development: Community and organization

PLAN
3. Develop goals, objectives, and policy options (putting forward multiple policy options
demonstrates flexibility to stakeholders)
4. Identify decision-makers and influencers
5. Build support for the policy: Strategies might include negotiation, information sharing,
public briefs, letter-writing
6. Draft and/or revise the policy

IMPLEMENT
7. Implement the policy

EVALUATE
8. Evaluate and monitor the policy

Question 154

Name 2 subcutaneous vaccines

Answer 154

Measles

YF

Question 155

Can 2 live vaccines be given at the same time?

Answer 155

• Timing/interference: Live vaccines and TB skin tests must be given at the same time or
  at least 28 days apart

Question 156

What is EVALI or VALI?

What has been associated with the recent US outbreak of EVALI?

What are the risk communication messages related to vaping?

Answer 156

Vaping-associated lung illness

The Government of Canada continues to investigate vaping-associated lung illness, also known as severe pulmonary illness associated with vaping. Vaping is the act of inhaling and exhaling an aerosol produced by a vaping product, such as an electronic cigarette.

Vaping does have risks and the potential long-term health effects of vaping remain unknown.

Evidence from the recent US outbreak of e-cigarette, or vaping, associated lung injury (EVALI) suggests a strong association with vitamin E acetate, which is used as a cutting agent in illegal and unregulated THC-containing vaping products. In Canada, most cases of vaping associated lung illness do not appear to have been associated with the use of THC-containing products. The cause or causes of cases in Canada is still under investigation.

Canadians concerned about the health risks related to vaping should consider refraining from using vaping products. Youth, persons who are pregnant, and those who do not currently vape should not vape.

Vaping products may contain dozens of chemicals. Most vaping substances available for sale are flavoured and contain nicotine. Canadians should not use vaping products obtained illegally, including any vaping products that contain cannabis.

Risk comm messages:

If you do not vape, do not start.

Non-smokers, people who are pregnant, and youth should not vape.

If you do vape, do not:

use vaping products that have been obtained from illegal or unregulated sources, including any products that contain cannabis, as they are not subject to any control or oversight and may pose additional risks to your health and safety

modify vaping products or add substances to products that are not intended by the manufacturer

return to smoking cigarettes if you are vaping nicotine-containing products as a means of quitting cigarette smoking

Situation in Canada:

In Canada, as of August 14, 2020, 20 cases of vaping-associated lung illness have been reported to the Public Health Agency of Canada from Alberta (1), British Columbia (5), New Brunswick (2), Newfoundland and Labrador (1), Ontario (5), and Quebec (6). No deaths have been reported.

Case definition:

To be considered a case of vaping-associated lung illness, the following criteria must be met:

symptoms such as shortness of breath, cough, chest pain, with or without diarrhea, vomiting, abdominal pain, or fever

negative results on tests for a lung infection or, if a lung infection cannot be ruled out, a determination by the patient’s physician/clinical team that the lung infection is not the sole cause of the patient’s symptoms

abnormalities on x-ray or other imaging technology compatible with vaping-associated lung illness

a history of vaping or dabbing in the 90 days prior to symptom onset

no evidence in medical records of alternative plausible diagnoses

The difference between a confirmed case and a probable case is:

in a confirmed case, lung infection has been ruled out

in a probable case, a lung infection could not be ruled out but the physician/clinical team caring for the patient believes it is not the sole cause of the illness

Question 157

What is the difference between vaccine efficacy and vaccine effectiveness?

Answer 157

• Vaccine efficacy: Percent reduction in disease incidence in a vaccinated group
  compared to an unvaccinated group under optimal conditions
• Vaccine effectiveness: Ability of vaccine to prevent outcomes of interest in the real
  world

Question 158

What is the life expectancy at birth in Canada?

Answer 158

Life expectancy:

• Canada, overall (2015-17) = 82.1 years
• Canada, men (2015-17) = 80.0 years
• Canada, women (2015-17) = 84.1 years
• First nations, men 73, female 78
• Inuit, men 64, female 73
• World, overall (2019) = 73.3 years
• World, men (2019) = 70.8 years
• World, women (2019) = 75.9 years

Question 159

What are public health interventions to reduce the risk of pool-associated infections?

Answer 159

Public health interventions
- **Pool hygiene education**: Don’t swim when you have diarrhea, wash your hands after
using the toilet or changing diapers, check children's’ swim diapers every 30-60 min,
don’t swallow pool water, rinse in the shower before entering the pool
- **Pool operator education and regulation**: Maintain proper disinfection level and pH;
recognize and manage fecal incidents
- **Testing**: If pH, chlorine residual, and maintenance are within normal limits, lab testing is
not required (and may be misleading, as E. coli is very chlorine-sensitive and will not
usually be detected even if there is a problem; Pseudomonas is a better indicator of pool
health); biological testing is only required in outbreak situations

Question 160

What are biases and mitigation strategies related to pre-post evaluation designs?

Answer 160

Potential sources of bias: selection/assignment, natural history, regression to the mean, test–retest, maturation, observer, retrospective, Hawthorne, measurement, attrition, and reporting/publication bias.

Mitigating strategies: using a control group, blinding, matching before and after cohorts, minimizing the time lag between cohorts, using prospective data collection with consistent measuring/ reporting criteria, time series data collection, and/or alternative study designs, when possible

Question 161

Define OneHealth

Answer 161

OneHealth
- OneHealth: 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)

• Zooeyia: Benefits of animals on health (the inverse of zoonosis)

Question 162

Name study reporting standards (3).

Name study critical appraisal tools (4).

Name biases associated with the publication process (5).

What are funnel plots and forrest plots?

Answer 162

Publication reporting requirements
- STrengthening the Reporting of OBservational studies in Epidemiology (STROBE):
Instrument to standardize the reporting of observational studies (cohort, case-control,
and cross-over)
- Transparent Reporting of Evaluations with Nonrandomized Designs (TREND):
Instrument to standardize the reporting of nonrandomized controlled trials (similar to
CONSORT)
- Consolidated Standards of Reporting Trials (CONSORT): Evidence-based instrument to
standardize the reporting of randomized trials

Biases associated with the publishing process
- Publication bias: Papers with significant positive results are more likely to be submitted
and accepted for publication
- Tower of Babel bias: Papers with significant positive results are more likely to be
published in a major journal written in English
- Database bias: Papers with significant positive results are more likely to be published
in a journal indexed in a literature database, especially in low- and middle-income
countries
- Citation bias: Papers with significant positive results are more likely to be cited by other
authors
- Multiple publication bias: Papers with significant positive results are more likely to be
published multiple times

• *Critical appraisal:** The systematic evaluation of a study in order to determine if:
  1. The study addresses a clearly defined question;
  2. The study uses valid methods to address the question;
  3. The study results are important; and
  4. The study results are applicable to a particular population of interest

Critical appraisal tools
- A MeaSurement Tool to Assess systematic Reviews (AMSTAR): Instrument for
assessing methodological quality of systematic reviews
- Critical Appraisal Skills Programme (CASP): Instruments to assess the methodological
quality of systematic reviews, qualitative studies, RCTs, case-control studies, cohort
studies, economic evaluations, and clinical prediction tools
- Appraisal of Guidelines for REsearch and Evaluation II (AGREE II): Instrument for
assessing the methodological quality of guideline development
- Jadad scale: Instrument to assess the methodological quality of a clinical trial

Systematic review and meta-analysis
- Narrative review: Descriptive summary of an author’s knowledge of a topic, usually
supported by a non-systematic literature search
- Scoping review: Multiple definitions; often refers to a systematic identification and
summary of research on a topic, without extensive critical appraisal; used for broader
questions than systematic reviews for which multiple study designs are helpful to
consider

• Systematic review: Systematic identification and critical appraisal of all research on a
  specific topic; to avoid bias, systematic reviews must state objectives, materials, and
  methods; and follow an explicit and reproducible methodology (however, systematic
  reviews are vulnerable to publication bias)
• Funnel plot: Scatter plot of each of the estimated effects for the trials identified
  by a systematic review horizontal axis against the standard error of the estimated
  effect on the vertical axis (inverted axis, with 0 at the top); if there is no reporting
  bias, the funnel plot should be symmetrical around the total overall estimated
  effect (formal statistical test to detect asymmetry is called Egger’s test)
• Meta-analysis: Quantitative summary of multiple studies; most commonly, systematic
  review is used to identify the studies included in a meta-analysis
• Forest plot (aka blobbogram): Graphical display of the results of a metaanalysis;
  shows the point estimates and confidence intervals of each included
  study as well as the whole meta-analysis

Question 163

What HIV test is available for point of care testing in Canada?

Answer 163

Point-of-care testing (POCT) (hot topic): HIV testing for which results are available in
the same visit; tests for antibodies to HIV, rather than the presence of the virus itself
(INSTI HIV-1/HIV-2 Antibody Test is the only POCT approved in Canada); generally
preferred to traditional testing by individuals wishing to be tested and increases uptake
of testing; reduces barrier in traditional testing that individuals must return 1-2 weeks
later for results
- Window period: Period of up to 3 months during which a person can be HIV+
without detectable antibodies to HIV (POCT will be falsely negative during this
time); if individual is in the window period and the test is negative, recommend
confirmatory testing
- POCT is a screening, rather than a diagnostic, test; positive tests require
confirmatory testing
- INSTI HIV-1/HIV-2 Antibody Test sensitivity = 99.6%; specificity = 99.3

Question 164

Define cognitive bias and give examples.

Answer 164

A cognitive bias is a systematic error in thinking that occurs when people are processing and interpreting information in the world around them and affects the decisions and judgments that they make.

• Anchoring: Failing to change your first impression when new evidence is presented
• Status quo: Failing to consider options other than the status quo
• Sunk cost: Pursuing a less-desirable option because it’s already been paid for
• Confirming evidence: Seeking out evidence that supports a preferred option
• Excessive prudence: Acting in an overly-cautious manner
• Overconfidence: Assuming that you understand all the possible options/scenarios
• Recallability/salience: Assuming that the current scenario is the same as the last worst case

Question 165

What are Sandman’s risk communication model and risk communication strategies?

What is the protection motivation theory?

What are TCCR risk communication principles?

Answer 165

Risk communication

Joint information centre: Coordinates release of information to the public; place where media can visit to obtain access to experts; JIC activated when an agency is aware of a risk to public
health; includes information gathering, information dissemination, operations support, and liaisons

Sandman’s risk communication model

Perceived risk = Hazard + Outrage
Low hazard + High outrage = Outrage management, calm dowm
High hazard + High outrage = Crisis mmunication, we’ll get through this
High hazard + Low outrage = Precaution advocacy, watch out

Sandman’s risk communication strategies
Note: It is usually not possible to pursue all three strategies; resources are limited and the
strategies are often at odds with one another (e.g., mobilizing support will increase outrage;
managing outrage through conciliation will decrease support)
1. Support mobilization: Mobilize and empower your supporters
2. Public relations: Reach out to those who are uninterested or disinterested
3. Outrage management: Convert your strong opponents into weaker opponents and your weak opponents into disinterested parties

1) Stake out the middle, not the extreme.
2) Acknowledge prior misbehavior.
3) Acknowledge current problems.
4) Discuss achievements with humility.
5) Share control and be accountable.

Avoid risk comparisons
(E.g., Risk of X is less than driving a kilometre in your car)
- Individuals can readily identify the benefits in their everyday risks, but may be unable to
identify benefits in the comparator
- Individuals usually choose to be exposed to everyday risks, but the comparator is
usually being imposed on them
- Individuals’ perception of risk is coloured by aesthetics, which is not captured in the
comparison
Instead: Use temporal comparisons (e.g., risk of X is equivalent to 1 person in your town of
2000 dying every 3500 years)

• *Protection motivation theory** (for risk community for communicable disease)
• Severity: How severe does one perceive the disease?
• Vulnerability: How likely are you to contract it?
• Response efficacy: Do you think the behaviour protects against the disease?
• Self-efficacy: Are you capable of performing the behaviour?
• Response costs: Costs associated with protective behaviour?
• *TCCR risk communication principles**:
• Transparent
• Clear
• Consistent
• Reasonable

Question 166

Discuss fetal alcohol spectrum disorder (FASD) in Canada and available public health interventions

How is FAS and partial FAS defined?

What are alcohol-related birth defects?

Answer 166

Alcohol use in pregnancy and fetal alcohol spectrum disorder (FASD)
FASD is an umbrella term that includes:
- Fetal Alcohol Syndrome: Characteristic pattern of facial anomalies + evidence of
growth retardation + evidence of CNS abnormalities; does not require confirmed history
of prenatal alcohol exposure
- Partial FAS: Some facial anomalies + evidence of growth abnormalities OR evidence of
CNS abnormalities OR complex pattern of behavioural or cognitive abnormalities;
requires confirmed history of prenatal alcohol exposure
- Alcohol-related neurodevelopmental disorder (ARND): Presence of one or both of:
- CNS abnormalities (e.g., decreased cranial size, microcephaly, impaired fine
motor coordination)
- Complex pattern of behavioural or cognitive abnormalities (e.g., learning
difficulties, poor capacity for abstraction)
- Alcohol-related birth defects (ARBD): Verbatim from Clarke and Gibbard, 2003:
- Cardiac: Atrial septal defects, ventricular septal defects, aberrant great vessels,
Tetralogy of Fallot.
- Skeletal: Hypoplastic nails, shortened fifth digit, radioulnar synostosis, joint
contractures, camptodactyly, clinodactyly, pectus excavatum and carinatum,
Klippel-Feil syndrome, hemivertebrae, scoliosis.
- Renal: Aplastic, dysplastic, hypoplastic kidneys, horseshoe kidneys, ureteral
duplications, hydronephrosis.
- Ocular: Strabismus, refractive problems secondary to small globes, retinal
vascular anomalies.
- Auditory: Conductive hearing loss, neurosensory hearing loss.

Alcohol-related effects by trimester:
- First trimester: Disruption of organ and craniofacial development, especially brain
abnormalities and cardiac defects
- Second trimester: Disruption of fetal brain development; increased risk of spontaneous
abortion
- Third trimester: Disruption of fetal brain development; reduced height and weight gain

• *Frequency in Canada:**
• FASD: Incidence =10 cases/1000 births (1999 estimate); prevalence = 1% of Canadians
• FAS: 0.5-3 cases/1000 births (1999 estimate)
• FASD is the leading cause of preventable developmental disability in Canadians

Alcohol consumption in pregnancy:
- “The absolute amount of alcohol that will not cause damage to the developing fetus is
not known” (Clarke and Gibbard, 2003)
- Risk factors for FASD:
- Frequent drinking during pregnancy (>7 drinks/week)
- Binge drinking during pregnancy (even infrequently)

• Risk factors for alcohol consumption during pregnancy:
• Partner who drinks heavily (most women drink with their partners)
• Past history of sexual of physical abuse (95% of mothers of children with FAS
  report physical or sexual abuse during their lifetime)
• Mental illness (96% of mothers of children with FAS report current mental illness)
• Polysubstance abuse
• Social isolation and lack of social support
• *Interventions:**
• Low-risk alcohol drinking guidelines
• Supportive counselling or case management for pregnant women who drink
• Promoting contraceptive use in mothers of children with FASD

Question 167

What are examples of population health indicators

(from CIHI Health Indicator Framework)?

Answer 167

Population health indicator frameworks: CIHI Health Indicator Framework (2013)

• *Health status**
• Well-being (e.g., life satisfaction)
• Health conditions (e.g., self-injury hospitalization rates)
• Human function
• Death (e.g., potentially avoidable mortality)
• *Non-medical determinants of health**
• Health behaviours (e.g., smoking prevalence)
• Living and working conditions
• Personal resources (e.g., neighbourhood income quintile)
• Environmental factors
• *Health system performance (menomonic AAACCEES)**
• Acceptability
• Accessibility (e.g., wait time for hip fracture surgery)
• Appropriateness
• Competence
• Continuity
• Effectiveness
• Efficiency (e.g., inflow-outflow ratio)
• Safety
• *Community and health system characteristics**
• Community (e.g., population)
• Health system (e.g., number of physicians)
• Resources

Equity (e.g., disparity rate ratio)

• *Other population health indicators**
• Mortality, morbidity, and health-related quality of life
• Potential years of life lost (PYLL): Difference between age at actual death and average life expectancy for a person of that sex; usually summed over a population for a particular disease
• Health-adjusted life expectancy (HALE): “Estimate of the average time in years that a person at a given age can expect to live in the equivalent of full health”; not specific to a disease
• Prevalence and incidence of chronic and communicable disease, mental illness, and injuries
• Prevalence of health behaviours
• Family health outcomes
• Population demographics

Question 168

Describe basic facts about brucellosis

Organism, Reservoir, Mode of transmission

Incubation period, infectious period

Epidemiology

Presentation, Testing

Case management, Contact management

+/- Immunization

Answer 168

Brucellosis

• *Organism**: Multiple Brucella spp.
• *Reservoir**: Most commonly, livestock
• *Mode of transmission**: Infected animal tissue
• *Presentation**: Intermittent fever, weakness, arthralgia, myalgia, weight loss +/- endocarditis
• *Case management**: Tx = Doxy + rifampin x 6 wks
• *Public health interventions**: Predominantly an occupational disease (workplace health
  interventions) ; cook meat; pasteurize milk; vaccinate cows and sheep

Question 169

Regarding assessing causality,

what are the Koch’s postulates (4)?

what are the Bradford Hill criteria (8)?

what is Rothman’s causal pie model?

Answer 169

Assessing causality

Koch’s postulates
Robert Koch’s postulates (1877) serve as a decision tool to determine if a specific
microorganism causes a specific disease.
1. Association: The microorganism or other pathogen must be present in all cases of the
disease;
2. Isolation: The pathogen can be isolated from the diseased host and grown in pure
culture;
3. Inoculation: The pathogen from the pure culture must cause the disease when
inoculated into a healthy, susceptible laboratory animal;
4. Re-isolation: The pathogen must be reisolated from the new host and shown to be the
same as the originally inoculated pathogen

Bradford Hill criteria
Austin Bradford Hill (no hyphen) published an “aid to thought” in 1965 to assist epidemiologists
in determining whether or not an exposure caused a health outcome. (SSPACCE-TB)
1. Strength of association: Bradford Hill proposed that strong associations are more likely
to be causal than weak associations; in modern epidemiology, strong associations are
less common
2. Specificity: One-to-one relationship (e.g., rubella virus causes rubella); this criterion is
most relevant only to infectious disease and is similar to the Association and Inoculation
postulates of Koch
3. Plausibility: Biological plausibility is helpful, but Bradford Hill notes that “What is
biologically plausible depends upon the biological knowledge of the day. … [Plausibility
is] too often based not on logic or data but on prior beliefs.”
4. Analogy: Clear-cut analogies may add to the weight of evidence that an association is
causal (e.g., “Quantification of exposure and accurate measurement of all confounders
[of the association of passive smoking with lung cancer] may be difficult. However, by
analogy to the known risk of lung cancer in active smokers, persons exposed to
secondhand smoke plausibly have an increased lung cancer risk mediated by the same
biological pathway.”)
5. Consistency: A causal relationship is more likely if the association is found in a variety
of situations (different study designs, different populations). At the same time, lack of
consistency might suggest important effect modifiers or confounders.
6. Coherence: Similar to plausibility: does a causal relationship make sense in light of
other knowledge? (e.g., “the ‘hygiene hypothesis’ as a cause of some autoimmune and
allergic diseases coheres with trends in developed countries to both fewer childhood
infections and an increasing incidence of allergic and autoimmune disorders”)
7. Experiment: Is the association demonstrated in randomized controlled trials? In
Bradford Hill’s opinion, this is the strongest argument in favour of causality
8. Temporality: The exposure must precede the outcome; the only necessary criterion
9. Biological gradient: A causal relationship is more likely if a dose-response curve can
be demonstrated; however, there are many causal relationships that have threshold or
nonlinear associations

Rothman’s causal pie model
Rothman developed the pie model of causality in 1976 to explain multifactorial causality in noninfectious diseases.
- Sufficient causes: A group of component causes that, together, cause disease (i.e., a
“pie”); diseases may have multiple sufficient causes (e.g., “pies” for lung cancer might
include radon + smoking, radon alone, asbestos + smoking + radon, etc.)
- Component causes: Individual factors that make up the sufficient cause (i.e., the “slices
of pie”); each component cause is a step on the causal pathway
- Necessary causes: A factor that is required for a disease to occur (i.e., a “slice of pie”
that must show up in every pie); in the figure below, A is the necessary pie slice

Question 170

Describe the behavior change model: Precaution-adoption process model

Answer 170

Precaution-adoption process model
- Model describes an individual’s path from lack of awareness to action to maintenance

• Stages:
  1. Unaware of issue
  2. Unengaged by issue
  3. Deciding whether or not to act
  4. Acting
  5. Maintenance

Question 171

Describe the behavior change model: Community development

Answer 171

Community development
- Community development: “Process of supporting community groups in identifying their
health issues, planning and acting upon their strategies for social action and social
change, and gaining increased self-reliance and decision-making power as a result of
their activities”

• Problem defined by the community
• Focuses on increasing the community’s capacity to address the problem
• Decision-making power is constantly negotiated (i.e., doesn’t rest with the
  institution)
• Critical consciousness: Reflective awareness of the differences in power and privilege
• Empowerment education: Critical-consciousness raising about factors influencing health
  and development of the skills needed for individual and collective action to address those
  factors

Question 172

Define and compare immigrants and refugees.

What is the Interim Federal Health Program?

Answer 172

Immigrants and refugees

• Temporary foreign worker: Individual working temporarily in Canada who fills “genuine
  labour needs as a last and limited resort when qualified Canadians or permanent
  residents are no available”. Temporary foreign workers in Canada: 94,109 (2014) (most common country of origin = the Philippines)
• International Mobility Program (IMP): Similar to the temporary foreign worker program,
  but does not require employers to prove that the Canadian labour market will not be
  impacted. - IMP workers in Canada: 259,339 (2014) (most common country of origin = US)
• Immigrant: Person from one country who permanently settles in another country
• Economic class: Class of individuals selected by Citizenship and Immigration to
  immigrate to Canada because of their “ability to contribute to Canada’s economy”
• Family class: Class of individuals who are relatives of current Canadian citizens
  or permanent residents
• Refugee: A person who, “owing to well-founded fear of being persecuted for reasons of
  race, religion, nationality, membership of a particular social group or political opinion, is
  outside the country of his nationality and is unable or, owing to such fear, is unwilling to
  avail himself of the protection of that country; or who, not having a nationality and being
  outside the country of his former habitual residence as a result of such events, is unable
  or, owing to such fear, is unwilling to return to it” (Geneva Convention definition); classes
  of refugees in Canada include:
  *- Government-assisted refugees
• Privately-sponsored refugees
• Blended Visa Office-referred refugees
• Refugee claimants*
• In-Canada refugee claimants in 2014 = 13,423
• Top five more common countries of origin = China, Pakistan, Iraq, Nigeria, Colombia
• Canada accepts approximately 25,000 refugees/year; in 2014,
• 7,573 were GARs
• 4,560 were SARs
• 7,749 were accepted in-Canada refugee claimants (this is lower than the
  historical average)
• 3,227 were refugee dependents
• 177 were BVORs
• Permanent resident: An individual who is living in Canada and has been granted
  permanent resident status, but who is not yet a citizen of Canada; g_ranted most rights
  and responsibilities of citizens, except the right to vote_; includes all classes of refugees
  except refugee claimants. Permanent residents in Canada = 260,404 (2014)
• Interim Federal Health Program: Provides temporary healthcare coverage for refugees
  and refugee claimants until they are eligible for provincial or territorial health insurance
• In 2012, the federal Harper government made substantial cuts to the IFHP
  (funding to government-assisted refugees, but not to other classes or refugees
  and refugee claimants, was restored a few months later after public outcry)
• In 2014, these cuts were declared unconstitutional and “cruel and unusual” by
  the Federal Court of Canada and some coverage to non-GARs was restored
• In 2016, the IFHP was restored by the federal Trudeau government

Question 173

Describe basic facts about pneumococcus

Organism, Reservoir, Mode of transmission

Incubation period, infectious period

Epidemiology

Presentation, Testing

Case management, Contact management

+/- Immunization

Answer 173

Pneumococcal disease (reportable)
- Organism: Streptococcus pneumoniae (>90 serotypes)
- Reservoir: Humans (asymptomatic colonization is common)
- Mode of transmission: Direct oral contact, indirect contact with respiratory secretions,
and respiratory droplets
- Epidemiology:
- Common cause of community-acquired pneumonia, AOM
- Case-fatality rate of bacteremic pneumococcal pneumonia is 5-7%
- High risk groups: Very young, very old, immunocompromised, other medical
conditions (e.g., cochlear implants, CSF leak), alcoholism, drug use,
homelessness
- Presentation: Invasive pneumococcal disease usually presents as bacteremia and
meningitis in children < 2 years; IPD usually presents as bacteremic pneumococcal
pneumonia in adults (often following influenza)
- Incubation period: Unknown, but may be 1-3 days
- Case management: Appropriate abx + supportive case
- Contact management: None
- Vaccine:
- Pneu-C-13: Conjugate vaccine covering 13 serotypes; for kids, and adults with a
high risk if IPD
- Pneu-P-23: Polysaccharide vaccine covering 23 serotypes (covers all the same
strains as Pneu-C-13 except serotype 6A); for kids with a high risk of IPD, and
adults 65+ years old; less immunogenic in kids than the conjugate vaccine
- For individuals receiving both vaccines, the Pneu-C-13 vaccine should be
followed at least 8 weeks later by the Pneu-P-23 vaccine; if Pneu-P-23 is given
first, Pneu-C-13 must be administered at least 1 year later

Question 174

What organisms causes Lymphogranuloma venereum (LGV)?

Answer 174

Lymphogranuloma venereum (LGV)
- Organism: Chlamydia trachomatis, serovars L1, L2, L3 (more invasive than serovars that
cause chlamydia, preferentially infect lymph tissue)
- Reservoir: Humans
- Mode of transmission: Direct contact (sexual)
- Epidemiology: Uncommon in Canada (but not nationally notifiable, so national rate
unknown), but endemic in Africa, Asia, South America, and Caribbean; earlier cases
almost all travel-acquired, but recent outbreaks in MSM (associated with concurrent HIV,
other STI, or hep C infection) in the last 10 years
- Presentation:
- Primary: Painless, self-limited papule or ulcer (often unnoticed)
- Secondary: Inguinal or femoral lymphadenopathy; proctitis or proctocolitis
causing bloody, purulent, or mucous d/c; fever, chills, malaise; abscesses +/-
draining sinuses
- Tertiary: Irreversible scarring of lymph tissue → strictures of genitals or rectum,
fistulas, genital elephantiasis; more common in females than males
- Incubation period: 3-30 days
- Testing: Culture and NAAT do not distinguish between LGV and non-LGV serovars of C.
trachomatis, but C. trachomatis in bubo fluid is highly suggestive of LGV; definitive dx
requires DNA sequencing at NML (forward if suspicious)
- Case management: Doxycycline or erythromycin x 21 days; test of cure 3-4 weeks after
treatment completed
- Contact management: Provide empiric chlamydia tx for all sexual partners within the last
60 days, unless symptoms indicative of LGV (then provide LGV tx)

Question 175

Regarding breast cancer,

What is the epidemiology?

Risk factrs?

CTFPHC screening recommendations?

Answer 175

Breast cancer
Epidemiology
- 1 in 9 lifetime risk of developing breast cancer for women
- Incidence increased through the early 1990s, in part due to increased screening, but have stabilized since 2004
- 80% of breast cancer cases occur in women > 50 years of age
- EEK! “Annual mammography in women aged 40-59 does not reduce mortality from breast cancer beyond that of physical examination or usual care when adjuvant therapy for breast cancer is freely available. Overall, 22% (106/484) of screen detected invasive
breast cancers were over-diagnosed, representing one over-diagnosed breast cancer for every 424 women who received mammography screening in the trial.” (Miller et al., 2014)

Risk factors
- Early age at menarche
- Late age at menopause
- Late age at full-term pregnancy
- Diabetes
- Hormone replacement therapy
- Family history/specific genetic mutations

CTFPHC 2018 update verbatim:

RECOMMENDATIONS

For women aged 40 to 49 years, we recommend not screening with mammography; the decision to undergo screening is conditional on the relative value a woman places on possible benefits and harms from screening. (Conditional recommendation; low-certainty evidence)

For women aged 50 to 69 years, we recommend screening with mammography every two to three years; the decision to undergo screening is conditional on the relative value that a woman places on possible benefits and harms from screening. (Conditional recommendation; very low-certainty evidence)

For women aged 70 to 74 years, we recommend screening with mammography every two to three years; the decision to undergo screening is conditional on the relative value that a woman places on possible benefits and harms from screening. (Conditional recommendation; very low-certainty evidence)

Recommendations on other screening modalities, apart from mammography, for breast cancer screening:

We recommend not using magnetic resonance imaging (MRI), tomosynthesis or ultrasound to screen for breast cancer in women not at increased risk. (Strong recommendation; no evidence)

We recommend not performing clinical breast examinations to screen for breast cancer. (Conditional recommendation; no evidence)

We recommend not advising women to practice breast self-examination to screen for breast cancer. (Conditional recommendation; low-certainty evidence)

Question 176

Describe basic facts about diphteria

Organism, Reservoir, Mode of transmission

Incubation period, infectious period

Epidemiology

Presentation, Testing

Case management, Contact management

+/- Immunization

Answer 176

Diphtheria (reportable)

• Organism: Exotoxin-producing strains of Corynebacterium diphtheriae
• Reservoir: Humans
• Mode of transmission: Droplet (person-to-person)
• Epidemiology:
• Rare in Canada (0-5 toxigenic strains of diphtheria bacilli detected/year in
  Canada, but rarely associated with classic diphtheria); endemic in many LMICs
• Case fatality rate = 5-10% (highest in very young and old)
• In temperate climates, most common in the winter and spring
• Presentation:
• Respiratory diphtheria: Fever, sore throat, difficulty swallowing, loss of appetite
  that may progress to “bull neck”, resp distress, upper airway obstruction, and
  asphyxia; pathognomonic sign: Pseudomembrane on tonsils, pharynx, and nasal
  cavity (adherent, asymmetrical, grayish-white)
• Cutaneous diphtheria: Cutaneous ulcer; rarely associated with systemic complications
• Chronic carriers: Asymptomatic; colonized with C. diphtheriae on skin or in
  nasopharynx
• Incubation period: 1-10 days (mean: 2-5)
• Testing: Swabs +/- pseudomembranous material for culture (serology is no longer
  regularly performed in Ontario)
• Case management: Administer diphtheria antitoxin (purified Ig from horses
  hyperimmunized with diphtheria toxoid) if there is clinical suspicion of diphtheria without
  waiting for lab confirmation; perform sensitivity testing to equine serum first to avoid
  allergic reaction (see also: Balto, public health dog-hero); _infection does not confer
  immunity, so vaccine should be provided after recover_y
• Contact management: All close contacts should receive prophylactic abx (PCN) + close
  contacts of a diphtheria case who are not fully immunized should receive a dose of
  diphtheria toxoid-containing vaccine as appropriate for age, and series should be
  completed; diphtheria antitoxin is not recommended
• Vaccine:
• Only available in combination vaccines
• Protects against the effects of the toxin, but does not protect against infection:
  carriage of C. diphtheriae can occur in immunized adults
• Rarely results in an arthus reaction (type II hypersensitivity reaction); individuals
  who develop arthus reactions should not receive addition Td vaccine for at least
  10 years

Question 177

Why is the built environment a public health issue?

Describe components of healthy built environments.

Answer 177

Built environment
Definitions
Built environment: “…all aspects of the physical parts of where we live and work”; includes:

housing quality and availability, population density, neighbourhood design, aesthetics, walkability

availability of public transportation,bicycle infrastructure, pedestrian safety,

environmental pollution,
access to healthy foods

• Why is the built environment a public health issue? Built environment influences
  physical activity, heat island effect, pollution, access to food, housing, and safety, which
  all impact health; as well, the benefits of the built environment and the impact of the built
  environment are inequitably distributed, so the built environment is also a health equity
  issue

Healthy built environments are composed of:
- Healthy neighbourhood design: Neighbourhood density, availability of public spaces
and facilities, and availability of community level services
- Healthy housing: Affordable, accessible, and free of hazards
- Healthy food systems: Food security (which includes affordable housing and
transportation so that money is available for food) and reduction in food waste
- Health natural environments: Green space and control of environmental pollutants
- Healthy transportation:Safe and accessible transportation systems for all ages and
abilities
Walkability: Extent to which the built environment is walking-friendly; higher walkability
associated with mixed land use, higher population density, and high street connectivity
Active transport: Modes of transport that require physical exertion (e.g., walking, biking)
Complete streets: Streets that are designed for all ages, abilities, and types of transport;
includes shading, parking for bikes and cars, bike paths, pedestrian sidewalks with curb cuts,
traffic calming, retail space, open space, and trees/vegetation

Epidemiology
- Neighbourhood walkability α resident physical activity and development of diabetes;
association with obesity less clear
- Neighbourhood self-selection: People who like to walk choose to live in more
walkable neighbourhoods; co confounder of the walkability and physical activity
relationship?
- Transit use α physical activity
Equity considerations:
- Improvements in the physical built environment or transportation without concomitant
housing support can lead to gentrification
- Associations between green space and reduced mortality are strongest in low SES
neighbourhoods
- Long travel distances to rural areas increase food costs and limit the availability of fresh
foods, especially in remote Indigenous communities

WHO Healthy Cities
- Healthy city: A city that is “continually creating and improving those physical and social
environments and expanding those community resources which enable people to
mutually support each other in performing all the functions of life and developing to their
maximum potential”
- Healthy city approach: Locally-driven, long-term international development initiative
that aims to include healthy as a consideration in decision-making, resulting in cities that
protect health and sustain development; specific aims include:
- Creation of supportive environments
- Good quality of life
- Basic sanitation and hygiene
- Access to healthcare
- Requirements to be designated a healthy city: “a commitment to improve a city’s
environs and a willingness to forge the necessary connections in political, economic, and
social arenas”; does not require infrastructure to be currently in place

Question 178

What are legal considerations for writing public health orders?

Answer 178

• *Legal considerations for writing public health orders**
  1. Precedent
  2. Discretionary vs. mandatory power
  3. Quality of evidence to support reasonable belief
  4. Reasons for order: Is this the purpose of the legislation?
  5. Charter considerations
  6. Least intrusive measures

Question 179

Contrast privacy and confidentiality.

Which Canadian act provides individuals with the right to access and correct personal information the Government of Canada holds about them?

What is personal health information?

Which Canadian act ses a​ requirement to safeguard personal health information by putting in place physical, technological, or administrative controls?

Answer 179

Health information and privacy
Concepts
- Privacy: An individual’s right to be free from intrusion or interference by others in
relation to their bodies, personal information, thoughts and opinions, personal
communications with others, and the spaces they occupy
- Confidentiality: An _ethical obligation of an individual or organization to protect
information from unauthorized_access, use, disclosure, modification, loss, or theft
- Security: Physical, administrative, and technical safeguards used to protect information

• Identifiable information: Data that may reasonably be expected to identify an individual
• Directly identifying: E.g., name, personal health number
• Indirectly identifying: E.g., date of birth, place of residence
• Coded information: Direct identifiers removed and replaced with a code;
  possible a specific individual could be re-identified
• Anonymized information: Data are irrevocably stripped of identifiable information; no
  code is kept that allows future re-linkage; risk of re-identification based on remaining
  information is very low
• Anonymous information: Data have never had identifiers; risk of identification is low or
  very low
• Personal health information: Any identifying information about an individual in oral or
  recorded form that relates to an individual’s physical or mental health, family history,
  receipt of health care, eligibility for health care, organ donation, health number, or
  substitute decision-maker

Privacy Act (Canada)
- Like FIPPA, but only applies to certain federal government institutions
- Provides individuals with the right to access and correct personal information the
Government of Canada holds about them
- Compliance is overseen by the Office of the Privacy Commissioner of Canada

Personal Information Protection and Electronic Documents Act (Canada)
- Like PHIPA (requirement to safeguard personal health information by putting in place physical, technological, or administrative controls), but applies to all private-sector organizations about all personal information
(not just health information)
- Does not apply in Alberta, BC, or Quebec, because these provinces have similar
legislation that supersedes PIPEDA (i.e., in provinces that do not have similar legislation,
PIPEDA applies)
- Defines how personal information can be collected, used, or disclosed
- Compliance with PIPEDA is also overseen by the Office of the Privacy Commissioner of
Canada

FIPPA (Ontario)
- Freedom of Information and Protection of Privacy Act applies to: Provincial ministries,
most provincial agencies (e.g., PHO), colleges, universities, LHINs, and hospitals
- Requires government to protect individual privacy and gives individuals the right to
access government-held information
- Privacy protection: Rules for government around the collection, retention, use,
disclosure, and disposal of personal information; Information and Privacy Commissioner
of Ontario; ability for individuals to correct errors/omissions in information about them
- Information access: Individuals can request access to government-held information ($5
fee) and the government institution must reply within 30 days

PHIPA (Ontario)
- Personal Health Information Protection Act
- Health information custodians (HICs) are required to safeguard personal health
information by putting in place physical, technological, or administrative controls
- The MOH, not the BOH, is the HIC
- HICs must notify individuals if personal health information has been stolen, lost, or
accessed by an unauthorized person
- Applies to record retention, transfer, and disposal
- Gives individuals the right to access personal health information and correct errors; HIC
must respond within 30 days
- Under certain grounds, HICs may or must disclose personal health information, even if
consent has not been obtained (e.g., duty to report reportable diseases, disclosure to
MOHs in other provinces)

Question 180

What are challenges to chronic disease surveillance?

Answer 180

Question 181

Define and give examples of a recombinant vaccine and conjugated vaccines?

Answer 181

Protein-based: Use specific, isolated protein of the pathogen (e.g., acellular pertussis, Hep B)

• Recombinant vector: Yeast has been engineered to grow hep B protein antigen
• Polysaccharide: Use the bacterial polysaccharide capsule as the antigen (some bacteria use a polysaccharide capsule to evade the immune system; this is particularly effective in young children); polysaccharides are not very immunogenic (especially in
  infants) and tend not to induce durable immunity (e.g., Men-ACYW135, polysaccharide pneumococcal)
• Conjugate: Also use the bacterial polysaccharide capsule, but add a conjugated carrier protein that induces longer-term immunity and induce immune response in infants (e.g., Hib, conjugated pneumococcal)

Question 182

What is the four-pillar approach of the Canadian Drugs and
Substances Strategy?

Answer 182

Street drugs
Epidemiology
- Substance use is twice as common in individuals with mental illness than the general
population; 20% of individuals with mental illness have a co-occurring substance use
disorder
- ?After cannabis, the most commonly reported illicit drugs used by Canadians include
ecstasy, hallucinogens, and cocaine/crack
- 24% of Canadians report using psychoactive pharmaceuticals (opioids, stimulants, or
sedatives); 6% of those Canadians report using these pharmaceuticals for nonprescription
reasons

Philosophical approaches and population-level interventions:
- Prohibition: Use of psychoactive substances is a morally corrupt behaviour that can be
prevented by legal sanctions
- Interventions: Enforcement and control

• Legalization: Variety of underlying rationales; e.g., legal sanctions against the use of
  psychoactive substances are more detrimental than the use of psychoactive substances
• Interventions: Education; in jurisdictions without legalization, drug courts
• Medicalization: Use of psychoactive substances indicate a medical disorder that
  requires medical treatment
• Interventions: Treatment and rehabilitation, including behavioural therapy,
  medications (methadone, buprenorphine, NRT, bupropion, varenicline,
  naltrexone, disulfiram), case management, and peer support
• Harm reduction: Interventions that reduce the harms of using psychoactive substances
  for individuals unwilling or unable to stop; does not require cessation of drug use;
  pragmatic and empowering
• Interventions: E.g., Supervised injection sites, needle exchange, managed
  alcohol treatment
• Four-pillar approach: Combination of prevention, harm reduction, treatment, and
  enforcement approaches to drug use; current approach used in the Canadian Drugs and
  Substances Strategy

Question 183

How is the level of immunity necessary to stop transmission of a disease calculated?

Answer 183

Immunity in population required to stop transmission = (1 - 1/Ro) x 100%

Question 184

Define pandemic.

What are WHO pandemic phases?

What are 5 pandemic preparedness principles?

Name international, federal and provincial examples of pandemic plans.

Answer 184

Pandemics
Definitions:
- Pandemic: An epidemic that has spread across a large region or across international
borders
- Influenza pandemics occur when there is antigenic shift in the influenza A virus; i.e., a
novel hemagglutination protein or novel hemagglutination and neuraminidase protein
combination arises (different from antigenic drift, where these glycoproteins continually
change during replication, but not substantially enough to produce a new protein
subtype)
- WHO pandemic phases
Phase 1 Virus circulating among animals; no reports of human infection
Phase 2 Virus circulating among animals; reports of human infection
Phase 3 Sporadic cases or small clusters of disease in people; no sustained human-to-human transmission
Phase 4 Sustained human-to-human transmission resulting in verified community-level outbreaks
Phase 5 Sustained community-level outbreaks in 2+ countries in 1 WHO region
Phase 6 Phase 5 + community-level outbreaks in 1+ countries in an additional WHO region

Post-peak period: Disease activity in most countries with adequate surveillance have
dropped below peak levels
Post-pandemic period: Disease activities in most countries with adequate surveillance have
returned to seasonal levels

Pandemic preparedness principles
1. Whole-of-society approach: Involve all sectors in pandemic preparedness and response
2. Preparedness at all levels: Local, regional, national, and global governments should
prepare to respond to pandemics; plans should be flexible to accommodate multiple time
scales
3. Attention to critical interdependencies: Develop continuity plans for essential services
and the critical interdependencies of those services
4. Scenario-based response: Develop and plan for multiple scenarios, using clearly defined
planning assumptions (e.g., attack rates, fatality rates, pandemic duration, multiple
waves) (“plan for the worst but hope for the best”)
5. Respect for ethical norms: Pandemic plans should reflect fundamental human rights;
governments should identify and protect vulnerable groups

Pandemic plans

International:
- WHO Pandemic Influenza Preparedness (PIP) Framework: Framework objective is to
share influenza virus codes with pandemic potential and improve access to vaccines;
adopted by the WHA in 2011
- North American Plan for Animal and Pandemic Influenza (NAPAPI): Outlines how
Canada, Mexico, and the US would work together in the event of an influenza pandemic

Federal:
- Canadian Pandemic Influenza Preparedness (CPIP):Outlines how F/P/T will work
together in response to a pandemic; overall purpose: “First, to minimize serious illness
and overall deaths, and second, to minimize societal disruption among Canadians as a
result of an influenza pandemic”; guiding principles include collaboration, evidence-informed
decision-making, proportionality, and flexibility
- Emergency Management Act (2007): Each minister must identify the risks within
his/her area of responsibility and prepare corresponding emergency
management and response plans
- Quarantine Act (2005): Pandemic influenza A is listed in the Act’s Schedule of
Diseases

Provincial:
- Ontario Health Plan for an Influenza Pandemic (OHPIP): Describes how the Ontario
health system should prepare for and respond to a pandemic, including health sector
communications, surveillance, public health, occupational health, IPAC, outpatient
services, immunization, laboratory services, and primary health care

Question 185

Discuss the public health implications of cannabis legalization [to update and research further]

Answer 185

Case study: Marijuana (hot topic)
Epidemiology
- Cannabis is the most commonly used illegal drug in Canada
- About 40% of Canadians report ever using cannabis; only 10% report use in the last
year
- 1 in 4 of youth report using marijuana in the last year
- 1 in 6 youth who use marijuana will develop a cannabis use disorder
- Cannabis use does not lead to the use of other illegal substances

Health impacts
- Health risks are primarily concentrated in those who use cannabis frequently or those
who begin cannabis use at an early age
- Regular use of cannabis during adolescence interferes with the development of the
endocannabinoid system of the brain, resulting in behavioral and cognitive impairments;
the duration of persistence after ceasing cannabis use is unknown
- Regular use of cannabis in adults can also reduce motivation and learning performance,
but effects usually dissipate a few weeks after use is discontinued
- MVCs secondary to reduced motor coordination, attention, and reaction time while under
the influence of cannabis; risk associated with cannabis-impaired driving is lower than
that associated with alcohol-impaired driving
- Risk of psychosis and later development of schizophrenia, especially in those with a
personal or family history of psychosis
- 9% of cannabis users develop dependence; withdrawal can result in irritability, anxiety,
restlessness, and sleep disturbances
- Smoke inhalation may cause respiratory problems; difficult to separate effects from
concurrent tobacco use

Legalization
- Criminalization of cannabis causes harm, without dissuading people from use
- 500,000 Canadians have a criminal record due to simple possession of cannabis
- Cannabis is legal in the Netherlands, Portugal, Uruguay, and the US states of Colorado
and Washington
- Legalization provides the opportunity to regulate the use of marijuana based on public
health evidence, therefore reducing the harms associated with use; without sufficient
regulation, legalization may increase cannabis use and increase harm
- Ability to regulate is not available with decriminalization
- ⅔ of Canadians support legalization

• Proposed low-risk cannabis use guidelines from CAMH (note that methodology differs
  substantially from low-risk drinking guidelines, because low levels of alcohol have a
  beneficial health effect and cannabis use does not):
• Use is delayed until early adulthood
• Frequent (daily or near-daily) use is avoided
• Users shift away from smoking cannabis towards less harmful (smokeless)
  delivery systems such as vaporizers
• Less potent products are used, or THC dose is titrated
• Driving is avoided for 3 to 4 hours after use, or longer if needed
• People with higher risk of cannabis-related problems (e.g. people with a personal
  or family history of psychosis, people with cardiovascular problems, and pregnant
  women) abstain altogether
• Proposed guidelines for regulation from CAMH:
  1. Establish a government monopoly on sales.
  2. Set a minimum age for cannabis purchase and consumption.
  3. Limit availability. Place caps on retail density and limits on hours of sale
  4. Curb demand through pricing while minimizing the opportunity for continuation of
  lucrative black markets.
  5. Curtail higher-risk products and formulations (e.g., higher-potency formulations,
  products designed to appeal to youth).
  6. Prohibit marketing, advertising, and sponsorship. Products should be sold in
  plain packaging with warnings about risks of use.
  7. Clearly display product information. In particular, products should be tested and
  labelled for THC and CBD (cannabidiol) content.
  8. Develop a comprehensive framework to address and prevent cannabis-impaired
  driving.
  9. Enhance access to treatment and expand treatment options.
  10. Invest in education and prevention.

Question 186

Describe basic facts about rubella

Organism, Reservoir, Mode of transmission

Incubation period, infectious period

Epidemiology

Presentation, Testing

Case management, Contact management

+/- Immunization

Answer 186

Rubella (reportable)

• Organism: Rubella virus (German measles), an RNA Togaviridae virus
• Reservoir: Humans
• Mode of transmission: Droplet or direct contact
• Epidemiology: Occurs worldwide
• Presentation: Up to 50% of infections are subclinical, complications outside of CRS (congenital rubella syndrome) are rare
• Classic illness: Transient rash, postauricular and suboccipital lymphadenopathy, arthralgia, low-grade fever
• Congenital rubella syndrome: Miscarriage, congenital heart disease, cataracts, deafness, mental retardation, diabetes, panencephalitis; highest risk in the first trimester
• Incubation period: 14-21 days
• Infectious period: 1 weeks before onset of rash to 4 days after onset of rash (*infants with CRS are infectious for up to 1 year)
• Testing: NPS (nasopharyngeal swab), throat swab, urine, or aborted material for viral culture and PCR + acute and convalescent sera
• Case management: Supportive
• Contact management: PEP with vaccine or IG does not alter the clinical severity of rubella after exposure; PEP is not recommended, but all exposed susceptible individuals should be vaccinated to provide future immunity
• Vaccine:
• Vaccine only available in Canada in combination products
• Rubella vaccination is given to toddlers to generate herd immunity to protect fetuses; rubella is generally not a severe disease in children (i.e., rubella immunization does not usually benefit the individual, but benefits the population)
• Second dose is not a booster dose; it is a primary dose for the 1-5% of initial non-responders
• Contraindicated in pregnancy due to theoretical risk to fetus, but there have never been any documented cases of CRS in pregnant women given the vaccine
• Rubella-containing vaccines may induce acute transient arthritis/arthralgia

Question 187

Describe basic facts about legionellosis

Organism, Reservoir, Mode of transmission

Incubation period, infectious period

Epidemiology

Presentation, Testing

Case management, Contact management

+/- Immunization

Answer 187

Organism: Legionella pneumophila (18 serogroups; most disease caused by serogroup 1)
- Reservoir: Water, soil, mud (can multiply between 25-45 C and can remain dormant at <
20 C) (see also: Biofilms)
- Mode of transmission: Primarily aerosolization from water systems, cooling towers,
whirlpool spas, humidifiers
- Epidemiology:
- Risk factors for Legionnaires’ disease: Extremes of age age, dialysis, smoking,
immunocompromise, male sex
- Legionnaires’ CFR = 15%
- Up to 5% of community-acquired pneumonia cases may be Legionnaire’s
disease
- Presentation:
- Legionnaires’ disease: Similar clinical and radiological findings to communityacquired
pneumonia, but may progress to respiratory failure
- Pontiac fever: Self-limiting coryzal-type symptoms x 2-5 days; probably due to
antigen inhalation rather than bacterial invasion
- Incubation period: 2-10 days
- Testing: Culture (gold standard in environmental testing), PCR (respiratory specimens),
urine antigen testing (only detects L. pneumophila serogroup 1); preferable to have
sputum culture if environmental testing will take place, to link epi and lab results
- Other:
- Sampling should only occur in response to cases, because Legionella is
ubiquitous and its presence may not relate to disease outcomes, making positive
samples hard to interpret (exception: transplant units should have regular
sampling as part of a HACCP system)
- Environmental prevention: Avoid water stagnation, avoid rubber in water
systems, control release of water spray, adequately treat water (chlorination,
thermal heating, copper silver ionization, monochloramine)

Question 188

What are examples of IPAC interventions using the hierarchy of control framework?

Answer 188

IPAC interventions

Elimination: Physically remove the hazard
- Work exclusion
- Visitor restriction
- Immunization

Engineering controls: Isolate people from the hazard
- Environmental and equipment cleaning
- Cleaning: Removing infectious agents or other organic matter from surfaces by scrubbing or washing; cleaning must be performed prior to disinfection or sterilization
- Disinfection: Eliminates most infectious agents on surfaces
- Concurrent disinfection: Application of disinfection immediately after
infectious material is released or discarded
- Terminal disinfection: Application of disinfection after patient has been discharged

• Physical barriers (e.g., acrylic windows in reception areas, screens to prevent insect entrance, single rooms)
• HVAC:
• Positive pressure: Prevents infectious agents from entering a room
• Negative pressure: Prevents infectious agents from leaving a room
• Cohorting:
• Patient cohorting: Placing individuals who are infected or colonized with the same microorganism in the same room
• Staff cohorting: Assigning staff who are infected or colonized with an organism to only care for patients with the same organism
• *Administrative controls**: Change the way people work
• Point-of-care sharps disposal
• Point-of-care hand washing stations
• Staff training (e.g., sharps injury prevention program)
• Restrictions on where food and drinks may be consumed
• Respiratory etiquette

PPE: Personal protective equipment

Question 189

How is Chagas disease transmitted?

Answer 189

Triatomine bugs (“kissing bugs”): Vector of Trypanosoma cruzi (causative agent of
Chagas disease); disease is transmitted when bug feces is inoculated into the bite
wound or eye (latter causes a characteristic swelling of the eyelid called Romana’s sign);
generally live in substandard housing in the southern US and South America; nocturnal

Question 190

Define population health approach.

What is a population health assessment and how is it done?

Contrast population health assessment and surveillance.

Answer 190

Population health assessment
Definitions
- Population health: The health of a population as measured by health status indicators and as influences by the determinants of health (FPT Advisory Committee on Population Health, 1997)
- Population health approach: “Population health is an a_pproach to health that aims to improve the health of the entire population and to reduce health inequities among population groups_. In order to reach these objectives, it looks at and acts upon the broad range of factors and conditions that have a strong influence on our health.” (PHAC,
2012)
- Compared to a health promotion approach, there is a greater focus on shifting the curve in the population health approach, rather than focusing on marginalized populations

• Population health assessment: Core function of public health (“Population health assessment – Understanding the health of communities or specific populations, as well as the factors that underlie good health or pose potential risks, to produce better policies and services.) assessment and analysis of data for decisionmaking (Ontario MOHLTC); regular collection, analysis, and sharing of information about conditions, determinants, risks, and priorities
• Community health needs assessment: Basically the US version of a population health
  assessment; includes the identification of resources and focuses on filling in gaps

Population health assessment vs. disease surveillance
Process
See also: Health needs assessment
1. Determine scope and purpose, and identify stakeholders (consult with stakeholders throughout)
2. Data access, collection, and management (see Monitoring chronic disease in Canada
and Public health surveillance for examples of data sources)
3. Data analysis and interpretation
4. Report and dissemination
5. Action based on results
6. Evaluation or ongoing monitoring

Question 191

How is testing performed for C. trachomatis?

Answer 191

• Testing:
• Urine NAAT usually preferred by patients; urine NAAT is acceptable when pelvic
  examination is not warranted (note: symptoms warrant an examination)
• NAAT can also be performed on urethral, vaginal, and rectal swabs
• Culture is recommended for throat specimens
• Screen all sexually active individuals < 25 years of age (clear evidence of benefit
  in women; benefits in men unclear), all individuals treated for chlamydia (6 mos
  after treatment)
• Screen all pregnant women; repeat testing in third trimester for high-risk women

Question 192

What pathogens are associated with raw milk?

Answer 192

Pathogens associated with raw milk:

Campylobacter (#1),

Salmonella spp. (#2),

E. coli (#3),

Yersinia enterocolitica, L. monocytogenes, S. aureus toxins

• Note that Canada has been bovine brucellosis-free since 1985
  Sources of pre-processing contamination:
• Inside the udder (e.g., infection of the mammary gland or mastitis)
• Outside the udder (e.g., skin flora, soiling of the udder, contamination due to
  human handling)
• Milking equipment (e.g., inadequate cleaning, cleaned with contaminated water)
  At-risk populations: Very young, elderly, pregnant women, immunocompromised
  persons
• Purported benefits: Reduced incidence of atopy
• In Ontario, the HPPA prohibits the sale of raw milk (although it does not prohibit the onfarm
  consumption of raw milk by farmers and their families)

Question 193

What are recent epidemiologic trends of adverse events following vaccinations?

Answer 193

• AEFI reporting rate (2012): 10.1 reports / 100,000 persons
• 95% of reported AEFIs were non-serious (e.g., reactions near vaccination site,
  rash, fever)
• AEFI reporting is inversely related to age
• AEFI reporting rate has been declining since 2005
• Adverse events more likely with the first dose of live vaccines than subsequent doses;
  otherwise, adverse

Question 194

Describe the six pollutants that the Clean Air Act requires the US EPA to set National Ambient Air Quality Standards for.

Name 3 secondary air pollutants.

Answer 194

1. Carbon monoxide (CO): Combustion
2. PM10 (largest “inhalable particle”) Soil, other crustal materials (e.g., dust from unpavedroads, construction)
3. PM2.5 (fine PM → more likely to be toxic than coarse PM because can be inhaled more deeply into the lungs) Direct emission: Combustion of fossil fuels, smokestacks, fires
   Secondary formation: Reactions of SOx and NOx, soot, and acid condensates
4. Ozone (O3) Secondary pollutant produced by the reaction of NOx and VOCs; usually higher in rural areas than urban areas
5. Sulfur dioxide (SO2) Fossil fuel combustion, especially power plants
6. Nitrogen dioxide (NO2) Secondary pollutant; forms from primary pollutants released by fossil fuel combustion, especially vehicles
7. Lead (Pb) Metal processing plants, leaded aviation fuel, waste incinerators, battery manufacturers

Question 195

What are the steps to responding to a hazardous materials transportation incident?

Answer 195

Technological/infrastructure events
- Society is evolving towards increasingly centralized infrastructure for transportation,
water, electricity, and other utilities
- Society is also developing increasing reliance on infrastructure networks that span long
distances
- These extensive, convoluted distribution systems with multiple interdependencies
among separate components creates vulnerabilities; a single event can result in
cascading and escalating effects
- Examples of infrastructure events include:
- Electricity outage
- Transportation emergency
- Water system failure
- Structural collapse (e.g., bridge)
- Hazardous material release
- Fire
- Nuclear power station failure

Responding to a hazardous materials transportation incident
(e.g., overturned tanker truck; verbatim from 2016 Emergency Response Guidebook)
First response (*note that most steps are not within the scope of public health)

1. Approach cautiously from UPWIND, UPHILL or UPSTREAM:

a. Stay clear of Vapor, Fumes, Smoke and Spill
b. Keep vehicle at a safe distance from the scene

2. SECURE THE SCENE
a. Isolate the area and protect yourself and others

3. IDENTIFY THE HAZARDS using any of the following:
   a. Placards
   b. Container labels
   c. Shipping documents
   d. Rail Car and Road Trailer Identification Chart
   e. Material Safety Data Sheets (MSDS)
   f. Knowledge of persons on scene
   g. Consult applicable guide page

4. ASSES THE SITUATION

a. Is there a fire, a spill or a leak?
b. What are the weather conditions?
c. What is the terrain like?
d. Who/what is at risk: people, property or the environment?
e. What actions should be taken – evacuation, shelter in-place or dike?
f. What resources (human and equipment) are required?
g. What can be done immediately?

5. OBTAIN HELP
   a. Advise your headquarters to notify responsible agencies and call for assistance
   from qualified personnel
6. RESPOND
   a. Enter only when wearing appropriate protective gear
   b. Rescue attempts and protecting property must be weighed against you becoming
   part of the problem
   c. Establish a command post and lines of communication
   d. Continually reassess the situation and modify response accordingly
   e. Consider safety of people in the immediate area first, including your own safety

ABOVE ALL: Do not assume that gases or vapors are harmless because of lack of a smell –
odorless gases or vapors may be harmful . Use caution when handling empty containers
because they may still present hazards until they are cleaned and purged of all residues.

Question 196

Define and contrast tolerable daily intake (TDI) and acceptable daily intake (ADI)

Answer 196

- TDI (tolerable daily intake): Estimated total daily exposure to a substance that will not
result in adverse health outcomes; like an RfD, for things you are not supposed to eat
(e.g., phthalates)
- ADI (acceptable daily intake): Like the TDI, but for things you are supposed to eat, but
not too much of (e.g., food additives, pesticides)

• EDI (estimated daily intake): Estimated total daily exposure to a substance from all
  exposure pathways; if EDI > RfD, individual is at risk of adverse health outcomes

Question 197

How are QALYs and DALYs calculated?

Answer 197

Health-adjusted life years (QALYs and DALYs)
- HALYs: An umbrella term; a “ population health measures permitting morbidity and
mortality to be simultaneously described within a single number. They are useful for
overall estimates of burden of disease, comparisons of the relative impact of specific
illnesses and conditions on communities, and in economic analyses”

Quality-adjusted life-years
- Quality-adjusted life-years = Years lived in perfect health + (Years lived in less than-
perfect health * utility value)
- Developed in the late 1960s for use in cost-effectiveness analyses

• Health-related quality of life (HRQL or HRQoL): The morbidity or quality of life
  component of HALYs; captured on a scale of 0-1.0; Calculating the utility value (HRQL):
• Standard gamble: A choice between a less preferred health state and a gamble
  between perfect health and death; e.g., “ Imagine you have a body mass index above
  35, with no other adverse health outcomes. Now suppose there’s a surgery available to
  you that would reduce your body mass index to a perfect level, thus giving you perfect
  health. However, there’s a probability of death associated with the surgery. How low
  does the probability of death have to be for you to be indifferent between your certain
  health, with a body mass index above 35, and the gamble of taking the surgery, which
  could lead to death or perfect health?”
• Time trade-off method: A choice between two certain options; e.g., “Imagine that your
  remaining life expectancy is 20 years. How much of your remaining life expectancy
  would you give up to eliminate your severe angina so that you have perfect health?”

Disability-adjusted life-years
- Disability-adjusted life-years = Years of life lost (YLL)+ Years lived with disability (YLD)
- YLL = Number of deaths * (standard life expectancy - age at death)
- YLD = Number of incidence cases in the reference period * disability weight *
average duration of condition
- Developed as a consistent measure that can be used to assess the causes of disability
between different jurisdictions; developed by the World Bank and World Health
Organization in 1993 for the original Global Burden of Disease Study
- DALYs were developed as a way to give credit to interventions that reduced the time
spent living with a disability, rather than just crediting interventions that prevented death
- Disability weights range from 0 (perfect health) to 1 (representing death); weights closer
to 1 imply that a year spent in that condition is perceived as being more equivalent to
death than to a state of health; currently used weights were developed based on
household survey results from Bangladesh, Indonesia, Peru, Tanzania, and the US and
an open-access web-based survey
- Previously, the weights were developed by groups of experts, but there was
concern that the experts were taking prognosis into account when developing the
weights
- Disability weights do not vary widely across cultural, educational, environmental,
or demographic circumstances, so this new methodology has not changed the
weights much

Question 198

What are the steps of contact management in outbreak investigations?

Answer 198

Contact management

1. Confirm contact
2. TOCIS history to assess susceptibility: Travel, occupation, contacts, immunization status, date of symptom onset
3. Education/counselling
4. Offer PEP or presumptive treatment if required: - Chemoprophylaxis: Antibiotics, antiparasitics, or antivirals - Immunoprophylaxis: Active or passive immunization - Presumptive treatment: Assumes infection; treatment of contacts before the contact’s test result is known - Patient-delivered partner therapy: Case delivers presumptive treatment, prescription, or test kit to his/her partner
5. (+/- Quarantine): Social separation of an individual who has been exposed to an infectious disease, but is not infectious

Question 199

What federal organizations are under the health portfolio?

Answer 199

Health portfolio in Canada Organizations that support the federal Minister of Health; comprises:

• Canadian Food Inspection Agency: Responsible for preventable health risks related to
  food and zoonotic diseases (used to fall in the Minister of Agriculture’s portfolio)
• Canadian Institutes of Health Research: Responsible for health research and
  knowledge translation
• Health Canada: Responsible for health product safety (e.g.s, assessing new medicines
  and issuing a Notice of Compliance), Canada’s Food Guide, safe living and working
  environments, and First Nations and Inuit Health
• Patented Medicine Prices Review Board: Responsible for _ensuring that patented
  medicine prices are not excessive by ordering price reduction_s if a price is found to be
  excessive; arm’s length quasi-judicial body
• Public Health Agency of Canada: Responsible for health promotion, infectious disease
  control, chronic disease and injury prevention, and emergency preparedness and
  response; created in 2004
• Pan-Canadian Public Health Network: Network comprising federal, provincial,
  and territorial public health leaders, as well as other public health partners (e.g.,
  CPHA); meet to set pan-Canadian public health priorities and share information
  and best practices
• National Collaborating Centres for Public Health: Funded by PHAC to
  synthesize, translate, and share public health knowledge; 6 centres across
  Canada

POSITIONS:

• Deputy minister: Head of Health Canada reporting directly to the Minister of Health
• Chief Public Health Officer of Canada: Provides advice to the Minister of
  Health and PHAC President; federal spokesperson on public health issues; when
  PHAC was established, the role of the CPHO included what are now the
  responsibilities of the PHAC President (roles were split in 2014)
• PHAC President: Equivalent position to deputy minister; responsible for staffing
  and budgeting of PHAC

Question 200

What are 3 altitude illnesses and their symptoms?

Answer 200

Altitude sickness: Acclimatization (gradual ascent, 300-500m/night) + acetolazamine

• Acute mountain sickness: Headache, anorexia, fatigue, dizziness, sleep disturbance within 12 h at high altitude
• High-altitude cerebral edema (HACE): Lethargy, ataxia, altered mental status, coma, death
• High-altitude pulmonary edema: Dry cough, SOBOE progressing to SOB at rest, pink frothy sputum

Question 201

Regarding organization governance, what are common roles and responsabilities of a board?

Answer 201

• Common responsibilities of (or modes of operation for, according to Corbett and Mackay) a board:
• Fiduciary: Responsible for ensuring resources result in value and for acting in good faith in the interests of an organization
• Strategic: Responsible for determining the vision of the organization
• Generative: Responsible for protecting the sustainability of the organization
• Statutory compliance: “Thing you can go to jail for” - Dr. Goel; responsible for ensuring compliance with laws
• Common roles for a board: Management of the senior executive (vs. role of the CEO: oversees implementation of strategy)
  1. Establish a framework for performance oversight (approve strategic goals and direction, along with a performance oversight framework)
  2. Oversee program effectiveness and quality (monitoring, reporting, evaluation)
  3. Oversee financial condition and resources (fiscal oversight; approving operating and capital budgets)
  4. Oversee enterprise risk management (e.g., information integrity, procurement, insurance, pensions)
  5. Supervise leadership (MOH assessment, CEO succession planning)
  6. Oversee stakeholder relationships (relationship building with other organizations)
  7. Manage the board’s own governance (board self-assessment)
• *Organizational governance**
• Governance: The structures and processes of direction-setting and organizational control
• Structure: Includes Board membership, constitution, veto power, voting, etc.
• Processes: Include agenda, relationships, documentation, etc.
• Board: Group of individuals that govern an organization; accountable for the success and sustainability of the organization, so must act in the best interests of the organization; approves an organization’s bylaws and financial statements
• Necessary conditions for good board governance:
• Role: Board’s role and directors’ duties are explicit and separated from those of the organization’s executive team
• Quality: The board’s size, composition, terms, orientation, education, and evaluation are appropriate for its role
• Processes: Committee membership and leadership position terms, selection, and work are clearly defined; meeting processes are explicit
• Evolution of the role of the board: As organizations grow and mature, the role of the board evolves to fit the needs of the organization
• Working board: In the start-up phase of an organization, the board members often do some of the work of the organization; high operational involvement
• Management board: As an organization matures and becomes larger, the board shifts into an oversight role; however, the organization may still lack key skills like accounting or law, and the board members remain in a management role in these areas; moderate operational involvement
• Policy board: Once an organization is highly developed, the board focuses on longer-term issues of sustainability and success; low operational involvement
• Carver model: A policy board approach proposed by John Carver; in this model, the board determines the mission, vision, and values, sets broad policy directions, and strategic plans, and provides oversight, but the board delegates the operationalization of these broad goals to the CEO
• Common board committees:
• Program committee: Reviews program effectiveness
• Finance committee: Reviews budget, funding, revenue, insurance, reporting
• Audit committee: Reviews risk specific to processes and information
• Risk management committee: Reviews enterprise-level risks

Question 202

What are individual and population level interventions available to control tobacco exposure?

What is MPOWER?

What are the 3 first line clinical steps in managing smoking cessation according to the Ottawa model (3As)?

Answer 202

Smoking and tobacco
Tobacco is the leading preventable cause of death globally.
Definitions
- Nicotine: Parasympathomimetic; stimulant (releases epinephrine); tobacco contains
nicotine, which results in dependence, tolerance with repeated use, and withdrawal upon
cessation of use (together, resulting in addiction)
- Unlikely carcinogenic, but can cause birth defects and poisoning
- First-hand smoke: Smoke inhaled by a smoker from a cigarette
- Second-hand smoke: Smoke exhaled by a smoker or smoke released from the end of
a burning cigarette
- Third-hand smoke: Smoke residue and gases that remain after a cigarette is no longer
burning

Individual-level interventions
Pharmacotherapy: Continuous abstinence rate at 12 months is better for all of the options
listed below + behavioral support compared to behavioral support alone
- Bupropion (Wellbutrin, Zyban): Norepinephrine-dopamine reuptake inhibitor (also a
nicotinic antagonist)
- Varenicline (Champix): Partial nicotinic acetylcholine receptor agonist; superior to the
other pharmacotherapies for continuous abstinence at 12 months
- NRT (gum, inhaler, or patch): Increase the rate of quitting by 50 to 70%

Ottawa Model for Smoking Cessation
- Ask: Identify smoking status of all patients at each clinic visit
- Advise: Provide personalized advice on quitting
- Act: Provide support for a quit attempt via brief counselling, pharmacotherapy, setting a
quit date, or self-help, and then provide follow-up support

Population-level interventions
Interventions recommended in the Community Guide:
- Comprehensive tobacco control programs
- Incentives/competitions among workers (only when combined with other interventions)
- Increase tobacco unit price
- Mobile-phone based cessation interventions
- Quitlines
- Reducing cost for cessation treatments
- Smoke-free policies

WHO Framework Convention on Tobacco Control (WHO FCTC):
- First global public health treaty; entered into force in Feb 2005; 180 parties to the
convention
- Objective: “to protect present and future generations from the devastating health, social,
environmental and economic consequences of tobacco consumption and exposure to
tobacco smoke”
- Requires parties to establish infrastructure for tobacco control and regulation that are
free from interference by tobacco companies, including prohibiting misleading
packaging, banning tobacco advertising, developing national cessation guidelines, and
eliminating illicit tobacco trade (amongst other things)
MPOWER: Measures recommended by the WHO to assist in the implementation of the WHO
FCTC; includes 6 components, which correspond to one or more of the articles in the WHO
FCTC:
1. Monitor tobacco use and prevention policies
2. Protect people from tobacco smoke
3. Offer help to quit tobacco use
4. Warn about the dangers of tobacco
5. Enforce bans on tobacco advertising, promotion, and sponsorship
6. Raise taxes on tobacco

Question 203

What are risk and protective factors for aboriginal suicide and prevention strategies?

Answer 203

Risk factors:

Community: effects of colonization (residential schools, forced adoptions, forced relocation, denial of existence), acculturative sress, marginalization, intergenerational trauma, eradication of culture, erosion of traditional values, loss of traditional family stability, contagion of suicide clusters, discrimination + racism

Individual: depression, alcohol and drug, low self-esteem, sexual abuse and violence, parental loss, homelessness

Protective factors: self-government, land control, control over education, command of police and fire services, health services control of culture activities, indigenous language widely spoken

Prevention strategies: community wellness, spirituality, gatekeeper training, school-based prevention program, means of suicide restriction, peer support program

Question 204

Regarding folate intake,

what are recent epi trends?

health impacts?

and available interventions?

Answer 204

Folate
RDI

• Women who may become pregnant = 0.4 mg/day

- 1 mg moderate risk (dm, fhx ntd not personal, epilepsy drugs, crohn’s)

- 4 mg high risk (personal or partner had ntd, prev ntd pregnancy) until 12 wks, then 1 mg

Epidemiology

• About 60% of Canadian women report taking folic acid
  supplementation in the three months prior to pregnancy
• Individuals in higher-income households are more likely to take folic
  acid supplementation than individuals in lower-income households
• Prevalence of NTD 1/2000, does not increase with age

Health impacts

• Reduction in incidence of neural tube defects (highest period of risk
  for development of NTD is GA < 4 weeks, when most women do not
  know they’re pregnant)
• High levels of folic acid can mask B12 deficiency

Interventions

Fortification of flour, enriched pasta, and enriched corn meal is mandatory in Canada
*Some countries (New Zealand, parts of Western Europe) do not fortify
foods with folic acid because of a concern that it could enhance the growth
of neoplasm; however, large meta-analyses have not found this effect
Promote folic acid supplementation for all women who could become pregnant

Question 205

Discuss the public health implications of caffeinated energy drinks

Answer 205

Case study: Caffeinated energy drinks (hot topic)
Definition: “A beverage that typically contains large amounts of caffeine, added sugars, other
additives, and legal stimulants such as guarana, taurine, and L-carnitine.” (CDC)

• *Epidemiology**
• 30-50% of US teens report consuming energy drinks

Health impacts
- Psych: Increased alertness, attention, and energy, anxiety, insomnia
- Resp: Increased RR
- CVS: Increased BP, HR, arrhythmias, heart failure
- Other: Dehydration, masks depressant effect of alcohol leading to increased
consumption and increased alcohol-related harms

Interventions
- AAP recommendation: Adolescents ages 12-18 years should not consume energy drinks
and should not consume more than 100 mg of caffeine/day (equivalent to about one cup
of coffee)
- Do not sell energy drinks in school; do not use or recommend energy drinks for
hydration

• Health Canada actions:
• Prohibited the use of energy drinks in pre-mixed alcoholic beverages;
• Requires label stating that energy drinks are “not recommended for children,
  pregnant/breastfeeding women, individuals sensitive to caffeine”, “do not mix with
  alcohol”, and “high source of caffeine”

Question 206

What are resource procurement principles in the public sector?

What are 5 procurement methods?

Answer 206

• *Finance**
• Finance: How an organization obtains and manages money
• In Ontario, LPHAs are financed by the provincial government and municipal governments
• Mandatory programs cost-shared (75% provincial/25% municipal)
• The MOHLTC funds Boards of LPHAs based on an equity-adjusted population
  formula
• Non-appropriability: Inability of a provider to receive returns from the purchase of a
  service; economic basis for government action (i.e., governments should finance nonappropriable
  goods and services)
• Failure of exclusion: No way to prevent people from using a service even if they haven’t paid for it
• Non-exhaustion: One person’s use of the service does not preclude anyone else’s use
• *Resource procurement in the public sector**
• OPS (Ontario Public service) procurement principles:
  1. Value for money
  2. Vendor access, transparency, and fairness
  3. Responsible management
  4. Geographic neutrality and reciprocal non-discrimination
• Procurement steps (determined by delegation of authority):
  1. Obtain approval to procure
  2. Determine who signs off on the contract
  3. Determine who signs off on the invoice
• Procurement methods (start at the top of the list; if good or service can be obtained via
  that method, do not pursue a lower method):
• Common service: Government provides the services to government agencies
  (e.g., in Ontario, ITS provides network services)
• Vendor of record: Agreement between a government-funded organization and a
  vendor; after the agreement is established, the organization purchases specific
  goods and services from a single or limited set of vendors; established via an
  RFP; time-limited and price-specified
• Open competition: Invite all vendors to bid to provide the good or service;
  usually used for expensive items (less expensive items can use an invitational
  process, which is usually faster)
• Invitational competition: Invite a pre-specified number of vendors to bid to
  provide the good or service (in OPS, 3 vendors must be invited)
• Non-competitive: Usually avoided unless there is a sole source vendor (e.g.,
  you want Windows: the sole source is Microsoft)
• Single source: Choosing one of many vendors
• Sole source: Only one vendor supplies the product or service you want
• Procurement directives: Rules for the purchase of goods and services with public
  funds; in Ontario, all goods and services purchased by government-funded organizations
  above certain amounts (amount depends on good/service type) must be procured via an
  open, competitive process
• Procurement requests: Fair, open, and transparent procurement process through
  which a government-funded organization purchases goods or services or establishes a
  vendor of record
• Requests for Proposal (RFP): “Procurement documents that request vendors to
  supply solutions for the delivery of complex products or services or to provide
  alternative options or solutions”
• Requests for Tender (RFT): “Procurement documents that request a vendor
  response to supply goods or services based on delivery requirements,
  performance specifications, and terms and conditions”
• Requests for Qualifications (RFQ): “Procurement documents used to solicit,
  from potential vendors, financial stability, technical information and product or
  service suitability, and which measure the products and services against stated
  evaluation criteria”

Question 207

Contrast vision, mission, values, strategies and goals.

What are elements of a strategic planning process?

What are the steps for strategic planning?

What is a SWOT analysis?

What are the benefits of strategic planning?

Answer 207

Strategic planning

• *Strategic plan**: “Where your organization is heading and why it’s heading there”; comprises:
• Vision: Image of the desired future; “what we want to be”
• Mission: Statement of the purpose of the organization; “why we exist”; “what we do, for whom, and why”
• Values: How an organization will carry out its mission; “how we behave”
• Strategic directions: Broad strategies or objectives that will contribute to achieving the vision and mission
• Goals: Concrete, medium-term objectives (~5 years) that fit within the strategic directions; targeted and measurable

Strategic planning: Systematic organized process (Situation analysis, future direction, strategy development, M&E) to document plans to progress from current to desired future state.

• *Strategic planning steps in government:**
  1. Assess readiness for strategic planning (e.g., organizational structure is in place, capacity for strategic planning is available) and organizational history

Determine planning process & team
Identify organizational mandate
Clarify organizational mandate, mission, vision, values

2. Develop the strategic plan
   a. Stakeholder consultation and analysis
   b. Environmental scan (aka PESTLE analysis): Environmental scan to assess external Political, Economic, Social, Technological, Legal, and Environmental trends that may affect your organization, which feeds into the OT of the SWOT analysis

c. SWOT analysis (based on organizational assessment, stakeholder consultation, and environmental scan): Identify critical issues facing the organization
i. Strengths: What factors internal to the organization help it fulfill its
mission?
ii. Weaknesses: What factors internal to the organization prevent it from fulfilling its mission?
iii. Opportunities: What factors external to the organization help or could help it fulfill its mission?
iv. Threats: What factors external to the organization prevent or could
prevent it from fulfilling its mission?

d. Identify key strategic areas/goals (i.e., areas that address critical issues) (e.g., if a critical issue is lack of resources, then a key strategic area/goal might be coalition building)
e. Align emerging themes from step d with other government directives (e.g., in public health in Ontario, this might include the OPHS, Immunization 2020, etc.) to identify organizational priorities
f. Validate organizational priorities with key stakeholders

g. Establish a framework for performance oversight (e.g., balanced scorecard, dashboard; see Operational planning and Performance management)
3. Implement: Finalize strategic plan and communicate internally and externally
4. Evaluate: Monitor progress using performance oversight framework

Benefits of strategic planning:

Promotion of strategic thinking, acting, and learning
Improved decision making
Enhanced organizatical effectiveness, responsiveness, and resilience
Enhanced effectiveness of broader societal systems
Improved organizational legitimacy
Direct benefits for the people involved, commitment + morale

Clearly DEFINE organizational purposes via mission and clarify future directions via vision.

Establish REALISTIC strategic directions, goals, objectives, priorities consistent with mission.

Ensure effective resource use by focusing on organizational key priorities

Improved communication of goals and objectives to stakeholders.

Develop a sense of ownership for the plan and thus greater commitment and retention among employees.

Solve major organizational problems

Improve public sector organizational legitimacy

Question 208

Describe the Workplace Hazardous Material Information System and the role of its different actors

Answer 208

Workplace Hazardous Material Information System (WHMIS)

Canada-wide system for providing information about hazardous materials in the workplace;

developed jointly by labour, industry, and federal, provincial, and territorial governments;

includes 1) labelling, 2) material safety data sheets, and 3) worker education programs

• On Feb 11, 2015, the federal government switched from WHMIS 1988 to WHMIS 2015, although employers don’t yet have to comply with WHMIS 2015 until December 1, 2018 (the WHMIS 2015 symbols are the same as the UN’s Globally Harmonized System of Classification and Labelling of Chemicals [GHS])
• In Ontario, enforced by the Ministry of Labour
• In federal workplaces, enforced by Human Resources Development Canada
• *Roles and responsibilities of SUPPLIERS (2)**:
  1. Identify whether their products are hazardous products
  2. Prepare labels and SDSs and provide these to purchasers of hazardous products intended for use in a workplace.
• *Role and responsibilities of EMPLOYERS (4)**:
  1. Educate and train workers on the hazards and safe use of hazardous products in the workplace
  2. Ensure that hazardous products are properly labelled
  3. Prepare workplace labels and SDSs (as necessary)
  4. Ensure appropriate control measures are in place to protect the health and safety of workers.
• *Role and responsibilities of WORKERS (3)**:
  1. Participate in WHMIS and chemical safety training programs
  2. Take necessary steps to protect themselves and their co-workers
  3. Participate in identifying and controlling hazards

Question 209

Regarding iodine intake,

what are recent epi trends?

health impacts?

and available intervention?

Answer 209

Iodine
RDI

Adults = 150 mcg/day (higher for pregnant and breastfeeding women)

Epidemiology

• About 30% of Canadians are mildly to moderately iodine deficient;
  15% of Canadians consume too much iodine
• Prevalence of low iodine levels has been increasing; attributed to
  decreasing salt intake, increasing non-iodized salt intake (e.g., sea
  salt), and replacement of iodine with bromine in breads

Health impacts

• Insufficient iodine intake can lead to goitre, growth stunting,
  intellectual impairment, stillbirth, and spontaneous abortion; these
  outcomes have been eliminated in Canada through salt iodization
• In the event of a radiological emergency, consumption of potassium
  iodide can prevent the uptake of radioactive iodine by the thyroid

Interventions Fortification of salt

Question 210

What is the purpose of International Health Regulations (IHR 2005)?

Define a Public health emergency of international concern (PHEIC).

Describe which events should be reported to WHO as potential PHEIC.

Answer 210

International Health Regulations

Purpose:

“prevent, protect against, control and provide a public health response to the international spread of disease

in ways that are commensurate with and restricted to public health risks,

and which avoid unnecessary interference with international traffic and trade”

Public health emergency of international concern (PHEIC):

Any event that:
1. Poses a public health risk to other states through international spread of disease;
AND
2. Potentially requires a coordinated international response

An event that meets any two of the four following criteria may be a PHEIC and so must be reported to the WHO (each criterion has sub-criteria not listed here):

• *- The public health impact is serious
• The event is unusual or unexpected
• There is significant risk of international spread
• There is significant risk of international travel or trade restrictions**
• In addition, S_mallpox, wild-type Polio, new subtypes of human Influenza, and SARS are always notifiable [mnemonic PISS]_

History

• International Sanitary Regulations drafted in 1951; implemented to prevent the spread of plague, cholera, yellow fever, smallpox, typhus, and relapsing fever through quarantine
• IHR first introduced in 1969 to replace the ISR; required state parties to report outbreaks of plague, cholera, yellow fever, smallpox, typhus, and relapsing fever
• IHR revised in 1973 and 1981 to include only cholera, yellow fever, and plague
• An outbreak of cholera in Peru in the early 1990s that led to unnecessary trade restrictions and the 1995 Ebola outbreak in the DRC led to the decision to update the IHR again
• Rather than focusing on a short list of infectious diseases, the IHR (2005) cover any “illness or medical condition, irrespective of origin or source, that presents or could present significant harm to humans”
• The revised IHR were finalized in 2005 and entered into force in 2007
• Significant changes in the IHR (2005):
• WHO can use information from sources other than state parties
• State parties must respond to WHO information verification requests
• The Director-General of the WHO can declare any event a PHEIC and issue nonbinding recommendations
• Requires states to designate “focal points” for communication with the WHO
• Requires more stringent surveillance capabilities
• *Related WTO policies**
• Agreement on the Application of Sanitary and Phytosanitary Measures (SPS Agreement): Describes the human health protection measures that could potentially affect international trade that state parties can take in response to public health concerns; requires scientific evidence to implement health protection measures
• General Agreement on Tariffs and Trades (GATT): Allows trade barriers to be erected if allowed under the SPS Agreement; also outlines mechanisms to resolve disputes

Question 211

What is a stakeholder analysis?

What are examples of stakeholders in public health programs?

What are stakeholder characteristics to consider in a stakeholder analysis?

What is a Mendelow matrix?

Answer 211

• *Stakeholder analysis**
• Stakeholder analysis: “Process of systematically gathering and analyzing qualitative information to determine whose interests should be taken into account when developing and/or implementing a policy or program” (WHO)
• “By carrying out this analysis before implementing a policy or program, policy makers and managers can detect and act to prevent potential misunderstandings and/or opposition to the implementation of the policy or program” (WHO)
• Stakeholders: “Actors (persons or organizations) who have a vested interest in the policy that is being promoted” (WHO)

(A MANIC HUG)
- Associations
- Media
- Academia
- NGOs
- Industry
- Clients/community
- Healthcare
- Unions
- Governments

• Stakeholder characteristics to consider in stakeholder analysis:

Knowledge, interests, position (for or against), ability to impact policy process (resources, power, leadership on other stakeholders), nature of engagement (funder, decision maker)
- Interest x influence grid (aka Mendelow matrix): Stakeholder analysis tool that indicates best tools/strategies for engaging stakeholders, according to grid quadrant

Question 212

Describe traffic-related air pollutants and determinants of their exposure?

Answer 212

• Primary vehicle pollutants (ultra-fine particles and NOx) concentrations are higher closer
  to major roads and highways, and decline quickly with increasing distance from
  roadways
• Secondary vehicle pollutants (NO2 and PM2.5) concentrations are also higher closer to
  major road and highways, but decrease more gradually with distance from roadways
• Most TRAP concentrations return to background levels by 500m from roadways
• Living within 500 m of a major road is associated with increased risk and severity of
  asthma
• Diesel vehicles are more efficient, but release more PM2.5 than light-gasoline vehicles
• Commute time is a major determinant of TRAP exposure

Question 213

What are pros and cons of different types of surveillance systems for chronic diseases?

Answer 213

Question 214

Describe basic facts about the reportable disease gonorrhea

Organism, Reservoir, Mode of transmission

Incubation period, infectious period

Epidemiology

Presentation, Testing

Case management, Contact management

+/- Immunization

Answer 214

Gonorrhea (reportable)

• Organism: Neisseria gonorrhoeae (bacterial STI)
• Reservoir: Humans
• Mode of transmission: Direct contact (sexual, vertical
• *Epidemiology**:
• Rates are increasing (60% increase between 2005 and 2014)
• Rates highest among young adults (ages 15-24)
• 2014 national incidence rate = 45.8/100,000
• Quinolone resistance rising in Canada

Presentation:
- F: Discharge, dysuria, abnormal vaginal bleeding, arthritis, disseminated
gonococcal infection
- M: Discharge, dysuria, testicular pain/swelling, epididymo-orchitis, arthritis,
disseminated gonococcal infection
- Ophthalmia neonatorum
- Sequelae: F: PID→infertility, ectopic pregnancy, chronic pelvic pain

Incubation period: 1-14 days (mean: 2-7 days)
Testing:
- Asymptomatic screening: Urine NAAT (+ rectal or pharyngeal culture for MSM
with exposure at these sites)
- Symptomatic F: Cervical culture (preferred) > cervical NAAT > urine NAAT
- Symptomatic M: Urethral culture (preferred) > urine NAAT
- Shift towards NAAT testing has made tracking resistance challenging

Case management:

• Ceftriaxone, 250 mg IM x 1 + Azithromycin, 1 g PO x 1; test of cure
  if there are risk factors for treatment failure; abstain from sex x 3 days post-tx
• Azithromycin treats chlamydia (high rates of concomitant infection) and offers a
  second mechanism of action against gonorrhea (could delay cephalosporin
  resistance)

Contact management: Notify, assess/test, and empirically treat all sexual contacts of the
case for whom contact occurred in the the last 60 days; abstain from sex x 3 days posttx

Question 215

What is the stand for conducting research with First Nations?

What are its 4 principles?

Answer 215

OCAP Principles
- Standard for conducting research with First Nations

• Developed in response to:
• A lack of a Western concept of community rights in research; and
• A problematic historical relationship between researchers and First Nations
  communities (information collected from First Nations under the early Indian Act
  was used to further the erasure of Indigenous culture)
• Developed by the national steering committee of the First Nations and Inuit Longitudinal
  Health Survey in 1998; the national steering committee evolved into the First Nations
  Information Governance Centre in 2010
• Four principles:
• Ownership: The First Nations community collectively owns the informationcollected for research purposes
• Control: The First Nations community controls all aspects of both the research and the dissemination
• Access: The First Nations community has access to data about their community, regardless of where it is held
• Possession: The First Nations community physically controls the data

Question 216

Compare and contrast different types of economic evaluations of policies:

• cost-benefit analysis
• cost-utility analysis
• cost-effectiveness analysis

Answer 216

Economic evaluation of policy

Definitions:
- Economic evaluation: “a comparative analysis of alternative courses of action in terms
of both their costs and consequences” (Drummond, 2007) “Best conducted once a program, policy, or intervention has proven effective but prior to widespread implementation and dissemination” (CDC podcast)
- Direct costs (aka financial costs): Costs of all goods, services, and other resources
consumed in the provision of an intervention; costs that show up on a budget. Quantity of resource use * unit cost
- Indirect costs (aka economic costs): Costs associated with lost or impaired ability to
work or engage in leisure activities + lost economic productivity
- Time horizon: Period over which costs are considered; should be long enough to
capture all the relevant differences in future costs and outcomes between interventions
being analyzed
- Discounting: Allowance for differential timing of costs and consequences; represents a
positive time preference (advantage to receive a benefit earlier and incur a cost later; “a
dollar later is worth less than a dollar today”); controversial, especially regarding health
effects, so not always applied in health economic analysis
- CHEERS = Consolidated Health Economic Evaluation Reporting Standards
- Return on investment (ROI): Value for spending; benefits/costs, with future benefits
and costs dicounted
- Cost effective: Typically $50,000/QALY considered “cost effective” in US and Canada
(?derived from annual cost of dialysis; arbitrary); WHO recommends an intervention be
considered “cost effective” if GDP/capita/DALY but cost effective does not equal
affordable
- Opportunity cost: The loss of a potential gain from other options after a decision to
pursue one option is made; ”Saying yes to something is almost always saying no to
something else”
- Sensitivity analysis: Verifying economic model by changing assumptions and observing results

Examples of other types economic analyses
- Cost-minimization analysis: Compares costs only; options are assumed to have the
same effectiveness
- Social return on investment: “A process for understanding, measuring, and reporting
the social, economic, and environmental value created by an intervention, programme,
policy, or organization” (Banke-Thomas et al., 2015)
- Cost of illness analysis: Estimates the total costs of a disease or condition (including
medical costs, nonmedical costs, and productivity losses) (usually the first step in a full
economic evaluation)

Question 217

Describe the burden of disease from air pollution in Canada and globally

Answer 217

Air pollution results in approximately 2,100 deaths/year in Canada (compare to other
things public health gets worked up about: approximately 238 deaths/year due to
foodborne illness, 2,000 deaths/year due to overdose, and 3,5000 deaths/year due to
influenza)
- Cardiac effects > respiratory effects; long-term effects > short-term effects; effects of
spatial variation > temporal variation (mean air quality in your neighbourhood is more
important than day-to-day changes in air quality)
- Global burden of air pollution = 5.5 million deaths in 2013; 10% of all deaths; air pollution
is the 4th highest-ranking risk factor for death globally

Question 218

What are the 7 roles of medical specialists in the canMEDS framework?

What are EPAs?

Answer 218

Medical education
- CanMEDS framework: Competency framework for medical specialists; first developed
by the Royal College in 1996, then updated in 2005 and 2015; consists of 7 roles:
- Medical expert
- Communicator
- Collaborator
- Leader
- Health advocate
- Scholar
- Professional

• Competency-based medical education: Medical education approach focused on the
  abilities of graduates as the key outcome
• Competency: “An observable ability of a health care professional that develops through
  stages of expertise from novice to master clinician”; stages of expertise in under the
  “Competency by Design” initiative include:
• Transition to discipline: Orientation to medical practice
• Foundations of discipline: Broad-based competencies shared by all specialties
• Core of discipline: Competencies core to the specialty
• Transition to practice: Competencies for autonomous practice
• Royal College “Competency by Design” initiative: Move towards credentialing
  physicians based on achieved of attained milestones of competence, rather than solely
  on the basis of time (i.e., expertise, not experience)
• Entrustable professional activity: “A key task of a discipline that be be entrusted to an
  individual who possesses the appropriate level of competence”
• Milestone: “The expected ability of a health care professional at a stage of expertise”

Question 219

What are bioterrorism Category A agents (6)?

What is this classification system based on?

What are epi clues of a deliberate epidemic?

Answer 219

(Mnemonic ABPSTV)

Anthrax, botulism, plague, smallpox, tularemia, VHF

Classification of bioterrorism agents
Classification is based on:
1. Ability to disseminate, contagiousness
2. Mortality rate, PH impact
3. Actions required for public health preparedness
4. Capability of causing public panic

Epidemiological clues that indicate a deliberate epidemic

Clue no. 1 – A highly unusual event with large numbers of casualties.

Clue no. 2 – Higher morbidity or mortality than is expected.

Clue no. 3 – Uncommon disease.

Clue no. 4 – Point-source outbreak.

Clue no. 5 – Multiple epidemics.

Clue no. 6 – Lower attack rates in protected individuals.

Clue no. 7 – Dead animals.

Clue no. 8 – Reverse spread.

Clue no. 9 – Unusual disease manifestation.

Clue no. 10 – Downwind plume pattern.

Clue no. 11 – Direct evidence.

Question 220

What pathogen are associated with raw cheeses?

Does aging raw cheeses eliminate the risk of contamination?

Answer 220

• Pathogens associated with raw cheeses: Campylobacter, Salmonella, Listeria, E. coli, Staphylococcus aureus, mycobaceterium bovis, cryptosporidium
• Almost 12% of dairy-related outbreaks are attributable to raw cheeses (in the US, most commonly queso fresco), although very few outbreaks are linked to 60-day aged raw cheeses
• From 1941-1944, typhoid outbreaks in Canada were linked to cheddar cheese made from raw milk
• Outbreak-related Salmonella typhi strains were recovered from 30-day old cheese, but not from 48- or 63-day-old cheese, resulting in Alberta prohibiting the sale of raw milk cheese ripened for less than 60 days
• In Ontario, the HPPA allows the sale of raw cheese aged for at least 60 days at temperatures > 2C
• I.e., fresh cheeses (e.g., ricotta, chevre, feta, queso fresco, mascarpone) and pasta filata cheeses (mozzarella, burrata, provolone) must be made with pasteurized milk
• Other cheeses (including soft and semi-soft cheeses) may be made with raw milk, but then must be aged according to the HPPA
• 60-day aging rule based on theory that cheese is not an hospitable environment for pathogenic bacteria and that the bacterial colony will die off to levels below the infectious dose by day 60
• Not fail-safe; multiple outbreaks associated with cheeses aged > 60 days (e.g.,2002 outbreak of E. coli 0157:H7 hemorrhagic colitis associated with raw milk gouda in Alberta)
• Cheese factors affecting pathogen survival: pH, moisture, salt content, temperature, humidity, and cheese microbial flora
• Soft and semi-soft surface-mold ripened cheeses are at greatest risk for pathogen survival because of their higher pH and moisture contents

Question 221

Regarding the CTFPHC guideline development process, what are the 2 elements that the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) method makes judgements about?

Answer 221

Guideline development and implementation

CTFPHC guideline development process
1. Topic selection: Informed by CTFPHC members, partners, key stakeholders,
practitioners, and the general public
2. Review evidence and assess quality: Systematic review
3. Identify and evaluate: External content experts review the systematic review; the
CTFPHC develops guidelines using the GRADE method (see below)
4. Produce guideline and tools: CTFPHC develops tools for providers and patients

Grading of Recommendations, Assessment, Development and Evaluations (GRADE)
GRADE: “a systematic and explicit approach to making judgements about quality of evidence
and strength of recommendations”; method for assessing the quality of evidence and
developing evidence-based clinical recommendations
Steps:
1. Develop the question in PICO (Population, Intervention, Comparator, Outcome) format,
including rating the relative importance of questions

2. Complete the systematic review and critically appraise each included study individually
3. Summarize the body of evidence (i.e., what does the systematic review tell you overall?)
   in evidence tables,
   a. GRADE evidence profile
   b. Summary of findings profile
   The quality of the evidence for each patient-important outcome is determined
   separately, in addition to the overall quality of evidence across outcomes.

The quality is graded as follows:
High We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect.
Very Low We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
The grade is reduced for: Inconsistency of results, indirectness of evidence, imprecision,
and publication bias.
The grade is increased for: Large magnitude of effect, dose-response gradient, and
when all residual confounding is expected to reduce the effect size.

4. Develop recommendations based on the confidence in the quality of the evidence,
   values and preferences, and resource use: “The strength of a recommendation reflects
   the extent to which a guideline panel is confident that desirable effects of an intervention
   outweigh undesirable effects, or vice versa, across the range of patients for whom the
   recommendation is intended”; recommendation options include:
   a. Strong recommendation for
   b. Weak recommendation for
   c. No recommendation
   d. Weak recommendation against
   e. Strong recommendation against

Question 222

Who should be screened for chlamydia (annually + targeted)?

What tests is used for chlamydia testing?

What are recent epi trends?

What are basic facts about chlamydia trachomatis?

Organism, Reservoir, Mode of transmission

Incubation time, infectious time

Epidemiology

Presentation, testing

Case management

Contact management

Answer 222

Chlamydia trachomatis

Chlamydia (reportable)

• Organism: Chlamydia trachomatis, serovars D-K (bacterial STI)
• Reservoir: Humans
• Mode of transmission: Direct contact (sexual), vertical transmission
• Epidemiology:
• Rates are increasing (50% increase between 2005 and 2014)
• Rates highest among females, 15-24 years of age
• 2014 national incidence rate = 307.4/100,000
• Presentation:
• F: 70% asymptomatic; if symptomatic, discharge, dysuria, lower abdo pain, cervicitis, reactive arthritis
• M: May be asymptomatic; if symptomatic, discharge, dysuria, urethritis, epididymo-orchitis, reactive arthritis
• Sequelae: F: PID→infertility, ectopic pregnancy, chronic pelvic pain, infertility
• Incubation period: 1-3 weeks
• Testing:
• Urine NAAT usually preferred by patients; urine NAAT is acceptable when pelvic examination is not warranted (note: symptoms warrant an examination)
• NAAT can also be performed on urethral, vaginal, and rectal swabs
• Culture is recommended for throat specimens

Annual screening:

• < 25 years
• Gay, bisexual, and other men who have sex with men (gbMSM) and transgender populations

Targeted screening:

• Offer screening and repeat screening based on risk factors in those ≥ 25 years old
• Screen at first prenatal visit. Rescreening at third trimester is indicated for those who test positive or who are at ongoing risk of infection
• Neonates born to women with chlamydia
• Case management: Azithromycin, 1 g PO x 1 (test of cure only if pregnant, treatment other than azithromycin used, or compliance a concern) OR doxycycline x 7 days + no unprotected intercourse x 7 days if positive test or compatible symptoms and test pending
• Contact management: All sexual partners within the last 60 days (or last sexual partner if contact > 60 days prior) should be tested and receive empiric treatment + no unprotected intercourse x 7 days
  *Note: Doxy contraindicated in pregnancy and children < 9 years of age

Question 223

What are basic facts about hepatitis C?

Organism, reservoir, mode of transmission

Incubation time, infectiousness

Epidemiology

Presentation, testing

Case management, treatment

Contact management

Screening (including latest CTFPHC recs)

Answer 223

Hepatitis C (reportable)

• Organism: Hepatitis C virus (flavivirus); 6 major genotypes
• Reservoir: Humans
• Mode of transmission: Predominantly parenteral (sexual and vertical transmission possible but uncommon)
• Epidemiology:
• Canadian prevalence = 0.6-0.7% (44% are unaware of their status)
• Prevalence in Canadian PWID = 66%
• Prevalence in Canadian federal prisoners = 24%
• Risk factors: IVDU, receipt of blood products prior to 1987, non-sterile healthcare or personal care equipment, infants of HCV+ women (**20-40% of cases do not have an identified risk factor**)
• Globally, 25-50% of cases of cirrhosis and hepatocellular carcinoma are attributable to HCV
• Egypt has the highest prevalence of HCV in the world (15%), due to a mass antischistosomiasis campaign in the 1960s to 1980s using contaminated needles
• Presentation: Only 20-30% of cases are symptomatic: insidious onset of anorexia, abdo discomfort, N/V; less likely to progress to jaundice than HBV infection; 75-85% of acute
  infections will become chronic
• Incubation period: 2 wks to 6 months
• Testing:
• Serology: Anti-HCV: Indicates recent or past infection with HCV (may persist in infants born to HCV+ mothers for up to 18 months, even if the infant is not HCV+); usually positive for life after infection
• PCR: HCV RNA: Measure of viral load; detected intermittently, so HCV RNAnegative last cannot rule out infection (if detected in an infant born to HCV+mother, indicates infection in the infant)
• HCV genotyping
• AST/ALT
• Case management: Counselling, re: no sharing toothbrushes/razors/etc, safer sex, harm
  reduction, no blood donation, avoiding hepatotoxins; HVA and HVB vaccination, new antivirals
• Contact management: No PEP available
• Treatment: New direct-acting antivirals achieve permanent cure in over 90% of cases, with fewer side-effects and shorter treatment regimens than interferon and ribavirin regimens (note that DAAs can reactivate HBV; all patients receiving DAAs for tx of HCV
  should be tested for HBV prior to treatment; infection followed by treatment and viral eradication does not result in immunity)
• Other:
• Screening: The US CDC and the Canadian Liver Foundation recommend birthcohort screening (prevalence is estimated to be highest in baby boomers) and the CTFPHC: We recommend AGAINST screening for HCV in adults who are not at elevated risk.
  (Strong recommendation, very low quality evidence) This recommendation applies to asymptomatic adults who are not at elevated risk for hepatitis C. it does not apply to pregnant women or adults who are at elevated risk for hepatitis C, such as:
• Individuals with current or past history of injection drug use
• Individuals who have been incarcerated
• Individuals who were born, travelled or resided in HCV endemic countries (Appendix 6)
• Individuals who have received health care where there is a lack of universal precautions
• Recipients of blood transfusions, blood products or organ transplant before 1992 in Canada
• Hemodialysis patients
• Individuals who have had needle stick injuries
• Individuals who have engaged in other risks sometimes associated with HCV exposure such as high-risk sexual behaviours, homelessness, intranasal and inhalation drug use, tattooing, body piercing or sharing sharp instruments or personal hygiene materials with someone who is HCV positive.
• Anyone with clinical clues suspicious for HCV infection (and above risk factors)
• Krever Commission: Recommended the creation of Hema-Quebec and the Canadian Blood Services after blood donations supplied by the Canadian Red Cross resulted in HIV and HCV infections

Question 224

Related to budgeting:

In human services organizations primarily unionized, why do compensation costs increase every year?

How can risks and negative variances be addressed (aka budget cuts)?

What is red circling?

What are the 4 steps in the budget cycle?

What are 3 different types of budgeting?

What are 5 functions of a budget?

Answer 224

• *Budgeting**
• *Budgets**: An estimate of income and expenditures for a defined period of time, including allocation and type
• Line items: Separate items on a budget
• Direct costs: Directly attributable to a single activity or employee (e.g., salary, transportation)
• In human services organizations, especially those that are primarily unionized, compensation costs increase every year (due to: 1. Cost of living adjustments (COLA); and 2. “grid progression”, both usually determined by collective agreement), so budget freezes in real terms = budget reductions
• Red circling: Occurs when an “employee’s pay rate is approved to be above the established salary maximum for that position. Hence, the employee is usually not eligible for further base pay increases until the range maximum surpasses the employee’s pay rate.” (e.g., when you reorganize an organizational structure, you may be required to move an employee down a stratum in the organizational structure; you cannot decrease the employee’s salary to match their new stratum, but the employee is no longer eligible to move to a new rung on the pay grid, although s/he will continue to progress through her/his current pay grid)
• Benefits (e.g., dental insurance, pension) are typically around 23% of salary
• Indirect costs: Not directly attributable to a single activity or employee (e.g., utilities)
• Fixed cost (aka “overhead”): Cost does not change in relation to services provided (e.g., rent)
• Variable cost: Cost changes in relation to services provided (e.g., electricity)
• Variance: Difference between actual expenditures and budgeted expenditures; may be positive or negative; examples of causes of variances include unanticipated changes in costs or revenues, unanticipated changes in timing of costs or revenues, budgeting
  error, or staffing changes
• Risk: Unbudgeted changes in supply or demand (e.g., increase in lab testing, reduction in provincial funding)
• Pressure: Type of risk; unbudgeted changes in demand (e.g., staff maternity leave)
  - MANAGING A BUDGET REDUCTION Risks and negative variances can be addressed through:

– Efficiencies (reducing cost but maintaining service levels);

– gapping; freezes (in hiring, discretionary spending, wages, or capital investments);

– layoffs/early retirement/red circling

– Revenue Gain (sale of assets, draw from reserve funds)

– Increase regular program funding (apply for funding from funders, increase cost of provided services)

• *Budget cycle**:
• Preparation: Estimate costs of providing services, justify requests
• Legislative/ministry consideration
• Execution
• Audit/evaluation: “Examination of records, facilities, systems, and other evidence to discover or verify desired information”
• Internal audit (aka “friendly” audit): Review compliance, processes, programs, and finance; best practice to conduct regular internal audits (auditor may be internal or hired externally)
• Internal compliance audit: Is there a directive in place? Do people in the organization follow the directive?
• Internal control audit: Is there a directive in place? Do people in the
  organization follow the directive? Is the directive appropriate and
  effective?
• Internal risk audit: Describe risks (e.g., privacy, business continuity,
  cyber, software asset management) and mitigation strategies
• External audit (aka “year-end” audit): Mandatory review of financial statements by an external auditor

Types of budgeting:

• Zero-based budgeting: New budget is based on the justification of the expense, regardless of the amount budgeted in previous years (i.e., no base taken into account) (this isn’t usually done IRL)
• Incremental budgeting: New budget is the product of incremental, small changes to the previous budget (i.e., previous budget is the “base”)
• Program-based budgeting and marginal analysis :

1. Review budgets at the program level;
2. Identify program outcomes that could be substantially improved with additional funding;
3. Identify program outcomes that would not be substantially weakened by decreased funding;
4. Allocate funding from programs identified in step 3 to programs identified in step 2 to maximize benefit and minimize opportunity costs
   - Activity or performance-based budgeting
   - Value-based budgeting

Functions of a budget:

1. Transparency and accountability (Fiscal responsibility)
2. Prioritization and planning, allocation of resources (Decision Making)
3. Control and monitoring of spending (Accounting)
4. Evaluation of performance of activities (Performance Monitoring)
5. Communication and coordination of operational plans within organisation (Communication/coordination)

Question 225

What are basic facts about syphilis?

Organism, reservoir, mode of transmission

Incubation, infectiousness

Epidemiology

Presentation, testing

Case management

Contact management

Screening

Clinical preventive actions?

Answer 225

Syphilis (reportable, vertically transmitted)

• Organism: Treponema pallidum
• DDx (other treponemal infections):
• Bejel (endemic syphilis): T. pallidum endemicum
• Yaws: T. pallidum pertenue
• Pinta: T. carateum
• Reservoir: Humans
• Mode of transmission: Direct contact (sexual), vertical, indirect contact (bloodborne)
• Epidemiology: Incidence is increasing in Canada (95% increase between 2005 and 2015); risk factors include MSM, sex work, anonymous sex; increased the risk of acquisition and transmission of HIV; rates highest among males, 25-29 years of age; 2014 national incidence rate = 6.6/100,000
• Presentation:
• Primary syphilis (infectious): Chancre, regional lymphadenopathy
• Secondary syphilis (infectious): Rash, fever, malaise, lymphadenopathy, mucous lesions, condyloma lata, alopecia, neurological involvement, uveitis, retinitis
• Early latent syphilis (infectious): Asymptomatic, <1 year; considered infectious due to risk of relapse to secondary state
• Late latent syphilis (non-infectious): Asymptomatic, >1 year
• Tertiary syphilis (non-infectious): CV syphilis (AA, aortic regurg), neurosyphilis (dementia, Argyll Robertson pupil, headache), gummatous disease
• Congenital syphilis: Disseminated infection, hepatosplenomegaly,
  lymphadenopathy, Hutchinson’s teeth
• Incubation period: 10 days to 3 months (usually 3 weeks) for primary
• Testing: Blood test; test individuals with risk factors, symptoms, or contact with a case; perform routine prenatal screening (repeat at 28-32 weeks and at birth if high risk)
• Non-treponemal tests: Detect non-specific antibodies formed by host response to syphilis infection; may be falsely negative in early primary syphilis and late syphilis and may be falsely positive due to other infections (esp treponemal infections, yaws, bejel, pinta), lupus, and very high antibody levels (hook effect) (in Ontario, rapid plasma reagin (RPR), which detects anti-cardiolipin antibodies,
  and T. pallidum particle agglutination (TPPA) are used); will decline with treatment
• Treponemal tests: Detect anti-treponemal IgG and IgM, but may be falsely negative early primary infection; usually positive for life after infection (in Ontario, chemiluminescent immunoassay (CLIA) is the treponemal test +/- fluorescent treponemal antibody absorbance (FTA-Abs) if RPR and TPPA are non-reactive or indeterminate)
• Case management: Abstain from unprotected sex until adequate serological response is attained; monitor serological response (e.g., RPR) until adequate serological response is
  attained (e.g., 4-fold drop at 12 months for early latent)
• Primary, secondary, early latent: Benzathine penicillin G, 2.4 million U IM x 1
• Late latent: Benzathine penicillin G, 2.4 million units IM q 1 week x 3 weeks
• Neurosyphilis, infants, penicillin allergies, pregnant women, HIV+ patients all get alternative courses to what is listed above
• Contact management:
• Empiric benzathine penicillin G, 2.4 million units IM x 1 for all sexual contacts of an infectious case, where contact occurred in the preceding 90 days
• Offer testing to all partners in the following time frames and treat if positive:
• Primary: 3 months
• Secondary: 6 months
• Early latent: 1 year
• Late latent and tertiary: Long-term partners and children
• Congenital: Mother and her sexual partners
• Other: Note that Jarisch-Herxheimer reaction could occur with treatment; resolves within 24 h

Prevention actions:

• Treat empirically when syphilis is probable, especially when follow-up cannot be assured
• Screen for HIV in all cases of syphilis
• Discuss the importance of _partner notification and treatmen_t to prevent transmission and/or reinfection*
• Do follow-up testing (serology) to ensure the treatment was successful*
• Consider treating sexual contacts who are within the 90 day window period, without waiting for results

Question 226

Define 5 income equity measures;

Gini index

LICO

LIM

Market basket measures

Marginalization index

Answer 226

• Gini coefficient: “Measure of the deviation of the distribution of income among individuals or households within a country from equal distribution. A value of 0 represents absolute equality; a value of 100 absolute inequality”
• Low income cut-offs (LICO): Income threshold below which a family is expected to spend 20 percent more of their income on necessities (food, shelter, clothing) than the average Canadian family; estimated by Statistics Canada by community and family size
• Low-income measure (LIM): Developed by the OECD in response to criticisms of the LICO (measure is relative to others, make 50% of median income, accounts only for family)
• Market basket measure: Develops in the late 1990s by the Canadian government; prespecified basket of goods and services that are deemed essential (food, clothing, footwear, shelter, transportation, etc.); the cost of this basket are calculated for different
  communities (requires extensive price data from many different communities)
• Marginalization index: Composite index comprising material deprivation, residential instability, dependency and ethnic concentration

Question 227

Contrast vaccine efficacy and effectiveness.

How is vaccine efficacy calculated?

What is a test-negative study design?

What is herd immunity, herd effect?

How is the immunity required in a population to stop transmission calculated?

How is the vaccine coverage necessary to reach herd immunity calculated?

Answer 227

Vaccine characteristics and calculations
- Vaccine efficacy: Percent reduction in disease incidence in a vaccinated group
compared to an unvaccinated group under optimal conditions
- Efficacy = (Attack rate in unvaccinated - attack rate in vaccinated) / Attack rate in
unvaccinated (RCT or cohort study)
- Vaccine effectiveness: Ability of vaccine to prevent outcomes of interest in the real
world
- Effectiveness = 1-OR (case-control study)

• Test-negative study design: Case-control study design used to estimate
  vaccine effectiveness; compares vaccine status between influenza test-positive
  cases and test-negative controls who present to clinicians with influenza-like
  illness; helpful for assessing vaccine effectiveness early in the influenza season
• Strengths: Feasibility, risk of overmatching due to shared healthcareseeking
  behaviour (but this leads to an underestimate of VE)
• Weaknesses: Mild presentations may be PCR- (VE overestimated), not
  validated for other diseases
• May differ from vaccine efficacy because: trial population and general population
  are different; vaccine production changed during scale-up; storage or cold-chain
  issues; waning immunity over time; pathogen has changed; herd effects
• Herd immunity: A level of immunity in the population that protects the whole population
  because the disease can no longer spread(applies only to diseases that are passed
  from person to person)
• Immunity in population required to stop transmission = (1 - 1/Ro) x 100%
• Coverage required to reach herd immunity, based on vaccine effectiveness
  = Immunity / VE x 100%
• Herd effect: Any reduced transmission of disease in a population due to the indirect
  effect of vaccination
• Impact: Population level effect of vaccination campaign or program; depends on vaccine
  coverage, herd immunity, and vaccine effectiveness; usually measured as decrease in
  disease incidence

Question 228

Regarding lung cancer,

what are recent epi trends?

risk factors?

CTFPHC recommendations?

Answer 228

Lung cancer

Epidemiology

• Most common type of cancer in Canada, excluding non-melanoma skin cancers (14% of alll cancer diagnoses)
• Leading cause of cancer death in Canada (27% of all cancer deaths)
• In men, incidence of lung cancer has been declining since the mid-1980s, following a decline in smoking in men in the 1960s
• In women, the incidence of lung cancer has plateaued since 2006, following a decline in smoking in women in the mid-1980s
• Incidence in men > incidence in women (58 vs. 48 cases/100,000); difference attributed to differences in tobacco use
• Tobacco smoke is the leading cause of lung cancer; 85% of lung cancer case are attributable to smoking
• Radon is the second most common cause of lung cancer after tobacco smoke; residential exposure to radon is estimated to cause 3-14% of all lung cancer

Risk factors
Known risk factors:
- Tobacco: First- and second-hand smoke
- Radiation: Radon, radiation therapy, nuclear accidents, occupational exposure to
radioactive ores
- Occupational exposures: E.g., asbestos, cadmium, chromium
- Outdoor air pollution: Diesel exhaust, benzene, particulate matter, PAHs (polycyclic aromatic hydrocarbons)
- Indoor air pollution: Burning coal, wood, dung, or grass; frying foods in oil at high
temperatures
- Family history of lung cancer
- Lung disease: COPD, TB, Chlamydophila pneumoniae
- Arsenic: Occupational exposure or exposure via drinking water
- Immunodeficiency
- Lupus
Possible risk factors: Genetic mutations, smoking marijuana, physical inactivity, diet low in fruits and vegetables

Screening recommendations from the CTFPHC
- We recommend screening for lung cancer among adults aged 55 to 74 years with at least a 30 pack-year smoking history, who smoke or quit smoking less than 15 years ago, with low-dose computed tomography (CT) every year up to three consecutive
years. Screening should only be done in health care settings with access to expertise in early diagnosis and treatment of lung cancer. (Weak recommendation, low-quality evidence.)
- We recommend not screening all other adults, regardless of age, smoking history or other risk factors, for lung cancer with low-dose CT. (Strong recommendation, very lowquality evidence.)
- We recommend that chest radiography, with or without sputum cytology, not be used to screen for lung cancer. (Strong recommendation, low-quality evidence.)

Question 229

What are the steps of case management in outbreak investigation?

Answer 229

Case management

1. Confirm case: Verify diagnosis based on signs, symptoms, and laboratory confirmation
2. Obtain TOCIS history: Travel, occupation, contacts, immunization status, date of symptom onset
3. Education/counselling
4. Treatment
5. (+/- Isolation): Social separation of an individual who is infectious
6. Contact tracing and notification: - Contact tracing: Process of identifying relevant contacts of a person with an infectious disease; a method of case finding; purpose of contact tracing it to identify symptomatic contacts as early as possible, reduce risk of transmission, and facilitate diagnosis and treatment;can be enhanced with provider or public health follow-up, referral cards, or reminders - Conditional contact notification: Case is initially responsible for encouraging contacts to seek medical evaluation; if the contacts do not seek medical evaluation within a predetermined length of time, public health practitioners will follow up - Patient contact notification: Case is responsible for encouraging contacts to seek medical evaluation; can be enhanced with patient-delivered partner therapy

Question 230

Describe basic facts about influenza, including vaccination recommendations for 20-21 season

Organism, Reservoir, Mode of transmission

Incubation period, infectious period

Epidemiology

Presentation, Testing

Case management, Contact management

+/- Immunization

Answer 230

Influenza (reportable)
Organism: Influenza virus
- Influenza A: Infects the 3Ps, pigs, poultry, and people; most severe; further divided into
subtypes based on 2 viral surface proteins, hemagglutinin and neuraminidase
- H5N1 (a highly pathogenic avian influenza; HPAI): Kills poultry host, unlike most
influenza infections in birds; usually manifests as severe pneumonia in humans
- H7N9 (a low-pathogenic avian influenza; LPAI): Asymptomatic illness in poultry,
but with high mortality rate in humans
- H1N1: “Swine flu”; one of two currently circulating strains
- H3N2: Second of two currently circulating strains
- Influenza B: Infects humans only; more common in children than adults; milder; not
divided into subtypes, although there are two genetically distinct lineages
- Influenza C: Occurs throughout the year; less common

• *Reservoir:** Aquatic birds
• *Mode of transmission**: Droplet, contact

Epidemiology:
- In temperate regions, local epidemics usually occur for 8-10 weeks annually, while
transmission occurs year-round in tropical areas with one or two peaks in activity
- High-risk groups: Children < 2 years, adults > 65 years, individuals with chronic medical
conditions, obesity, malnutrition
- Annual attack rate of 5-20% in the community in adults, 20-30% in children, to up to 50%
in closed communities (e.g., LTC)
- 90% of deaths occur in age > 65 years

Presentation: Typically, fever, cough, headache, myalgia, fatigue, pharyngitis, and coryza (+/-
GI symptoms in kids) x 5-7 days; cough can last 2+ weeks; can also result in croup,
bronchiolitis, febrile seizures, pneumonia, exacerbation of underlying chronic conditions
Incubation period: 2 days (range, 1-4 days)
Infectious period: 24 h before symptom onset to 3-5 days after symptom onset; children shed
virus for longer and in higher amounts than adults (infectious for 7-10 days after symptom
onset)

Testing: Usually RT-PCR on NPS; PPV of ILI symptoms during influenza season is high (i.e.,
once surveillance has confirmed influenza virus is circulating, testing is usually not necessary)

Case management: Isolation + supportive care +/- neuraminidase inhibitors within 48h of
symptom onset for individuals at increased risk of complications; resistance to oseltamivir and
zanamivir remain very low; do not use amantadine (influenza B inherently resistant; some
acquired resistance in H1 and H3 strains)
Contact management: In outbreaks in closed communities, provide oseltamivir for contacts
(including unvaccinated staff +/- vaccinated staff, depending on vaccine effectiveness) x 14
days or until 7 days have elapsed since the last case was diagnosed, whichever is longer

Evolution of influenza A:
- Antigenic drift: Small changes in viral surface proteins due to sloppy viral replication;
responsible for seasonal influenza (i.e., annual influenza epidemic) because previous
year’s infection or vaccination provides only partial immunity to new antigens; subtype
does not change
- Antigenic shift: Major changes in either or both of hemagglutinin or neuraminidase to
subtypes that have never or have not recently been circulating in humans; responsible
for pandemic influenza because a substantial population of the world’s population has no
immunity; can result in a new subtype

Vaccination: WHO recommendations for influenza vaccine composition are typically available in
Feb for the upcoming season (trivalent = 2 influenza A lineages + 1 influenza B lineage;
quadrivalent = same as trivalent + additional influenza B lineage)
NACI recommended vaccines for 2020-21 influenza season:
- Influenza vaccination recommended for everyone > 6 mos of age and particularly
recommended for people at high risk of influenza-related complications or transmitting
influenza to those at high risk; contraindications: GBS within 6 weeks of influenza
vaccination or allergy to any vaccine component except egg (egg allergy is not a
contraindication to TIV or QIV)
- Children 6 mos-9 years receiving their first influenza vaccine: Two doses, with at least 4
weeks between the doses(everyone else: 1 dose)
- Children 6-23 mos = QIV recommended because of greater burden of influenza B in
children; TIV and adjuvanted TIV also approved, LAIV contraindicated
- Children 2-17 years = LAIV (if no contradindication) or IIV4 recommended; if unavailable, then
TIV; LAIV is contraindicated for children currently receiving aspirin or aspirin-containing therapy, with most immune compromising conditions and with severe asthma or medically attended wheezing in previous 7 days
- Adults 18-59 = TIV or QIV or LAIV if healthy

• Adults 60-64 = TIV or QIV
• Adults > 65 years old = High-dose inactivated trivalent vaccine preferred (highdose
  contains 60 ug of haemagglutinin, compared to 15 ug in the standard dose). Standard TIV and QIV and adjuvanted TIV can also be used
• Pregnant and healthcare workers: TIV or QIV

https://www.canada.ca/content/dam/phac-aspc/documents/services/publications/diseases-conditions/flu-17-10-2018/64-02-20-2735-Seasonal-Flu-Pocket-Guide-EN-Web.pdf

Question 231

What is the epidemiologic triangle?

Answer 231

Host, agent, environment

Question 232

Quality improvement methods:

What is the goal of Six Sigma and what are its 5 steps?

What is the goal of PDSA cycles and what are its 4 steps?

What is the goal of Lean and what are its key concepts?

What are 8 types of waste?

Answer 232

Six Sigma
Goal: Eliminate defects in products and variation in process
Definition: A continuous process improvement methodology that focuses on identifying and
reducing variation in a process; the name derives from the standard deviation (𝜎), implying that
the production process will be error-free 99.99966% of the time (6 SD above the mean)
- Requires the identification and measurement of indicators for all processes of interest
Five steps to achieve goal: DMAIC
- Define: Which process are we investigating? Why are we investigating this process? [PROJECT CHARTER - problem statement, businness case, goals, timeline, scope, team]
- Measure: What are the metrics for this process? Are the metrics valid and reliable?
- Analyze: What do the metrics suggest about the process? What is the root cause of
underperformance?
- Improve: How can we improve the metrics? What are the consequences of
implementing improvements?
- Control: What processes can be put in place to ensure that the improvements are
maintained?

Plan-Do-Study-Act Cycle
Goal: Perform small tests of change that can be expanded if successful
Definition: “An interactive, four-stage problem-solving model used for improving a process of
carrying out a change”; steps:
- Plan: Identify your team, draft an aim statement (see below), describe the current
context and process, describe the problem, and develop alternatives
- Do: Implement one of the alternatives on a very small scale; collect data on outcomes
- Study: Evaluate the outcomes of the implementation
- Act: Based on the evaluation, decide whether or not the alternative should be
implemented in a more widespread way; if so, standardize the improvement and
implement it more broadly
- Repeat!
Aim statement: Statement that guides the PDSA cycle and answers the following questions:
1. What are we trying to accomplish?
2. How will we know that a change is an improvement?
3. What change can we make that will result in improvement?

Lean
Goal: Eliminate waste and increase efficiency in process
Definition 1: “An organization’s cultural commitment to applying the scientific method to designing, performing, and continuously improving the work delivered by teams of people,
leading to measurably better value” for stakeholders
Definition 2: “A systematic approach in identifying and eliminating waste (non-value-added activities) through continuous improvement by flowing the product at the pull of the customer in pursuit of perfection”
- Requires buy-in from all staff in the organization, especially frontline staff
Key concepts:
- Value-stream mapping: Map of the flow of a product or service through time; used to identify value-added activities, non-value added activities (e.g., activities that contribute to the eight types of waste), processing time, and lead time
- Spaghetti diagram: Map of the flow of a product or service through space; used to identify waiting, unnecessary motion, and transportation/handling
- 5Ss: A set of actions to address issues identified by value-stream mapping and the spaghetti diagram, including:
- Sort: “Distinguish needed items from unneeded items and eliminate the latter”
- Set in order (or simplify): “Keep needed items and set them in order so they are easily accessible”
- Shine (or sweep): “Keep the work area swept and clean”
- Standardize: “Standardize clean-up”
- Sustain (or self-discipline): “Make it a routine to maintain established procedures”

8 types of wate mnemonic: MOU - TIDE - W

1. Inventory: Inventory or information that is being stored or not being processed likely due to line imbalance or overproduction
2. Overproduction: Producing more product than what is required to meet current demand
3. Unrecognized talent: Failure to effectively engage employees in the process and fully utilize their knowledge and skills
4. Motion: Unnecessary motion of personnel, equipment or information due to inadequate workspace layout, missing parts or tools and ergonomic issues
5. Transportation: Transporting items or information that is not required to perform the process from one location to another
6. Waiting: Time waiting for parts, tools, supplies or the previous process step
7. Defects: Non-conforming products or services requiring resources to correct
8. Extra processing: Activity that is not adding value or required to produce a functioning part, product or service

Question 233

What are 3 categories of policy instruments?

What are 5 mechanisms for implementing a policy instrument?

How do governments decide which policy instrument to use?

Answer 233

In summary, policy instruments include:

Regulation/Deregulation/Legislation
Taxation/Tax credits/Subsidies
Information campaign/media
Spending on socioeconomic services or built environment

Policy instruments: “Set of techniques by which governmental authorities wield their power in attempting to ensure support and effect social change”

• *Categories of policy instruments:**
• Incentives (carrots)
• Disincentives (sticks)
• Information campaigns (sermons)

Mechanisms for implementing policy instruments:
- Legislation and regulation
- Constitution
- Court ruling
- Institutional rules
- Arbitration
- Inaction: Non-decision becomes policy “when it is pursued over time in a fairly consistent
way against pressures to the contrary”

How do governments decide which policy instrument to use?
- Effectiveness: “Degree of goal-realization”
- Efficiency: “Input-output/outcome ratio”
- Legality: “degree of correspondence…with the relevant formal rules as well as with
principles of proper (administrative) process)
- Democracy: “accepted norms as to government-citizen relationships in a democratic
political order”
- Legitimacy: Degree to which policy instrument choice is viewed as just

Question 234

What are workplace health programs?

What are components of a comprehensive workplace health program?

Describe the steps of the CDC workplace health model.

Answer 234

Workplace health programs
Definition: A coordinated, comprehensive set of strategies, including programs, policies,benefits, environmental supports, and community linkages, that meet the health and safety needs of all employees
Examples: Educational classes, fitness facility access, tobacco-free policies, healthy food choices in vending machines

Comprehensive workplace health program (CHOP)

Community engagement
Health promotion
Occupational health and safety
Psychosocial work environment

CDC Workplace Health Model
Assess (e.g., informal conversations, call for input, employee health survey, environmental
audit)
- Individual (e.g., lifestyle choices)
- Organization (e.g., physical working conditions, social support)
- Community (culture, policies, practices)
Plan and manage (including governance structure, strategic direction, champions,
communications)
- Leadership support
- Management
- Workplace health improvement plan
- Dedicated resources
Implement
- Programs (to begin, change, or maintain health behaviours)
- Policies (informal or formal written statements that protect or promote health)
- Benefits (part of compensation package, i.e., health insurance)
- Environmental support (physical factors)
Evaluate
- Worker productivity
- Healthcare costs
- Improved health outcomes
- Organizational change (e.g., culture of health)

Question 235

What are religious considerations for vaccines?

Discuss vaccine hesitancy epi in Canada.

Answer 235

Religious considerations in immunization
- God’s will: Some Plain people and practitioners of Dutch or Christian Reform believe
that vaccination interferes with God’s will
- Porcine-derived gelatin is used in Varivax, Zostavax, and MMR as a stabilizer; Islamic
scholars posit that “the transformation of pork products into gelatin alters them
sufficiently to make it permissible for observant Muslims to receive vaccines containing
pork gelatin”; for practitioners of Judaism, non-oral porcine-derived products are
acceptable
- Human cell lines derived from fetal cells from legal abortions that occurred the 1960s
are used in the production of MMR, varicella, hep A, rabies, Quadracel, and Tdap;
vaccines do not contain human cells; the Vatican has affirmed that “‘In the absence of
effective alternatives, individuals may use the morally tainted vaccines,’ and assert that it
is necessary to ‘provide for the good of one’s children,’ including the prevention of
disease where possible.”
- Immunoglobulin immunizations are blood products and may be declined by Jehovah’s
Witnesses

Epidemiology of vaccine hesitancy in Canada
Data from the Childhood National Immunization Coverage Survey, 2013
- Prevalence of parents/guardians reporting that their children had never received an
immunization: 1.5%
- Proportion of parents who agree vaccines are safe: 95%
- Proportion of parents who agree vaccines are effective: 97%
- Proportion of parents with concerns about vaccine side effects: 70%
- Proportion of parents who strongly agree that alternative practices (e.g., chiropractic,
homeopathy) can replace vaccines: 5%
- Between 75-90% of two-year-olds are up-to-date on their immunizations, depending on
the antigen (highest for MMR and polio, lowest for Var)

Question 236

What are the 2 components of capacity?

What are requirements for informed consent?

Answer 236

• *Consent and capacity**
• Capacity: Assumed to exist unless demonstrated otherwise; required to give consent; 2 components:
• Ability to understand information relevant to making a decision about treatment in question
• Ability to appreciate reasonably foreseeable consequences of a decision/lack of decision

- Requirements for consent:

• Capacity related to question at hand
• Informed [full and detailed disclosure of information (test/study, risks), without fraud or misrepresentation]
• Voluntary
• Types of consent:
• Express: Directly given orally or in writing; requires no inference
• Implied: Circumstances such that a reasonable person would believe consent has been given, but has not been explicitly; requires inference

Question 237

What are the levels of disease control?

What are reasons for disease emergence?

Answer 237

Levels of disease control

• Control: Reduction of disease incidence, prevalence, morbidity, or mortality to a locally acceptable level; continued intervention is required to maintain control (e.g., diarrheal diseases in North America)
• Elimination: Reduction to zero of the incidence of disease or infection in a geographical area; continued intervention is required to maintain elimination (e.g., measles, rubella, congenital rubella syndrome in Canada)
• Eradication: Permanent reduction to zero of the worldwide incidence of infection; interventions no longer needed (e.g., smallpox) - Indicators of eradicability: A disease is eradicable if there is an effective intervention, a sensitive and specific diagnostic tool is available to detect transmission, and humans are essential for the life cycle of the agent (i.e., no other vertebrate reservoir, no environmental amplification) - Other considerations for pursuing eradication: Cost-effectiveness analysis, social and political commitment, public health importance, equity
• Extinction: The specific infectious agent no longer exists in nature or in the laboratory (currently no examples)
• Re-emergence: A disease experiences resurgence because of changed host-agentenvironment conditions *Memory trick: Levels of disease control.

Reasons for emergence:

Microbial resistance
Climate change
War
Poverty
International travel
Changes in land use
Vector migration
Human susceptibility

Question 238

How does a bill become a law in Canada?

Answer 238

Legislative process (how a bill becomes a law)
1. Policy proposal: Submitted to and considered by Cabinet; if Cabinet approves, a bill is
drafted
2. First reading: Presentation of the bill to the House of Commons
3. Second reading: Debate of the principle of the bill; if the principle is adopted, it moves to
committee
4. Committee: The committee hears witnesses, examines the bill clause by clause, and
suggests amendments
5. Report stage: The committee reports its amendments to the House of Commons; House
votes for or against amendments
6. Third reading: Amended bill is reviewed in the House of Commons for the final time
(debate, then vote)
7. Senate: The bill goes through first, second, committee, and third readings again within
the Senate
8. Royal Assent: From Governor-General; bill becomes a law

Question 239

Describe basic facts about MERS-CoV

Organism, Reservoir, Mode of transmission

Incubation period, infectious period

Epidemiology

Presentation, Testing

Case management, Contact management

+/- Immunization

Answer 239

MERS-CoV (hot topic)

• *Organism**: Middle East respiratory syndrome coronavirus (MERS-CoV)
• *Reservoir**: Camels
• *Mode of transmission**: Droplet (most commonly in healthcare environments)

Epidemiology:
- First identified in Saudi Arabia in 2012; almost 2,000 cases between 2012 and
2017
- Case-fatality rate of approx 35%
- Majority of cases have occurred in Saudi Arabia, although cases have been
reported in 27 countries (as of Mar 2017) and a large outbreak occurred in the
ROK in 2015
- No evidence of sustained human-to-human transmission
- No cases of MERS in Canada

Presentation: Severe, acute respiratory symptoms; usually pneumonia +/- GI symptoms
+/- shock; mild and asymptomatic infections are possible

Incubation period: 2-14 days (mean: 5)

Testing: NPS and throat swab, lower respiratory samples, stool sample for PCR; acute
and convalescent sera for serology

Case management: Supportive care
Contact management: Contacts with unprotected exposures required daily assessments
for respiratory symptoms and fever x 14 days + acute (immediately post-exposure) and
convalescent (21 days post-exposure) sera

Question 240

Describe the project management triangle of constraints.

Answer 240

Program planning

The project management triangle (aka “the iron triangle”; aka “triple constraints”; aka “You can
have it good, fast, or cheap: pick two”) defines the constraints imposed on project management
(or program development).

• *Constraints:**
• Scope = Program features, number of clients served, geography served, + quality + resources
• Cost = Budget
• Schedule = Time available, required date of completion

Changes to any one of the corners of the triangle affects at least one other part of the triangle.
Typically, at least one of corners is fixed, which requires changes to the other corners. For example, a fixed budget might require a reduction in project scope, a reduction in quality, or postponing the completion date.

Question 241

Describe relevant social determinants of health for indigenous peoples

Answer 241

Summary cause and effect:

Indigenous race
↓
Colonial practices (residential schools, 60s scoop, dog slaughter, etc)
Systemic racism in healthcare, legal system and education
Environmental destruction
↓
Social and cultural disruption
Intergenerational trauma
Poverty
Poor living conditions
↓
Health disparities

Discrimination, institutionalized racism

• Indian Department: “I want to get rid of the Indian problem…Our object is to continue
  until there is not a single Indian in Canada that has not been absorbed into the body
  politic and there is no Indian question, and no Indian Department.” (Duncan Campbell
  Scott, Deputy Superintendent of Indian Affairs, 1920)
• Pass laws: Indigenous persons not permitted to leave their reserves without a pass from
  the Indian Agent
• Voting disenfranchisement: “Status Indians” living on reserve were not granted the right to vote
  until 1960
• Lack of court access: Indigenous persons not permitted to consult a lawyer regarding or
  use courts to enforce their rights until 1951
• Banning of traditional ceremonies under the Indian Act

Collective traumas
- Residential schools: Implemented in 1880s, last school closed in 1996; mandatory
attendance for children ages 6-16 years to “acquire the habits…of civilized people” -
Public Works Minister Hector Langevin, 1826-1906; attended by approx 150,000
children; resulted in systemic physical and sexual abuse, infectious disease outbreaks,
and undernutrition.“In many communities, a significant proportion of children attended residential
school. Thus to the extent they experienced abuse and neglect, this would affect
not only themselves as individuals, but also the fabric of their community. To the
extent that children experienced maltreatment, this would increase their risk of
engaging in poor parenting and negatively affecting their children. Thus, the harm
caused by the schools is passed on to future generations…. We would expect
that children who attended residential school and were exposed to multiple
traumatic events would be at greater risk for becoming aggressive adults, which
would place their children at risk for the intergenerational transmission of
violence.” - Rosemary Barnes and Nina Josefowitz, quoted by Rupert Ross
- Foster care: Half (48%) of all children in foster care in Canada are Indigenous children;
4% of all Indigenous children are in foster care (2013)
- Missing and murdered Indigenous women and girls (MMIW): Indigenous women are
overrepresented among Canada’s murdered and missing women; there have been
1,181 Indigenous women who have been murdered or gone missing since 1980; similar
to other missing and murdered women, most homicides were committed by men who
knew their victims
- Lateral violence: Occurs when a group experiences oppression and redirects
internalized powerlessness against other members of the same oppressed group;
“Lateral violence is a learned behaviour as a result of colonialism and patriarchal
methods of governing and developing a society” (NWAC, 2015)

• Suicide rate 30/100,000 (compared to 11/100,000 general population

Material deprivation

• Higher unemployment rate, 15% unemployed (compared to 6% general population
• Food insecurity
• Living in low income, 30% living in poverty (compared to 15% general population)

Question 242

Describe how to calculate:

• Sensivity, specificity
• Positive predictive value, negative predictive value
• Likelihood ratios
• Receiver-operating characteristic (ROC) curve

Answer 242

• Sensitivity (aka true positive rate): Ability of a test to detect true disease (probability
  that an individual with a disease tests positive)
  sens = true positives / everyone who has the disease
  = a / a + c
• SnOut: A negative sensitive test rules out a disease
• False negative rate: 1 - sens
• Specificity (aka true negative rate): Ability of a test to correctly identify those without a
  disease (probability that an individual without a disease tests negative)
  spec = true negatives / everyone without the disease
  = d / d + b
• SpIn: A positive specific test rules in a disease
• False positive rate = 1 - spec
• Positive predictive value (PPV): Probability that someone with a positive test has a
  disease; positive predictive value decreases as prevalence decreases (“falling
  prevalence leads to false positives”)
  PPV = true positives / all positive tests
  = a / a + b
• Negative predictive value (NPV): Probability that someone with a negative test does
  not have a disease
  NPV = true negatives / all negative tests
  = d / c + d
• Likelihood ratio: Probability of an individual with the condition having the test result /
  probability of an individual without the condition having the test result; LRs are
  interpreted as described in the table below, and can be used to estimate the odds of
  disease as follows:
  Odds of disease given a positive test = pre-test odds x LR+
  Odds of disease given a negative test = pre-test odds x LRLR
  Interpretation
  >10 Often conclusive increase in the likelihood of disease
  5-10 Moderate increase in the likelihood of disease
  2-5 Minimal to small increase in the likelihood of disease
  1 No chance in the likelihood of disease
  0.2-1 Minimal to small decrease in the likelihood of disease
  0.1-0.2 Moderate decrease in the likelihood of disease
  <0.1 Often conclusive decrease in the likelihood of disease
• Positive likelihood ratio (LR+): Probability of an individual with the condition
  having a positive test / probability of an individual without the condition having a
  positive test; sensitivity/1-specificity
• Negative likelihood ratio (LR-): Probability of an individual with the condition
  having a negative test / probability of an individual without the condition having a
  negative test; 1-sensitivity/specificity
• Receiver-operating characteristic curve (ROC curve): Graph of the true positive rate (sensitivity)
  along the y-axis and false-positive rate (1-specificity) along the x-axis; area under the ROC curve
  approximates accuracy of the test (i.e., the closer to 1, the better)

Question 243

What are basic facts about hepatitis B?

Organism, reservoir, mode of transmission

Incubation time, infectious time

Epidemiology, risk factors

Presentation, testing

Case management

Contact management

Vaccine

Screening

Answer 243

Hepatitis B (reportable, VPD)

• Organism: Hepatitis B virus (orthohepadnavirus)
• Reservoir: Humans
• Mode of transmission: Contact (percutaneous or mucosal), vertical; *HBV is much more infectious than HIV or HCV
• Epidemiology:
• Prevalence of chronic HBV in Canada < 1% (immigrants from endemic countries account for 70% of chronic infections in Canada)
• _Higher-risk groups: Indigenous peoples, MSM, street-involved youth, prisoners
• Risk factors: 1) unimmunized household contact of HB carrier, 2)adult with unprotected sexual activity, sharing IVDU equipment, needlestick, bite._
• 90% of infants, 30-50% of children, and 5% of adults who are acutely infected
  become chronically infected
• Presentation:
• 50-70% of adults are asymptomatic; most children and infants are asymptomatic
• Insidious anorexia, fatigue, abdo discomfort, fever, jaundice; 1-2% of infections
  result in fulminant hepatitis
• 15-50% of chronically-infected individuals will develop cirrhosis, end-stage liver
  disease, or hepatocellular carcinoma
• Chronic infection is usually asymptomatic
• Incubation period: 45-180 days (communicable when HBsAg is detectable)
• Testing: Recommended for individuals with findings suggestive of chronic liver disease
  or acute hepatitis (see also screening below)
• HBsAg: Protein on surface of virus; detection of HBsAg indicates that an
  individual is HBV+ and infectious (HBsAg is used to make the HBV vaccine); up
  to 50% of individuals with chronic infection with clear HBsAg
• HBeAg: Soluble protein “envelope” contained in the viral core; presence indicates
  high infectivity
• Anti-HBs: Antibodies produced in response to HBsAg, either due to natural
  infection or immunization; indicate immunity to HBV; titres may decline to
  undetectable levels, but individual may retain anamnestic immunity (titre > 10
  IU/mL indicate definitive immunity)
• Anti-HBc (total):Antibodies produced in response to HBcAg; indicates previous or
  current HBV infection
• Anti-HBc (IgM): IgM antibodies produced in response to HBcAg; IgM only
  produced during the first 6 months of HBV infection (or flares), so the presence of
  anti-HBc (IgM) indicates acute infection (or flares of chronic disease)
• Anti-HBe: Antibodies produced in response to the viral envelope; indicates
  current infection and low infectivity
• Case management: Safer sex until contacts immunized, no blood donation
• Contact management: Contacts include household members, sexual contacts,
  individuals exposed to body fluids, and infants born to HBV+ mothers; for all susceptible
  contacts:
• Infants born to HB-infected mothers: Vaccine + HBIg
• Persons exposed to potentially infectious body fluids: Vaccine + HBIg (see
  complicated chart in CIG for vaccinated contacts)
• Household contacts: Vaccine only
• Treatment: No cure, but antivirals and immunomodulators can reduce viral replication,
  reducing liver damage in chronic HBV
• Screening: Recommended for high-risk groups (immigration from or travel to
  intermediate or high endemicity country, family history, IVDU, transfusion prior to 1970,
  occupational exposure, incarceration) and individuals at high risk of complication
  (pregnancy, HIV or HCV infection, planned immunosuppressive therapy)
• Vaccination: Recommended for all children and high-risk groups
• Other: Hepatitis D (hepatitis delta) is a subviral satellite of hepatitis B (can only replicate
  in the presence of HBV); results in worse outcomes than HBV alone

Question 244

What entities make recommendations about vaccines in Canada?

Answer 244

Recommendation
- National Advisory Committee on Immunization (NACI): Expert committee that
recommends vaccines for use to the Chief Public Health Officer of Canada, based on
evidence (burden of disease, vaccine characteristics), focusing on the individual patient
(*starting Feb 2017, NACI will consider cost-effectiveness*)
- NACI recommendations are considered the standard of care; physicians should
advise patients of NACI-recommended vaccinations, whether or not the
vaccination is publicly-funded

• Canadian Immunization Committee (CIC): Representative committee made up P/T
  public health representatives; takes NACI recommendations and then considers the
  economic impact, feasibility, ethics of immunization programs; supposed to harmonize
  the immunization schedules across the country; ultimately reports to the Public Health
  Network Council
• Provincial Infectious Disease Advisory Committee-Immunization (PIDAC-I):
  Recommends vaccines for use in Ontario to the Ministry of Health and Long-term Care,
  considering local burden of disease, effectiveness/efficacy, cost-effectiveness, feasibility,
  ethics, and political implications (BC and Quebec have similar committees; some smaller
  provinces use CIC’s work instead)

Question 245

Describe the 5 stages of disease prevention and provide an example for each

Answer 245

Stages of disease prevention
- Primordial prevention: Prevent exposure to risk factors for disease by addressing the
determinants of health (e.g., improved sanitation, early childhood development
programs)
- Primary prevention: Prevent disease by reducing exposure to risk factors (e.g.,
smoking cessation, vaccination, fluoridation)
- Secondary prevention: Prevent disease progression through early identification and
treatment (e.g., blood pressure screening, mammography screening)
- Tertiary prevention: Prevent disease from impacting function, longevity, and quality of
life (e.g., cardiac rehabilitation following MI, weight loss following diagnosis with DMII)
- Quaternary prevention: Decrease harms related to medical care; prevent
overmedicalization and unnecessary medical testing or treatment, especially in the
context of death and dying

Question 246

What is the post-exposure treatment to anthrax?

Answer 246

Vaccine, doxy/cipro

Question 247

What are recent trends in Canadian cancer epidemiology?

What cancers are most frequent and most deadly among men and women in Canada?

Answer 247

Canadian cancer epidemiology
- Cancer is the leading cause of death in Canada
- 2 in 5 Canadians will develop cancer
- 1 in 4 Canadians will die of cancer
- Most common cancers in Canada are lung, breast, colorectal, and prostate
- Cancer is the leading cause of PYLL in Canada because deaths occur at a younger age
and more quickly than deaths due to other diseases
- Lung cancer is still the leading cause of cancer deaths in Canada, even though the
incidence of lung cancer is declining
- 89% of cancers occur in Canadians > 50 years of age

Breast ~1/9
Colon ~1/8
Lung ~1/7
Prostate ~1/7

• Bladder cancer: Little change in incidence since 2001; most cases attributed to smoking
  or occupational exposure to chemicals (aromatic amines, PAHs, and diesel exhaust)
• Uterine cancer: Incidence is increasing; risk factors include unopposed estrogen,
  obesity, genetic predisposition, diabetes, chronic anovulation, HNPCC; protective factors
  include increasing number of pregnancies and shorter menstrual lifespan
• Larynx cancer: Incidence is decreasing; decrease attributed to declines in alcohol and
  tobacco use
• Liver cancer: Incidence is increasing; increase attributed to immigration from areas with
  more frequent risk factor exposure (hep B, hep C, aflatoxin)
• Melanoma: Incidence is increasing; risk factors include UV radiation, fair complexion,
  immunocompromisation, history of blistering sunburns, family history
• Stomach cancer: Incidence is declining; decline attributed to improvement in diet,
  reduction in alcohol and tobacco use, and treatment of H. pylori infection
• Thyroid cancer: Incidence is rapidly increasing; increase attributed to overdiagnosis,
  exposure to diagnostic ionizing radiation

Question 248

Describe 5 healthy lifestyle behaviors during pregnancy

Answer 248

Health behaviours in pregnancy
Nutrition
- Avoid foods that may be contaminated with L. monocytogenes (hot dogs, deli meats,
refrigerated pate, refrigerated smoked seafood and fish, unpasteurized cheese, soft
pasteurized cheese)

• Avoid alcohol

Physical activity
- Maintain physical activity throughout pregnancy; any activity that feels comfortable is
appropriate for low-risk pregnancies
- As pregnancy progresses, replace high-impact activities (running, tennis) with lowerimpact
activities (swimming)

No smoking
- Smoking or being exposed to second-hand smoke during pregnancy reduces oxygen
delivery to the fetus → lower birth weight, preterm birth, placental abruption, and
increased the risk of miscarriage; also increases risk of childhood asthma, SIDS, and
cleft lip/palate

Oral health

• Periodontal disease increased the risk of pre-term birth and low-birth weight
• Pregnancy increases bleeding from brushing and flossing

Caffeine
- Max. 300 mg caffeine/day while pregnant (about 2 cups of coffee)

Question 249

Describe the following spatial representations:

graduated symbol map,

choropleth map,

and interpolated grid map (aka heat map).

Answer 249

Spatial analysis
Representations of spatial data
- Raster: A grid, where each square holds a value
- Discrete raster: Values that each square can hold are discrete (e.g., forest, field,
water)
- Continuous raster: Values that each square can hold are continuous (e.g.,
average land temperature)
- Vector: Data composed of vertices and paths
- Vertice (point): A single, dimensionless object (XY coordinate)
- Line: Path connecting a series of points
- Polygon: Area bounded by a set of lines

Types of maps
Graduated symbol map: Location of points on map; size of point indicate some characteristic
about that event

Choropleth map: Data are aggregated by area and the summary statistic is assigned to a
spatial location; the colour of the area indicates the magnitude of the summary statistic

Heat map (aka interpolated grid map): Visual representation of continuous data; sample
measurements are taken at specific locations; data between measurement sites is interpolated

Question 250

Related to hypothesis testing, define:

• Type 1 error
• Type 2 error
• Confidence interval
• P-value
• Power

Answer 250

Hypothesis testing
- Hypothesis: “A claim or statement about one or more populations”
- Hypothesis testing: “Reaching a conclusion about a population by examining a sample
from that population”; are the available data compatible with the hypothesis?
- Null hypothesis (H0): Condition that is assumed to be true until evidence proves otherwise
- Alternative hypothesis (Ha): Usually the same as the research hypothesis
- Possible conclusions to hypothesis testing: 1) reject the null hypothesis OR 2) fail
to reject the null hypothesis

• Type I error: False positive; error of rejecting the null when it is true; once the
  significance level of the hypothesis testing is set, this is equivalent to the significance
  level; sending an innocent person to jail (very bad); type I error rate = α
• Type II error: False negative; error of not rejecting the null when the null is false; setting
  a guilty person free (bad, but not as bad as jail); type II error rate = β. Type I and II error are inversely related.
• P-value (α): How unlikely the test statistic result is given the null hypothesis; the
  probability that the difference between the result and the null hypothesis is due to
  chance, probability of obtaining results at least as extreme as the observed result assuming that the null hypothesis is correct
• For normal distributions, general equation for calculating the p-value is the
  difference between the test statistic (z) and the null hypothesis (H0) / the standard
  error (SE); i.e., does standard error account for the difference between the
  observed and hypothesized value?
• How often are we willing to make a type I error? (usually 1 in 20 times, or at least
  so says RA Fischer)
• “A statistically significant difference is not necessarily an important difference”; if
  a sample is large enough, it is possible to distinguish between very similar
  population means
• Confidence interval (explanation based on 95% CI): Range that would contain the true
  population mean for 95% of the random sample we could get; “if we were to take 100
  random samples each of the same size, approximately 95 of the CIs would include the
  true value of the population mean”
• 95% of the CIs would include the true value; not “there is a 95% chance that the
  CI includes the true value”
• For continuous distributions, the probability of a statistic being the same as the
  parameter of interest is 0 (because there are infinite numbers in a continuous
  distributions)
• Wider intervals𝛼 more confidence 𝛼 less precision
• Power: The probability of NOT making a type II error; power=1-β

Steps for hypothesis testing:
1. State the hypotheses (null and alternative)
2. Specify the significance level
3. Compute the test statistic based on the sample data
4. Compute the p-value, compare it to the significance level alpha, and decide whether or
not to reject the null
5. State conclusions in terms of subject matter

Question 251

Define policy.

What are the determinants of policies?

What does healthy public policy mean?

Answer 251

Definitions
- Policy: Statutes, laws, regulations, executive decisions, and government programs;
governmental or organizational decisions that determine the boundaries of what is
acceptable or allocate resources
- Regulations: Details on implementing legislation; developed by Cabinet

• Determinants of policy:
• 3 Is: Interest, ideas, and ideologies
• 3 Ps: Politics, policy options, and problems
• Public health policy: Policy focusing on health at the population level or reduce health
  inequities
• Health policy: Policy focusing on health services and healthcare delivery
• Healthy public policy: Policy that “improves the conditions under which people live:
  secure, safe, adequate and sustainable livelihoods, lifestyles, and environments,
  including housing, education, nutrition, information exchange, child care, transportation,
  and necessary community and personal social and health services” (i.e., policies that
  improve the social determinants of health; see also Ottawa Charter)
• Evidence-based policy: Policy based on the best available research evidence; applies
  evidence-based medicine techniques to policymaking
• Probably not a thing IRL; evidence is “often used after the fact to bolster one’s
  own points”; instead, policy is more likely shaped by factors external to the policy
  subsystem, the formal and informal decision-making process, values, beliefs, and
  interests
• Evidence-informed policy: Policy that takes the best available research into account,
  recognizing that local context is important and that policymaking does not occur in the
  linear fashion assumed by EBM techniques
• Path dependency: An earlier policy decision determines the future possible policy
  options available (e.g., once you’ve laid a railroad of a certain gauge, you can only select
  from a certain number of train engines)

Question 252

What are the component of integrated pest management?

What are federal, providincial and municipal regulations regarding pesticides?

Answer 252

Integrated pest management: Four-tier approach to controlling pests based on prevention,
monitoring, and control
1. Identify and monitor
2. Set action thresholds: Nuisance, health hazard, economic threat
3. Prevent (e.g., reduce clutter, remove trash and overgrown vegetation, install barriers,
remove standing water)
4. Control (e.g., pest trapping, heat/cold treatment, physical removal, pesticide application)

Regulation
At Federal level: Pest Control Products Act
- Pest Management Regulatory Agency registers pesticides for certain uses
- Each regulated pesticide is reviewed every 15 years (or sooner, if new science emerges)
- Pest Management Regulatory Agency considered toxicology (short-term, long-term,
carcinogenicity), occupational exposure, and food residue exposure

Provinces are responsible for:
- Transportation, sale, use, storage/disposal
- Training/certification and licensing of applicators/vendors
- Managing spills/accidents
- Permits/use restrictions
- Compliance and enforcement

Municipalities may have the authority to:
- Apply bans on cosmetic use

Question 253

Regarding prevention approaches, compare and contrast the:

population approach, high-risk approach, targeted universalism, and proportionate universalism

What is the prevention paradox?

Answer 253

Population approach: Identify an intervention that will lower the whole distribution of the risk
variable (“shift the curve”); this is successful a successful approach at the population level, but
will only accrue small benefits to individuals
- The population approach leads to the prevention paradox: “A measure that brings large
benefits to the community offers little to each participating individual” - Geoffrey Rose
- Because gains to individuals are small, it is challenging to motivate individuals (and their
providers) to participate in population health programs

High-risk approach: Traditional medical approach; identify those at greatest risk of mortality
and provide them with preventive care (e.g., provide anti-hypertensives to individuals with
severe hypertension to reduce their risk of death due to MI) (“truncate the curve”); this is a
successful approach at the individual level, but because most deaths occur in in moderate-risk
individuals, this approach will not reduce mortality at the population level
- The high-risk approach can be ineffective because: “a large number of people at a small
risk may give rise to more cases of disease than the small number who are at high risk” -
also Geoffrey Rose
- Adverse costs are only born by those benefiting from the intervention
- Does not address the underlying cause of disease
- High risk of disease is often a result of inequitable distribution of health determinants; a
high-risk approach, when implemented correctly, best addresses health inequities

Targeted universalism: A blend of the population and high-risk approach; universal program
implemented, but high-risk populations identified and specific strategies are employed to ensure
the high-risk population can access the universal program (e.g., universal influenza
immunization program with a special outreach strategy for seniors)

Proportionate universalism: A blend of the population and high-risk approach; range of
programs targeting the same risk factor or outcome, with resources devoted to the programs in
proportion to the risk faced by the population targeted by that program

Question 254

What are the different forms of botulism?

Answer 254

Botulism
- Disease resulting from potent neurotoxin produced by Clostridium botulinum
- C. botulinum is ubiquitous in the soil, but neurotoxins are only produced in conditions
that promote spore growth
- Incubation period: 2 hours - 8 days
- Presentation: Descending paralysis, cranial nerve dysfunction (ptosis, blurred vision,
dysarthria, dysphagia), ventilatory failure; AFEBRILE, mental status preserved

• Forms:
• Foodborne: Ingestion of pre-formed toxin (e.g., in home canned foods)
• Wound: Contamination of wound with spores that then produce toxins
• Gastrointestinal: Ingestion of spores that then form the toxin in the colon; results
  in N/V, diarrhea in addition to other symptoms
• Infant: Presentation dissimilar to adults; due to ingestion of spores and then
  production of toxin in the person; includes poor suck, weak cry, weakness, loss
  of heald control
• Iatrogenic: Excessively high amounts of unapproved botulinum toxin injected for
  medical indications (Botox)
• Inhalational: Due to inhalation of aerosolized neurotoxin; has only happened
  once (in lab workers); theoretically could be used in a bioterrorism attack
• Treatment: Antitoxin (cannot reverse paralysis; only “mops up” unbound toxin) or
  botulism Ig
• Post-exposure prophylaxis: Antitoxin or botulism Ig for asymptomatic people strongly
  suspected of having eaten food contaminated with botulism toxin
• Not contagious

Question 255

What is the post-exposure prophylaxis for plague?

What are different types of plague?

Answer 255

Doxy/tetra/cipro x 7 days

Bubonic, septicemic, pneumonic types

Question 256

Compare and contrast different chemical agents

(nerve agents, blister/vesicant agents, cyanide, pulmonary irritants)?

What are key messages for chemical incidents?

Answer 256

Chemical incidents

Definitions

• Chemical incident, WHO definition: The uncontrolled release of a toxic substance resulting in the (potential) harm to public health and the environment
• Chemical incident, Health Canada definition: An abnormal event where actual orpotential human population exposure to one or more chemicals requires prompt action to save lives, reduce personal injuries, and protect and maintain public health
• Chemical warfare agent: Agent with no legitimate commercial application; the Chemical Weapons Convention prohibits production and use; usually challenging to produce and use
• *Chemical agents**
• Nerve agents: Most nerve agents interfere with acetylcholinesterase, disrupting nerve impulses and resulting in paralysis (e.g., organic insecticides, sarin gas, VX)
• Antidotes: Atropine, pralidoxime (2-PAM); large doses are required and may deplete a hospital’s entire stock if there are multiple casualties
• Blister/vesicant agents: Cause c_hemical burns to exposed tissues, including skin and airways_; results in pain, difficulty breathing, and difficulty seeing (e.g., mustard gas, lewisite)
• Cyanide: Interferes with cellular respiration, which can result in death
• Antidotes: Sodium nitrite, sodium thiosulfate, amyl nitrite
• Pulmonary agents/respiratory irritants: Cause lung injury if inhaled (immediate or delayed); can also cause eye irritation (e.g., chlorine, phosgene)

Sources of chemical agents

• Terrorism (e.g., Aum Shinrikyo, 1993 World Trade Centre bombing destroyed cyanide intended to contaminate the building)
• Military stockpiles (e.g., nerve agents, vesicants)
• Military use (e.g., Iraq government attack on its Kurdish population in 1980s)
• Industrial accidents (e.g., phosgene, cyanide, chlorine)

Case studies
- 1995 Aum Shinrikyo attack on Tokyo subway: Release of sarin gas in 5 subway trains during rush hour by the Aum Shinrikyo cult, affecting almost 3,800 and killing 12
- 1979 Mississauga train derailment: A mechanical problem led to the derailment of a train carrying propane, chlorine, styrene, and toluene, resulting in fires, explosions, and the evacuation of more than 200,000 people, six nursing homes, and 3 hospitals
- 2008 Sunrise Propane explosion in Toronto: Hose failure during a tank-to-tank transfer resulted in a major explosion, damaging the nearby neighbourhood and
releasing smoke and asbestos into the environment
- 2013 Lac Megantic train derailment: A train with almost 80 oil tank cars rolled from its nightstop location and derailed on a sharp curve in Lac Megantic, resulting in fire, explosions, 47 deaths, and the evacuation of 2,000 people

Shelter-in-place messaging for chemical emergencies: “Get inside, stay inside, and stay tuned”

1. Get inside right away.
2. Close and lock all windows and doors, then seal with plastic and duct tape if available.
3. For heavier-than-air gas leaks, seek shelter in the highest level of the building.
4. Turn off fans, air conditioners, and forced-air heaters, then seal with plastic and duct tape if available.
5. Turn on the radio and keep your phone charged. SMS text messaging usually more likely to work in an emergency than voice calls.
6. Drink stored water, not tap water.

Question 257

What are steps to developing a health communication campaign?

Answer 257

In summary:

Manage: Stakeholders, timeline, scope, resources

Assess: Situation, evidence-base, audience analysis

Plan: objectives, logic model, strategies, key messages

Implement: communication materials, launch

Evaluate

Mass media campaigns

• *Health communication**: Process of promoting health by disseminating messages through mass media, interpersonal channels, and events
• *Mass media health communication campaign**: Goal-oriented attempt to inform, persuade, or motivate behaviour change in a large, well-defined audience through health communication

WHO social marketing steps:

1. Background, purpose, focus
2. Situation analysis (SWOT, lit review)
3. Target audience profile (demographics, psychographics, geographics, relevant behaviors, social networks, community assets, stage of change, size of target audience)
4. Marketing objectives and goals
5. Factors influencing adoption of the behavior (perceived barriers, potential benefits, competing behavior, influece of important others)
6. Positioning statement
7. Marketing mix strategies (4Ps - product, price, place, promotion)
8. Plan for monitoring and evaluation
9. Budget
10. Plan for campaign implementation and management (partner roles)

• *PHO’s 12 steps to developing a health communication campaign**
  1. Project management: Identify stakeholders, establish a timeline, identify data needs
  2. Health promotion strategy: Develop a logic model
  3. Audience analysis: Develop an understanding of your audience demographics, psychographics (e.g., values, beliefs, role models), and behaviours (e.g., intentions, selfefficacy, skill level)
  a. Segmentation: Process of breaking down a large audience into subgroups that are as homogenous as possible
  4. Communication inventory: What communication resources are available to your organization?
  5. Communication objectives: Identify objectives for the campaign at the societal, organizational, network (e.g., family network, friend network), and individual level
  6. Select channels and vehicles: Based on reach, cost, and effectiveness
  a. Channel = Means by which message is sent (e.g., friend, TV, radio)
  b. Vehicle = Format used to deliver message (e.g., commercial, fb page, interview)
  7. Combining and sequencing: E.g., will the campaign build to a grand finale or have a big first event? Will it mix high- and low-visibility activities? Will it change with the season?
  a. Rule: 3 messages, 3 times, 3 different ways
  8. Develop the key message: What? So What? Now what?
  9. Develop project identity: Name, position statement, logo, images, etc.
  10. Production of materials
  11. Implementation
  12. Evaluation

The US Community Preventive Services Task Force recommends health communication campaigns that use multiple channels (one of which must be mass media) and are c_ombined with the distribution of free or reduced-price health-related products_ (e.g., condoms, NRT)

Question 258

What are conflict of interests and how can they be managed?

Answer 258

Conflict of interest
- Conflict of interest: Personal, financial, professional, or political interests that may
impact professional judgment or actions (Note: “Non-financial interests can be especially
problematic because they are less easily recognized and so less understood”)
- Real/actual COI: “The interest actually influences professional judgement (e.g.,
hiring a family member instead of the best candidate for a position)”
- Potential COI: COI or the appearance that COI could occur (e.g., a physician
solicited by industry representatives for a meeting)
- Apparent COI: “No actual bias or failure in judgement, but could be perceived as
such (e.g., member of an expert panel alongside industry representatives)”

• COI is not unethical if it is managed properly, but “individuals view themselves as moral,
  competent, and deserving and this view obstructs their ability to see and recognize
  conflicts of interest when they occur”
• Steps to identifying and managing COI:
• Awareness: Understanding that COI is a problem, COI involves both financial
  and non-financial interests, some COI is unavoidable
• Identification: Be aware and reflexive about your interests and responsibilities
  (e.g., consider what influences your decision-making, question your objectivity);
  the greater the risk the COI poses, the more preferable it is to have an external
  party identifying COI
• Evaluation: Determine the potential impact of the COI on the process
• Manage: Steps to mitigate COI:
• Avoid COI
• Disclose COI; consider how you will disclose and to whom
• Exclude/recuse yourself
• Addressing COI enhances:
• Quality (of research, teaching, judgment, service provision, etc.)
• Public trust (in professionals, research findings, scientific process, etc.)

Question 259

What are 5 different purposes for policy analyses?

What are 7 parameters for policy analysis?

Answer 259

Policy analysis
What is the role of public health actors in policy analysis?
Public health actors usually do not make policy decisions. Instead, policy analysis may be
undertaken in public health to:
1. Inform a decision-maker: Neutrally provide evidence about a single policy, or to use
evidence to compare multiple policy options
2. Advocate for the adoption of a particular policy: Promote a policy option that accords
with your organization’s mission
3. Evaluate policy

• *Types of policy analysis**
  1. Descriptive: What happened? (e.g., description of the development and implementation of the IHR 2005)
  2. Explanatory: Why did it happen? (e.g., why was the IHR 2005 developed and implemented?)
  3. Evaluative: Did it work? (e.g., did the implementation of the IHR 2005 reduce the risk of the international spread of disease?)
  4. Predictive: What will happen? (e.g., will the IHR 2005 continue to be effective in an increasingly globalized world?)
  5. Prescriptive: What should happen? (e.g., how can the IHR 2005 be amended to better address inequities in surveillance?)
  a. Root method: Start at the “roots” of the problem: What are all the contributingproblems? What are all possible outcomes of the the contributing issues? What are all the possible interventions? How does each intervention affect each outcome?
  b. Branch method: Instead of evaluating each possible intervention, only consider feasible interventions (incrementalism suggests that the most feasible options are usually those that are not too much of a departure from the status quo)

Parameters for policy analysis:

EFFECTS: E-U-E

Effectiveness

Unintended effects

Equity

IMPLEMENTATION: C-F-A

Cost

Feasibility

Acceptability

DURABILITY

Sharing policy analysis findings with policymakers: THE POLICY BRIEFING NOTE
Briefing note: A short (<900 word) summary of an issue that includes all facts critical to decision-making; an information management tool that conveys complex information upwards
through an organization; may be written in full sentences or in bullet points, infinite formats (key messages, background, current status, policy options, recommendations, conclusion)

Question 260

Describe the different types of fat.

What are health impacts of fat and available interventions.

Answer 260

• Fatty acids: Carboxylic acid + aliphatic tail
• Saturated: Aliphatic tail has no double or triple bonds (all
  possible hydrogen sites are “saturated”); very stable at room
  temperature and not prone to rancidity, so preferred for
  processed foods; consumption increases LDL cholesterol
  (e.g., dairy products, coconut oil, processed foods)
• Monounsaturated: Aliphatic tail has one double bond;
  consumption reduces total and LDL cholesterol levels (e.g.,
  olive and canola oil, avocados, nonhydrogenated margarine);
  protective against development and progression of CAD
• Polyunsaturated: Aliphatic tail has more than one double
  bond; increasing the number of double bonds increases the
  speed at which the fat goes rancid; consumption reduces total
  and LDL cholesterol levels
• Essential fatty acids: FAs that humans cannot
  synthesize, linoleic acid (an omega-6) and alphalinoleic
  acid (an omega-3)
• Trans unsaturated fatty acids: Unlike the other unsaturated
  fatty acids, the double bond that makes trans fats unsaturated
  predisposes trans fats to a linear conformation that promotes
  plaque formation; consumption increases LDL cholesterol and
  reduces HDL cholesterol; usually found in partially
  hydrogenated oil (e.g., packaged cookies and crackers)

*** In september 2018, Health Canada banned partially hydrogenated oils (PHOs)—the largest source of industrially produced trans fats in foods.***

• Cholesterol: Alcohol + steroid

RDI - Insufficient data available to determine a RDI or UL for total fat or
fatty acids; saturated fatty acid, trans fatty acid, and cholesterol
consumption should be as low as possible while still consuming a
nutritionally adequate diet

• Saturated FA, monounsaturated FA, and cholesterol are synthesized
  in the body and are not required in the diet

Prevalence of elevated cholesterol among Canadian adults = 15%

Question 261

What are core elements of hospital antibiotic stewardship programs?

Answer 261

Core elements of hospital antibiotic stewardship programs
- Leadership commitment
- Accountability: Appoint a single physician leader as responsible for program outcomes
- Drug expertise: Appoint a single pharmacist as responsible for improving antibiotic use
- Action: E.g., Antibiotic “time outs”, prior authorization, audit and feedback, automatic
changes from IV to PO
- Tracking: Antibiotic prescribing and resistance
- Reporting: Report tracking results to staff
- Education: Optimal prescribing

Question 262

What are high-risk groups for injuries?

What types of injuries are most common?

Answer 262

• WHO definition of injury: “Physical damage that results when a human body is suddenly
  or briefly subjected to intolerable levels of energy”
• Poisoning, burns, drowning sometimes also included as injuries
• Injury prevention: Eliminating hazards and managing risk while still allowing
  communities to be healthy and active
• Risk homeostasis theory: Suggests that people adapt their behaviour to changes in
  environmental conditions (i.e., the safer the situation, the riskier the behaviour, so the
  overall risk level is always the same)
• The theory also posits that the more an individual values his/her future, the less
  overall risk s/he will be willing to take; interventions that incentivize the future
  (e.g., rewards for safer behaviour) are hypothesized to be the most successful
• *Epidemiology**
• Injury is the leading cause of death amongst individuals ages 1-44 years
• Intentional injuries: 10% of injury hospitalizations
• Inflicted by another (violence, abuse) (3% of injury-related deaths)
• Suicide and self-harm (24% of injury-related deaths)
• Unintentional injuries: 90% of injury hospitalizations
• Transport-related (21% of injury-related deaths): Leading causes of motor vehicle collision (MVC) fatalities are: Speed (33%), Distracted driving (28%), Impaired driving (27%)
• Drowning
• Falls (18% of injury-related deaths; elderly especially at risk)
• Fire
• Poisoning (9% of injury-related deaths)
• Leading causes of injury-related deaths in Canadian children: MVC, drowning, choking
• High-risk groups incurring injuries:
• Adolescents ages 12-19 years (risk of injury is twice as all other age groups)
• Males
• Participants in sports
• Elderly (most commonly due to falls while walking or doing household chores)

Question 263

How are cold chain breaches managed for vaccines?

What are the 8 rights of vaccination?

Answer 263

From PHAC vaccine storage doc:

In the event of a cold chain failure, the following steps should be taken:
Notify the vaccine coordinator or delegate immediately. He/she will implement the Urgent Vaccine Storage and Handling Protocols (see 2.4: Urgent Vaccine Storage and Handling Protocols in Section 2: Vaccine Personnel and Vaccine Storage and Handling Protocols for more details).

Quarantine the affected vaccines within a functional storage unit or cooler, grouping them together and labelling them with a ”Quarantine” sign and the date on which the cold chain break occurred. Alert staff members of the situation to avoid the
administration of these vaccines.

Protect the vaccine supply by keeping it at appropriate temperatures (between +2°C and +8°C [+35°F to +46°F] for refrigerated vaccines and –15°C [+5°F] or colder for frozen vaccines). Continue to monitor the storage conditions.

If a faulty storage unit is the source of the cold chain failure, transfer the supply to an alternative storage unit or a cooler (see Section 9: Vaccine Distribution for instructions on packing a vaccine cooler).

Once the vaccines have been relocated,
identify the source of the malfunction (see Section 6: Storage Troubleshooting for more details). Take appropriate actions to rectify the situation.

Fill out the appropriate forms to report the cold chain break to your jurisdictional/local public health office or immunization program. See 6.1 Steps in Handling Inappropriate Vaccine Storage Conditions (Light and Adverse Temperature Exposure) in Section 6: Storage Troubleshooting for more details).

The information requested on these forms may include the following:
– Date and time the breach occurred (or was first noticed);
– Type of adverse exposure;
– Duration of adverse exposure;
– Site of the exposure (e.g. storage unit, transportation);
– Temperature inside the storage unit;
– Estimated temperature outside the storage unit
(a household thermometer may be used);
– Whether water bottles in the storage unit are still cold;
– Inventory of the vaccines affected and their expiration date;
– Whether vaccines exposed to adverse temperature or light exposure were administered to patients;
– Actions taken to remedy the situation.

Contact your jurisdictional/local public health office or immunization program for further instructions. They will determine whether the vaccine is still safe to use or should be discarded, and whether re-administration of the vaccine to patients is necessary.

Vaccine delivery
Cold chain: Process used to maintain optimal conditions during the transport, storage, and
handling of vaccines, from manufacturer to patient
- Coolers: Pre-chill coolers before transport
- Contingency plan for fridge failure
- Managing cold chain breaches:

Date and time breach occurred,

duration of breach,

point of breach (e.g., storage, transport), inventory, temperature inside and outside the unit;
must call all vaccine manufacturers to assess which vaccines will still provide adequate protection after exposure to the reported temperature for the maximum possible time
Storage
- Store between 2-8 C (most vaccines cannot be used if frozen)
- Refrigerators: Scientific fridge > kitchen fridge > bar fridge > bar fridge with freezer for maintaining consistent temperature
- Thermometers: Data logger (thermometer that logs continuous temperatures for 30-60 days) > min/max (thermometer that shows min and max temp since last check) > current temp (thermometer that only shows current temp); best to keep thermometer probe in
glycol-filled container to assess vaccine temp rather than air temp
Handling
- Plastics in syringes can degrade vaccine; do not pre-load syringes
Administration
- Timing/interference: Live vaccines and TB skin tests must be given at the same time or at least 28 days apart
- The 8 “rights” of vaccination: Right patient, right vaccine, right reason, right dose, right route (oral, IM, SC, ID), right frequency, right time, right site

• *Documentation**
• Record temperatures 2x/day
• Chart vaccine administration: Vaccine type, date given, route and site, vaccine lot and manufacturer, document informed consent, vaccinator’s signature

Question 264

Describe hepatitis B testing serologies

Answer 264

Testing: Recommended for individuals with findings suggestive of chronic liver disease
or acute hepatitis (see also screening below)
- HBsAg: Protein on surface of virus; detection of HBsAg indicates that an
individual is HBV+ and infectious (HBsAg is used to make the HBV vaccine); up
to 50% of individuals with chronic infection with clear HBsAg
- HBeAg: Soluble protein “envelope” contained in the viral core; presence indicates
high infectivity
- Anti-HBs: Antibodies produced in response to HBsAg, either due to natural
infection or immunization; indicate immunity to HBV; titres may decline to
undetectable levels, but individual may retain anamnestic immunity (titre > 10
IU/mL indicate definitive immunity)
- Anti-HBc (total):Antibodies produced in response to HBcAg; indicates previous or
current HBV infection
- Anti-HBc (IgM): IgM antibodies produced in response to HBcAg; IgM only
produced during the first 6 months of HBV infection (or flares), so the presence of
anti-HBc (IgM) indicates acute infection (or flares of chronic disease)
- Anti-HBe: Antibodies produced in response to the viral envelope; indicates
current infection and low infectivity

Question 265

Compare and contrast acute vs chronic radiation exposure

Answer 265

Acute exposure
- Death
- Acute radiation sickness: Anorexia, N/V, following minutes to hours after
irradiation; other symptoms depend on the organ primarily exposed to the
radiation

Chronic exposure:

• Cancer, benign tumours, cataracts
• Damages DNA by breaking molecular bonds; cells are typically only
  radiosensitive in their nonproliferative states (exceptions = lymphocytes, oocytes)
• Non-cancer effects require exceeding a threshold dose
• Cancer effects have no threshold and are stochastic (randomly determined)

Question 266

What are recent epi trends related to sexuality (sexual debut, use of condoms)?

Answer 266

Healthy sexuality: Skills, knowledge, and behaviours to make choices that maintain sexual and
reproductive health throughout life; comfort with sexuality

Epidemiology
- 30% of 15 to 17-year-olds, 68% of 18 to 19-year-olds, and 86% of 20- to 24-year-olds
report having sex
- Condom use declines with age: 80% of 15- to 17-year-olds report using condoms, while
63% of 20- to 24-year-olds report using condoms
- Baby boomers returning to dating following divorce or death of a spouse may be less
likely to use condoms regularly; rates of chlamydia, gonorrhea, and syphilis have been
rising in older Canadians, especially men over the age of 60(although rates are still
highest in young people)

Question 267

What are the 6 core functions of public health?

Answer 267

1. “Health protection: Actions to ensure water, air and food are safe, a regulatory framework to control infectious diseases, protection from environmental threats, and expert advice to food and drug safety regulators.
2. “Health surveillance: The ongoing, systematic use of routinely collected health data for the purpose of tracking and forecasting health events or health determinants. Surveillance includes: collection and storage of relevant data; integration, analysis and interpretation of this data; production of tracking and forecasting products with the interpreted data, and publication/dissemination of those products; and provision of expertise to those developing and/ or contributing to surveillance systems, including risk surveillance.
3. “Disease and injury prevention: Investigation, contact tracing, preventive measures to reduce the risk of infectious disease emergence and outbreaks, and activities to promote safe, healthy lifestyles to reduce preventable illness and injuries.
4. “Population health assessment – Understanding the health of communities or specific populations, as well as the factors that underlie good health or pose potential risks, to produce better policies and services.
5. “Health promotion: Preventing disease, encouraging safe behaviours and improving health through public policy, community-based interventions, active public participation, and advocacy or action on environmental and socioeconomic determinants of health.
6. “Emergency Preparedness and Response: Planning for both natural disasters (e.g. floods, earthquakes, fires, dangerous infectious diseases) and man-made disasters (e.g. those involving explosives, chemicals, radioactive substances or biological threats) to minimize serious illness, overall deaths and social disruption.”

Question 268

Explain the Cynefin (Kih-neh-vihn) framework.

Answer 268

Cynefin (Kih-neh-vihn) framework
“Helps leaders determine the prevailing operative context so that they can make appropriate
choices”
- Complex contexts: Many “unknown unknowns”; probe the context to learn more
- Chaotic contexts: Not possible to understand cause-and-effect; act to bring order and
transform a chaotic context into a complex context
- Complicated contexts: Expert analysis can find a solution
- Simple contexts: Categorize the cause-and-effect relationship and act accordingly

Question 269

What was the Krever commission?

Answer 269

Krever Commission: Recommended the creation of Hema-Quebec and the
Canadian Blood Services after blood donations supplied by the Canadian Red
Cross resulted in HIV and HCV infections

Question 270

Describe basic facts about group B strep

Organism, Reservoir, Mode of transmission

Incubation period, infectious period

Epidemiology

Presentation, Testing

Case management, Contact management

+/- Immunization

Answer 270

Group B strep (GBS) (reportable)
- Organism: Streptococcus agalactiae
- Reservoir: Humans
- Mode of transmission: Direct contact in the birth canal (early onset and some late onset
disease) +/- contact with colonized individuals (some late onset disease)
- Epidemiology:
- 15-40% of pregnant women are GBS-colonized; 40-70% of GBS-colonized
women pass on GBS to their infants; of the colonized infants, 1-2% develop a
GBS infection
- Risk factors: Early labour, ROM > 18h, febrile during labour, previous infant with
GBS infection, GBS UTI

• Presentation:
• Early onset disease (1-7 days): Sepsis, respiratory distress, apnea, shock,
  pneumonia, meningitis
• Late onset disease: Bacteremia, meningitis, focal infections
• Incubation period: 1-6 days (early onset disease)
• Testing: Culture
• Maternal management: Test all pregnant women for GBS between 35-37 GA; treat with
  intrapartum abx if positive or if tests results unavailable
• Infant management: Abx treatment

Question 271

Who should receive PEP for iGAS?

Describe basic facts about group A strep

Organism, Reservoir, Mode of transmission

Incubation period, infectious period

Epidemiology

Presentation, Testing

Case management, Contact management

+/- Immunization

Answer 271

Group A streptococcal disease

• Organism: Streptococcus pyogenes (gram+ coccus)
• Reservoir: Humans (skin and nasopharynx)
• Mode of transmission: Respiratory droplets or direct contact; contaminated food; humans no longer infectious after 24 h of abx
• Epidemiology of iGAS:
• Invasive disease most common in adults > 60 years, followed by children < 1 year, then children 1-4 years
• Invasive disease also more common among Indigenous populations than non-Indigenous populations
• In Ontario, 2.5% of iGAS cases have documented contact with another iGAS case
• Mortality: Strep TSS, up to 80%; nec fasc, 20%
• No occupationally acquired iGAS cases in HCWs in Ontario in the last 12 years
• Risk factors:

1) Varicella infection,

2) alcohol use,

3) extremes of age,

4) pregnancy,

5) underlying chronic conditions (e.g., cancer)

• Presentation:
• *Non-invasive**: Infection of non-sterile site (not reportable)
• Strep throat: Fever, exudative tonsillitis, anterior cervical lymphadenopathy; r_are complications = pediatric autoimmune neuropsychiatric disorder (PANDAS), glomerulonephritis, rheumatic fever, and rheumatic heart disease_
• Impetigo: Vesicles → pustules → Encrusted lesion; rare complication = glomerulonephritis
• Erysipelas: Acute skin infection with red, tender, edematous lesion with a raised border
• Scarlet fever: Usually strep throat + fine erythematous rash (“sandpaper rash” on neck, chest, axillae, elbows, and groin), circumoral pallor, strawberry tongue, fever, and N/V

Invasive: Infection of normally sterile site; includes strep toxic shock syndrome, necrotizing fasciitis, bacteremia, myositis, meningitis, pneumonia;

clinical evidence of iinvasive disease includes: Hypotension + one of renal impairment, coagulopathy, liver function abnormality, ARDS, or a generalized erythematous macular rash; soft-tissue necrosis; or meningitis

• Confirmed case: “Laboratory confirmation of infection with or without clinical evidence of invasive disease. Laboratory confirmation requires the isolation of GAS from a normally sterile site” (nationally notifiable)
• Probable case: “Invasive disease in the absence of another identified etiology and with isolation of GAS from a non-sterile site” (not nationally notifiable)
• Pneumonia with isolation of GAS from bronchoalveolar lavage is
  considered a probable case because BAL is not sterile
• Incubation period: Probably 1-3 days for iGAS (but unknown)
• Testing: No role for swabs and culture for in the community; swab LTC staff and residents in the same unit and treat colonized individuals
• Case management: Obtain culture and treat empirically for iGAS; contact and droplet precautions x 24h post-abx initiation; individuals with strep pharyngitis(esp kids) should self-isolate x 24h post-abx initiation
• Contact management: Contacts of iGAS should receive PEP if, within 7 days of case symptom onset to 24h post-abx, they were:

1) household contacts,

2) shared a bed or injection equipment,

3) are sexual partners,

4) or had direct mucous membrane contact (+/- some child care, hospital, and LTC contacts)

first-generation cephalosporin preferred (e.g., cephalexin);

contacts of all iGAS cases should be alerted to the S/S of iGAS and instructed to seek medical care should they occur

Question 272

Describe thermization, pasteurisation and sterilization

Answer 272

• Thermization: Pre-treatment prior to pasteurization that extends life of refrigerated milk;
  does not inactivate all pathogens
• Pasteurization: Eliminates all vegetative microorganisms; does not destroy pre-formed
  heat-resistant toxins or spores (e.g., B. cereus, B. botulinum)
• High temperature, short time (HTST) pasteurization = 71-74 C x 15-40 s
• Pasteurization changes the organoleptic (taste/smell) profile of milk (creating a
  “cooked” taste), but does not otherwise affect the nutritional profile of milk
• May reduce the allergenicity of milk
• Sterilization: Eliminates all vegetative microorganisms and most sporulating pathogens

Question 273

What is a conflict?

What are the Thomas-Kilmann conflict modes (5)?

What is the conflict resolution triangle?

Answer 273

Managing conflict

Conflict: A perceived incompatibility of actions, goals, or ideas, between interdependent parties, with non-constructive interaction

Thomas-Kilmann conflict modes:
- Thomas and Kilmann propose that, during conflict, an individual’s behaviour can be
assessed along two dimensions:
- Assertiveness: “The extent to which the individual attempts to satisfy his or her own concerns”
- Cooperativeness: “The extent to which the individual attempts to satisfy the other person’s concerns”
- Thomas and Kilmann use these two dimensions to define five modes of handling conflict: competing, collaborating, compromising, avoiding, and accommodating
- All people are capable of using all five modes to handle conflict, but most people use some modes more often as a result of their personality, skills, and work place
- Thomas and Kilmann recommend using a conflict mode appropriate for the situation, rather than personal predisposition to a mode

Competing: Assertive and uncooperative; pursues own concerns at another’s expense
- Use when: A quick decision is necessary (e.g., during an emergency), an unpopular
decision needs to be implemented (e.g., budget cut)
- Disadvantages: Using this mode too often teaches people not to disagree with you, so staff will not admit uncertainty to you or provide you with new information

Collaborating: Both assertive and cooperative; works to find solutions that fully satisfy the needs of both parties; requires time and commitment to identify underlying concerns
- Use when: The concerns of both parties are too important to compromise on; you want to incorporate multiple perspectives into a solution; you want to gain buy-in into a course
of action
- Disadvantages: Using this mode too often uses time and commitment unwarranted by the conflict (“trivial problems don’t require optimal solutions”); this mode can also be
used inappropriately to minimize risk by diffusing responsibility or postponing actions

• *Compromising**: Intermediate in assertiveness and cooperativeness; works to find expedient solutions that partially satisfy the needs of both parties (middle ground position)
• Use when: You need a temporary agreement on a complex issue; two parties are strongly committed to mutually exclusive goals (e.g., collective agreements)
• Disadvantages: Using this mode too often can result in gamesmanship (ongoing bargaining and trading) that undermines interpersonal trust

Avoiding: Unassertive and uncooperative; does not address a conflict (may be diplomatically avoiding a conflict or withdrawing from a threatening situation)
- Use when: The costs of confronting a conflict outweigh the benefits of resolving the conflict; the issue is unimportant; there is no chance that change will occur as a result of engaging; you will address the situation when there is more time, more information, or
people have cooled off
- Disadvantages: “Sometimes a dysfunctional amount of energy is devoted to caution and avoiding issues, indicating that those issues need to be faced and resolved”

• *Accommodating**: Unassertive and cooperative; addresses another’s concerns while neglecting his/her own (may be acting generously or obeying a command)
• Use when: The issue is more important to the other person than to you; you want to build up social credit; preserving harmony is more important than the solution you prefer
• Disadvantages: Using this mode too often can lessen your influence within an organization and lead to lax discipline

Conflict resolution triangle:
Consider the needs and perspectives of all of the following:
Manager needs: Attaining operational goals
- If you only consider your own needs as a manager (e.g., task completion), you will not build good relationships with staff
Individual needs: Acknowledgement and accommodation of individual circumstances
- If you only consider the individual’s needs, you may be taken advantage of Organizational needs: Equitable treatment across staff; attaining strategic goals
- If you only consider the organization’s needs, you will not provide appropriate accommodation

Question 274

Describe basic facts about ZIKA

Organism, Reservoir, Mode of transmission

Incubation period, infectious period

Epidemiology

Presentation, Testing

Case management, Contact management

+/- Immunization

Answer 274

Zika virus (vertically transmitted, travel-acquired) (hot topic)
Organism: Single-stranded RNA flavivirus; Flaviviridae family (same family as JE, West
Nile, yellow fever, SLE virus, and dengue); two lineages: African and Asian
Mode of transmission:
- Vector: Primary vector is Ae aegypti, but other Ae species may be competent
vectors (Aedes albopictus recently detected in Windsor-Essex)
- Vertical
- Sexual: ZIKV detectable in semen for up to 62 days
- Blood transfusion/transplant

Presentation:

Most infections are asymptomatic; only 20-25% of cases have S/S (nonspecific),
including low-grade fever, maculopapular rash, arthralgia, non-purulent
conjunctivitis x 2-7 days (similar to dengue or Chikungunya)

Complications: Guillain-Barre syndrome (~1 case/4,000 ZIKV infections; compare to 1-
2.6 cases/4,000 C. jejuni infections); fetal congenital anomalies = microcephaly,
hydrocephalus, fetal growth restriction, fetal death, arthrogryposis (in French Polynesia,
occurred in 1% of infants of mothers infected during the first trimester)

Incubation period: 3-12 days

Testing (outdated?): Currently only available to symptomatic individuals (current or resolved) and
asymptomatic pregnant women who have travelled to endemic area
- PCR (serum, urine, amniotic fluid, CSF, or blood samples): Perform within 14
days of symptom onset (for symptomatic individuals) or departure from endemic
area (for asymptomatic pregnant women); conduct chikungunya and dengue
PCR concurrently
- IgM serology: Perform in PCR+ patients who are pregnant or neonates; perform
for pregnant women 2-12 weeks after departure from endemic area
- ZIKV plaque reduction neutralization test (PRNT): Used if dengue IgM is positive
(due to cross-reactivity between flavivirus serology assays)

Case management:

Symptom relief; recommend males use condoms or practice
abstinence for the duration of a partner’s pregnancy or x 6 months after returning from
an endemic area (whichever is longer)
- Contact management: Women planning pregnancy should delay pregnancy x two
months after returning from an endemic area; couples planning pregnancy where the
male has travelled should delay pregnancy x six months after returning from an endemic
area

• *History**
• 1947: ZIKV isolated from a rhesus macaque in the Ziika Forest in Uganda
• 1952: First human cases of Zika reported in Uganda and Tanzania
• 2007: ZIKV outbreak on the Micronesian Island of Yap
• 2013: ZIKV outbreak in Tahiti (French Polynesia)
• 2014: ZIKV outbreaks in New Caledonia and the Cook Islands (Pacific islands)
• 2015: ZIKV outbreak in Easter Island

Options for surveillance: Reportable disease system, lab-based surveillance,
special-purpose system (e.g., microcephaly), sentinel surveillance, sero-prevalence studies,
cohort studies

Question 275

Discuss the epi and health effects of cigarettes

(and compare with e-cigarettes [to research more])

Answer 275

Question 276

Define systemic racism, provide examples and describe available public health interventions

Answer 276

Racism and health
Definitions
- Race: Social construction with no biological basis
- Racism: Avoidable and unfair actions that further disadvantages the disadvantaged or
further advantages the advantage
- Epistemic racism: Positioning the knowledge of one racialized group as
superior to another
- Systemic racism: Imbalance of power and resources maintained through
inequitable in treatment in law, policies, rules, and regulations
- Interpersonal racism: Belief that an individual possesses certain characteristics
based on their race alone
- Racial inequity in health: “_systematic, potentially avoidable differences in health–or in
the major socially determined influences on health–between groups of people who have
different relative positions in social hierarchies…”_It is a social determinant of health: racialized health disparities are a consequence of racism, not race; for example,

Examples of racial health inequities:
- In the US, infant mortality, obesity, mortality due to heart disease and stroke are
higher in Blacks than in Whites
- Indigenous people in Australia, Canada, and New Zealand are less likely than
non-Indigenous people to receive timely angiography/revascularization following
MI

Public health intervention:
- Public health agencies can advocate to dismantle, and dismantle their own, policies that
bolster systemic racism
- Public health research is required to understand the health impact of racism

Question 277

How does one approach media interviews?

Answer 277

Approach to media interviews
1. Understand the medium (TV, radio, print, social media), format (in-person, live, taped,
call-in), duration, audience, and topic of the interview
2. Develop key messages
3. Anticipate questions and develop answers for likely questions; answers should be < 20
seconds
4. Re-state key messages in multiple ways throughout the interview; _bridge back to the key
message_with phrases like “What I think you’re asking is…” or “What’s important to
remember is…”
5. Provide interviewer or reporter with backgrounders that substantiate your key messages

Media interview tips
- Limit jargon and acronyms: These can imply arrogance and limit rapport-building
- Tailor messages based on audience
- Use humour with caution, especially during a crisis (it is likely to be misinterpreted)
- Refute negative allegations without repeating them: Repeating any message
enhances its impact; if the reporter uses inflammatory words, reframe the question in
neutral language
- Gather feedback: Has your message been understood?
- Avoid one-liners and cliches: E.g., “There are no guarantees in life”
- Limit comments to what you know: Keep personal opinions to a minimum; say “I don’t
know, but I will find the answer”
- Don’t say “No comment”: Explain why you are unable to comment (e.g., the matter is
under investigation, you are not the right person to answer the question)
- There is no such thing as “off the record”
- Reframe hypothetical questions to address legitimate concerns without speculating
- Resist the urge to fill dead airtime: Reporters will pause and hope you will continue
talking, especially about controversial issues; dead airtime will be edited out or filled by
the reporter
- Look at the reporter, not the camera

Question 278

Describe income maintenance programs available in Canada

Answer 278

Canada-wide
Old Age Security
Canadian Pension Plan
Employment Insurance (includes pregnancy and parental leave)

Ontario-specific
Welfare: Ontario Works (OW)
Disability support: Ontario Disability Support Plan (ODSP)
Workers’ compensation: Workplace Safety and Insurance Board (WSIB)

Question 279

What are the travel recommendations regarding:

Cholera + ETEC

Rabies

Hepatitis A, Hepatitis B

Japanese encephalitis

Typhoid Fever

Yellow Fever

Malaria

Meningitis

Altitude sickenesses

Answer 279

Travel health
See also: Emerging, travel-acquired, and tropical pathogens
Travel medicine made easy: “Don’t get bit. Don’t eat shit. Don’t get lit. Don’t get hit. Don’t do
it.” - Dr. Isaac Bogoch
Concepts
- Travel medicine: Pre-travel preventive care, focusing on the prevention of infectious
diseases, avoidance of environmental risks, and maintenance of personal safety
- Tropical medicine: Diagnosis and treatment of illnesses associated with foreign travel
Epidemiology
- Most common illness acquired while travelling: Diarrhea
- Most common cause of mortality while travelling: MVCs
- Most common cause of fever in a returning traveller: Malaria
- Individuals visiting friends and relatives (VFRs) are at higher risk of acquiring infectious
diseases than other travellers
- Other higher-risk populations include health care and humanitarian aid workers,
individuals travelling to mass gatherings, and immunocompromised travellers

Travel vaccinations
- Cholera and enterotoxigenic E. coli (Dukoral): Efficacy of 25% in preventing
travellers’ diarrhea; provides 2 years of cholera serogroup O1 protection and 3 months
of ETEC protection(no protection against cholera serogroup O139 or other Vibrio spp.);
immunization can result in self-limited abdo pain, diarrhea, and N/V; recommended by
CIG only for high-risk travellers (e.g., humanitarian workers, health workers)

• Rabies: CIG recommends for travellers to rabies-endemic areas where there is
  inadequate access to PEP, especially for children (at high risk of animal bites); also
  recommended for spelunkers
• Note that some low-income countries still use a nerve-tissue vaccine (Semple or
  Fuenzalida vaccine), while high-income countries use cell-cultured or
  embryonated egg-based vaccines. Nerve-tissue vaccines are less immunogenic
  and can have severe side effects (rabies from incomplete activation of the virus
  or severe neurological events due to immune response directed at the body’s
  own CNS)
• Hepatitis A: CATMAT recommends HAV vaccine for all non-immune travellers to
  LMICs; can administer up to the day of departure; pre-exposure Ig is recommended for
  individuals with contraindications to active vaccination, in immunocompromised
  individuals who may not respond adequately to active vaccination, or infants < 1 year
• Hepatitis B: CATMAT recommends HBV vaccine for all non-immune travellers to
  LMICs; full series must be completed for full protection, but one or two doses will still
  provide some protection
• Japanese encephalitis: CATMAT recommends JE vaccination for travellers visiting
  rural, JE-endemic areas during transmission season (i.e., not recommended for
  travellers visiting JE-endemic countries who will remain in urban areas)
• Typhoid (Ty21a [tablets] or Vi polysaccharide [injection] vaccine): Duration of protection
  not well-defined (3 years?); CATMAT recommends for Canadian travellers visiting South
  Asia; CATMAT recommends against for Canadian travellers visiting other destinations
• Yellow fever: CATMAT recommends YF vaccination for travellers visiting endemic or
  transitional areas; however, proof of YF vaccination (International Certificate of
  Vaccination or Prophylaxis; ICVP) may be required for entry into some countries where
  there is no or low potential for exposure (to protect countries with a competent mosquito
  vector + non-human primates from the risk of importing the virus); YF vaccination may
  only be provided at Yellow Fever Vaccination Centres designated by PHAC; Vaccination protection is life-long; for individuals with contraindications to YF vaccinations, designated providers can provide a Certification of Medical Contraindication to Vaccination; serious adverse events associated with YF vaccination:
• Hypersensitivity reaction (rash, urticaria, asthma, anaphylaxis): 1 case in 250,000
  vaccines administered
• Yellow fever vaccine-associated neurotropic disease: Meningoencephalitis, GBS;
  0.8 case in 100,000 vaccines administered; higher risk at the extremes of age
  (vaccine may no longer be administered to infants < 6 months, which has
  reduced the rate of occurrence)
• Yellow fever vaccine-associated viscerotropic disease: Multi-organ failure; risk
  increases with age, thymus disease, thymoma, myasthenia gravis; 1 case in
  100,000 vaccines administered in 60-69 year olds; 3 cases in 100,000 vaccines
  administered in 70+ year-olds
• Meningitis (required for Hajj and Umrah)
  +All regular immunizations

Chemoprophylaxis
- Altitude sickness: Acclimatization (gradual ascent, 300-500m/night) + acetolazamine
- Acute mountain sickness: Headache, anorexia, fatigue, dizziness, sleep
disturbance within 12 h at high altitude
- High-altitude cerebral edema (HACE): Lethargy, ataxia, altered mental status,
coma, death
- High-altitude pulmonary edema: Dry cough, SOBOE progressing to SOB at rest,
pink frothy sputum

• Malaria: Mosquito avoidance +/- chloroquine, hydroxychloroquine, atovaquoneproguanil,
  doxycycline, mefloquine, or primaquine (depending on local drug resistance
  patterns and personal preferences)
• Mosquito avoidance: Screened accommodations, bed nets, insect repellant (20-
  30% DEET or 20% icaridin), + long pants and sleeves

Question 280

What are potential health impacts of wind turbines?

Answer 280

Wind turbines
There is no evidence to support a causal association between exposure to wind turbines and
adverse health effects, with the exception of annoyance.
- “The evidence consistently shows a positive relationship between outdoor wind turbine
noise levels and the proportion of people who report high levels of annoyance.” The
impact is lessened when an individual receives economic benefit from the wind turbine,
or cannot see the wind turbine.
Wind turbines can cause a risk to health and safety due to ice throw or structural failure. This
risk can be reduced with setbacks, warning signs, gated access, and operation shut-down
during icy conditions. (Note that the Ontario Environmental Protection Act requires a set-back
of 550 m from buildings)
- Structural failure: Occurs in every 1 in 2,400 to 1 in 20,000 turbines per year; the
maximum distance an entire blade has been thrown is 150 m and the maximum distance
a blade fragment has been thrown is 500 m.
- Ice throw: Ice can form on wind turbines and be thrown by the blades; most ice falls or
is thrown within 100 metres of the turbine
Other health concerns about wind turbines include:
- Noise: In Ontario, wind turbines must be at least 550 m away from residential or
institutional buildings to ensure that the sound is less than 40 dBA. This is similar to the
sound level when standing about 15 m away from light traffic and quieter than most air
conditioning units. Prolonged, unprotected exposure to sounds above 90 dBA is a risk
for noise-induced hearing loss. People find it difficult to do simple tasks when noise
levels are above about 100 dBA and difficult to do complex tasks when noise levels are
above about 75 dBA. The sound produced by wind turbines is far below these levels,
but may still cause annoyance.
- Electromagnetic radiation: Wind turbines are not a significant source of
electromagnetic radiation. No evidence of impact on health.
- Vibrations: The vibrations produced by wind turbines are very weak and generally
cannot be felt by humans. No evidence of impact on health.
- Flicker: Flickering shadows secondary to the rotation of wind turbine blades are most
common when the sun is low in the sky (i.e., at sunset and sunrise). The frequency of
flickers produced by wind turbines is below the frequency necessary to induce seizures
in people with photosensitive epilepsy. May cause annoyance.

Question 281

Regarding radiological and nuclear incidents,

what are health impacts?

What are available treatments?

Public health roles?

Key communication messages?

Answer 281

Radiological and nuclear incidents

Types of radiation emergencies:
- Nuclear emergencies: Nuclear weapon or improvised nuclear device
- 2011 Fukushima radiation exposure comparison: http://xkcd.com/radiation/
- Dirty bomb: Use of explosives to scatter radioactive material in order to cause
radioactive contamination; radioactive materials unlikely to cause immediate illness,
except to individuals in the immediate blast site
- Radiological exposure device: Non-accidental hidden source of radiation exposure
- Accidental or non-accidental damage to nuclear plants, transportation accidents, or
spent fuel rod storage sites

Health impacts
Short-term health impacts (threshold effects):
- Acute radiation syndrome: Acute illness caused by penetrating irradiation of > 70
rads/0.7 Gy of most of the body in a short period of time; results from the depletion of
immature stem cells; causes N/V + anorexia +/- diarrhea, followed by a latent stage of
no symptoms for a few hours to weeks, then manifest illness that presents in three
syndromes:
- Bone marrow syndrome: Infection and hemorrhage as a result of bone marrow
stem cell death; most people survive
- GI syndrome: Infection, dehydration, electrolyte imbalance as a result of death of
cells lining GI tract; death usually occurs within 2 weeks
- CV/CNS syndrome: Collapse of circulatory system, increased ICP, edema,
vasculitis, and meningitis; death usually occurs within 3 days

• Cutaneous radiation syndrome: Local radiation injury to the skin; inflammation,
  erythema, blistering, and desquamation of the exposed area of skin
• Cataracts
• Sterility
• Fetal death (if exposure < 2 weeks) or fetal development of cataracts, malformation, and
  mental retardation (if exposure at > 2 weeks)

Long-term health impacts (non-threshold effects):

• Cancer in exposed individuals
• Childhood cancers in exposed fetuses

Treatments for radiation exposure
- Calcium and zinc diethylenetriamine penta-acetate (aka Ca-DTPA et Zn-DTPA)__: Enhance the excretion of radioactive particles
- Ferric hexacyanoferrate (aka Prussian blue): Enhances the excretion of radioactive
cesium and thallium from the body; and
- Potassium iodide: Prevents the thyroid from taking up radioactive iodine, decreasing the
risk of future thyroid cancer
- Filgrastim: Treatment for neutropenia

Public health roles in radiological and nuclear incidents:
- Surveillance and epidemiological investigation
- Community preparedness (e.g., all-hazards training)
- Community recovery (e.g., environmental clean-up)
- Dispensing medical countermeasures
- Coordinating emergency operations
- Emergency public health information (e.g., recommend showering, changing clothes,
sheltering-in-place)
- Information sharing
- Responder occupational health and safety

Shelter-in-place messaging for radiological emergencies: “Get inside, stay inside, and stay
tuned”
1. Remove your outer layer of clothes before entering the building. Wash the exposed skin
once inside.
2. Get inside right away (preferably into a brick or concrete multi-story building with a
basement)
3. Close and lock all windows and doors.
4. Go to the basement or middle of the building (avoid the walls and roof; radioactive
material settles on the outside of buildings)
5. Turn off fans, air conditioners, and forced-air heaters.
6. Turn on the radio and keep your phone charged. SMS text messaging usually more
likely to work in an emergency than voice calls.

Question 282

Regarding alcohol,

what are recent epi trends,

health impacts,

Canadian low-risk drinking guidelines,

and available population-level interventions?

What does SAFER stand for?

Answer 282

Alcohol
Epidemiology
- 91% of Canadians report ever drinking alcohol; 78% of Canadians report drinking
alcohol in the last year
- Average age of initiation of drinking in Canada = 16 years
- Per capita alcohol consumption is increasing in Canada (14% increase since 1996)
- Approximately half of all alcohol consumed in Canada is consumed in excess of the lowrisk
drinking guidelines

Health impacts
- Short-term negative impacts: Injury (motor vehicle- and non-motor vehicle-related),
social harms (physical violence, sexual violence, vandalism, public disorder,
interpersonal problems, financial problems)
- Long-term negative impacts:
- Impacts that can occur with any regular consumption: Risk exists at levels as low
as 1-2 drinks/day and increases with every increase in average daily alcohol
consumption
- Cancer: Mouth, pharynx, larynx, esophagus, liver, breast, colon, rectum
- CVD: Hemorrhagic stroke, dysrhythmias, hypertension
- GI: Liver cirrhosis, pancreatitis, hepatitis/gastritis
- Impacts that occur with hazardous levels of consumption:
- Psych: Alcohol dependence, psychosis
- CNS: Polyneuropathy, myopathy
- Cardio: Cardiomyopathy
- Fetal effects: Low birthweight, fetal alcohol spectrum disorder

• Long-term positive impacts: Result from low levels of consumption (0.5-1 standard
  drinks/day); lower risk of premature death from CAD, ischemic stroke, and diabetes

Canadian low-risk drinking guidelines
Guidelines are based on the level of daily consumption of alcohol where the potential health
risks and benefits of drinking cancel each other out (i.e., net risk of premature death is the same
as a lifelong non-drinker)
1. Do not drink in these situations: When operating any kind of vehicle, tools or machinery;
using medications or other drugs that interact with alcohol; engaging in sports or other
potentially dangerous physical activities; working; making important decisions; if
pregnant or planning to be pregnant; before breastfeeding; while responsible for the care
or supervision of others; if suffering from serious physical illness, mental illness or
alcohol dependence.

2. If you drink, reduce long-term health risks by staying within these average levels
   a. Women: 0-2 drinks/day; no more than 10 drinks/week
   b. Men: 0-3 drinks/day; no more than 15 drinks/week
   c. Everyone: Some non-drinking days per week
3. If you drink, reduce short-term risks by choosing safe situations and restricting alcohol
   intake/occasion to:
   a. Women: 3 drinks/day
   b. Men: 4 drinks/day
   c. Everyone: Drink with meals, no more than 2 drinks/3 h, alternate alcoholic drinks
   with non-alcoholic drinks
4. When pregnant or planning to be pregnant, the safest option is not to drink at all.
5. Uptake of drinking by youth should be delayed until the late teens and be consistent with
   local legal drinking age laws.

• *Population-level interventions:**
• Interventions recommended by the Community Guide:
• Dram shop liability
• Increasing alcohol taxes
• Limiting days and hours of sale
• Regulation of alcohol outlet density
• Enforcement of laws prohibiting sales to minors
• Interventions recommended against by the Community Guide:
• Privatization of retail alcohol sales (“strong evidence that privatization results in increased per capita alcohol consumption”)

WHO SAFER

S Strengthen restrictions on alcohol availability

A Advance and enforce drink driving counter measures

F Facilitate access to screening, brief interventions and treatment

E Enforce bans or comprehensive restrictions on alcohol advertising, sponsorship, and promotion

R Raise prices on alcohol through excise taxes and pricing policies

• Key components of municipal alcohol policies:
• Designation of properties/facilities/events where alcohol may or may not be served
• Maximum drink limit
• Prevention strategies (e.g., training of servers)
• Signage that conveys the rules
• Monitoring procedures

Question 283

What are concussions,

what are the symptoms,

what are recent epi trends

and what can be done about it?

Answer 283

Concussions
Definition: Brain injury due to acceleration-deceleration +/- rotation that results in a change in
brain function with no visible injury to the structure of the brain
Signs and symptoms: Immediate loss of consciousness, memory loss, headache, emotional
lability, slowed reaction time, insomnia

Epidemiology:
- 80-90% of concussions resolve in 7-10 days; concussions in children take longer to
resolve
- Concussions in football, soccer, and hockey are increasing in incidence compared to
other injuries
- 63% of ED visits in Canada for sports-related injuries in Canadian children and youth
resulted in a diagnosis of concussion or possible concussion

Prevention:
1. Graduated return to play
2. Graduated return to learn
3. Rule changes in sports to reduce common concussion mechanisms
4. Encourage fair play and respect; discourage violence and aggression
5. Education to parents, players, and coaches regarding concussion detection and safe
return to play
6. Fed/Prov/Ter Working Group on Concussions in Sport is developing _{pan-Canadian Concussion<br></br>Guidelines} focusing on five components: Awareness, prevention, detection,
management, surveillance

*Note that while helmets reduce direct head trauma (cuts, fractures), they do not reduce the
incidence of concussion

Question 284

What are the vaccine trial phases?

Answer 284

Preclinical: Lab and animal studies

Clinical:

• Phase I: Safety, immunogenicity, toxicity (10-100 individuals)
• Phase II: Efficacy, safety (50-500 individuals)
• Phase III: Compared to standard of care, optimal dose and schedule, rare adverse events (300-30,000 individuals)

Post-licensing:

-Phase IV: Monitoring for rare or delayed adverse events

Question 285

What is fracking and what are possible health impacts of fracking?

Answer 285

• Fracking: Hydraulic fracturing; blasting fracturing fluid into relatively impermeable rock to crack the rock and release natural gas into the well; one-quarter to one-half of the fracking fluid returns to the surface
• Fracturing fluid = water + _viscosity-reducing agent_s + proppants (material that holds the fracture open, like silica or ceramic beads) + antimicrobials (to prevent bacterial growth on well casing) + corrosion/scale inhibitors (e.g., hydrochloric acid, glutaraldehyde, benzene, naphthalene)
• Natural gas: Mixture of hydrocarbons (e.g., methane, ethane, propane, pentane, butane) +/- impurities (e.g., sulphur); produces fewer emissions than gasoline or diesel
• Conventional natural gas: Natural gas that migrated into porous rock; can be accessed through a single vertical well
• Unconventional natural gas: Natural gas that was formed and trapped in rock strata; requires complex process to access; unconventional natural gas includes tight gas (in sandstone and limestone), coal bed methane (in coal seams); and
  shale gas (in laminated sedimentary rock)
• P/Ts with fracking: BC, Alberta, New Brunswick (major shale gas basins are located in BC and Alberta)
• P/Ts with moratoriums against fracking: Quebec, Newfoundland, Nova Scotia
• *Exposure routes and health impacts:**
• Water: Methane and other substances have been detected in well water near fracking operations, but baseline data prior to fracking was unavailable and it is unknown if the drinking water quality is due to natural processes or fracking
• Accidental surface spills leaching into groundwater
• To date, there is no evidence of upward migration of fracturing fluid leaching into aquifers, although this is theoretically possible
• Waste water
• Air: Fracking releases NOx, SOx, O3, VOCs, crystalline silica, H2S, PM, CO2, and radon, in some cases in amounts exceeding air quality guidelines, but baseline data prior to fracking and evidence of health impacts are unavailable or weak
• Point sources: Stack or pipe
• Mobile sources: Trucks and drill rigs
• Fugitive sources: Leaks

Question 286

Define emergency, hazard and risk.

What are the public health roles during the 5 different stages of emergency management cycles?

Answer 286

Public health roles in emergencies
*Public health is neither a first responder nor a first receiver

Definitions

• Emergency: “A serious situation that happens unexpectedly and demands immediate action” because the event may or will overwhelm the ability to provides services
• Hazard: “An event of physical condition that has the potential to cause fatalities, injuries, property damage, infrastructure damage, interruption of business, or other types of harms or loss”
• Risk: “A chance or possibility of danger loss, injury, or other adverse consequences”

Prevention
- HIRA (Hazard identification and risk assessment) to identify hazards and work with community partners to develop prevention mechanisms
- Communicate about risks to stakeholders
Mitigation
- Mass immunization
- HIRA to identify hazards and work with community partners to develop mitigation mechanisms
- Contribute to the hazmat component of community emergency response plan
Preparedness
- Community preparedness through training and exercises
- Maintain an inventory of medical assets, experts, and laboratories
Response
- Mass immunization
- Mass prophylaxis
- Surveillance (especially early event detection)
- Epidemiological investigation
- Determine the hazard, who may have been exposed, and how harm can be minimized
- Crisis communication: Provide timely information to first responders, medical professionals, decision-makers, and the public (e.g., health risks, PPE required, signs and symptoms, evacuate vs. shelter in place)
- Sheltering in place is usually the most appropriate option due to transportation grid-locking, risk of irrational mass behaviour, challenge of finding shelter, and risk of increased exposure (“Go in, stay in, and tune in”)
- Lab services
Recovery
- Community recovery: Return individuals and communities back to a sense of normalcy
- Scientific and evidence-based advice to the health care system, emergency responders,
and policymakers
- Reduce unnecessary trade and travel restrictions
- Communication with the public
- Reduce demands for unneeded treatment
- Population health assessment (e.g., epidemiological studies, community psychosocial assessment)

Question 287

What are sources of non-ionizing radiation and what are their potential health effects?

What is electromagnetic hypersensitivity?

What is Health Canada Safety Code 6?

What are radiofrequency risk mitigation strategies?

Answer 287

• *NON-ionizing radiation**
• *Definition**: Electromagnetic wavelengths that are longer and less energetic than ionizing radiation; all objects with temps > 0K emit radiation, usually in infrared (increasing temp α decreasing wavelength)

Ultraviolet radiation (200-400 nm)
Health effects: (IARC, Group 1 carcinogen)
- Absorbed by nucleic acids and proteins → chemical reactions → skin CA, corneal damage, skin aging
- Photokeratitis → snow blindness (or blindness due to arc welding)
Window glass, clothing, sunscreen, and subcutaneous tissue block UV radiation

Visible light (400-700 nm)
Health effects:
- Bleaching of visual pigments → temporary scotoma
- Coagulation of retina → permanent scotoma

Infrared (700 nm-1mm)
Health effects: Burns, cataracts

Radiofrequency and microwave radiation (hot topic)

Part of EM spectrum, frequencies below visible light, NON-ionizing
3kHz to 300 000 MHz
Health effects: Unclear whether or not there are any deleterious long-term health effects from exposure (RF and magnetic fields from high lines are IARC, Group 2B)

• Electromagnetic hypersensitivity: _Set of non-specific symptoms (e.g., nausea, headache, dizziness) assumed to arise from exposure to EM-emitting sources; no study has confirmed that symptoms are related to exposure to or strength of EM radiation (_studies
  use sham EM-emitting sources or vary distance to EM-emitting source)
• At high levels, radiofrequency energy can induce currents in the human body, resulting in rapid heating (e.g., like microwave ovens); effects are most significant on eyes and testes because of the relative lack of blood flow available to dissipate heat
  Sources:
• Cell phones: Largest source of radiofrequency exposure exposure for most individuals is mobile phones; increased risk for glioma, acoustic neuroma, and meningioma with ipsilateral cell phone use of greater than 10 years
• WiFi: Lower strength radio-frequencies than those from cell phones (<1% of what is received during typical cell phone use)
• High-voltage power lines: Some studies have reported an association between radiowaves generated by high-voltage power lines and leukemia, lymphoma, and CNS cancers, but other studies have found no association; “The studies indicate that if there
  is a link between long-term, low level EMF exposure and cancer, it is a very weak one.
  That is, the excess risk of cancer from living near power lines is at best zero, and at worst very low.”
• MRI: MRI induces radio waves; no known health risks
• Broadcast stations
• Radar
• Satellite transmissions
• The Big Bang (true story, see: cosmic microwave background radiation)
• *Health Canada Safety Code 6**: Sets exposure limits for controlled (safety factor of 10 applied) and uncontrolled (safety factor of 50 applied) exposures to radiofrequency; all WiFi devices must meet Safety Code 6
• Specific absorption rates: Watts/kg absorbed (based on non-human primate studies; primary endpoint was tissue heating)
• Power densities: Watts/m^2 measured at the source

Radiofrequency risk mitigation strategies:

• Limit cell phone calls, use texts, wear at hip, limit children’s exposure

Question 288

What is bullying and how frequent is it in Canada?

What are available public health interventions against bullying?

Answer 288

Bullying (hot topic)
Definition: Conscious, wilful, and deliberate form of aggression intended to harm another
person; can be physical, verbal (threats of physical violence or verbal abuse), social (e.g.,
exclusion), sexual and can occur in person or online (cyber-bullying)
- Bullying care result in low self-esteem, guilt, inability to deal with problems, depression,
exclusion from opportunities, and suicide

Epidemiology:
- 36% of Canadian youth report being the victim of bullying
- Girls and boys engage in bullying at the same rates, but girls are more likely to use
indirect forms of bullying (e.g., gossip) while boys are more likely to use direct forms
(e.g., violence)

Interventions:
Individual-level:
- Education regarding coping skills for bullied children (+/- health professional involvement)
- Effective, learning consequences for bullying behaviour
- School tribunals for bullying behaviour

School-level:

• Whole-school anti-bullying policies
• Playground improvement
• Peer-support programs

Community-level:

• Education regarding recognition and intervention for both children and adults
• Community anti-bullying campaigns

Question 289

What is an operational plan and what are its 3 main components?

Answer 289

Operational planning

MNEMONIC

“As Good As Possible”

Annual Goals/objectives
Actions
Performance indicators

Operational plan (aka annual business plan): Short-term objectives (1 year or less) that map to the longer-term strategic objectives; connects the strategic plan to outcomes; see logic model
below from RAND linking program planning (top level), operational planning (bottom levels), and strategic planning (right column and mission)

Components of the operational plan
- Annual goals/objectives: The program activities that will be completed and outputs that
will be generated within the year; should be SMART:
- Specific
- Measureable
- Attainable
- Realistic
- Time-bound

• Actions: The activities that will be undertaken to achieve the goals outlined in the
  strategic plan
• Each action should be associated with a timeframe (when will the action be
  completed?), resources (what is needed to complete the action?), responsibility
  (who is responsible for completing the action?), and performance indicators
• Performance indicators

MNEMONIC

“As Good As Possible”

Annual Goals/objectives
Actions
Performance indicators

Question 290

What are 3 different types of organizational structures?

Answer 290

Organizational structures
- Organizational design: Alignment of positions, accountability, authority, people,
deliverables, and tasks
- Time span analysis: Method to determine the complexity of work of a position;
time span = time horizon for deliverables; positions with larger time spans should
be located in higher strata of the organization than positions with smaller time
spans (e.g., CEO is responsible for five-year strategic plan; manager is
responsible for quarterly results)

• The organizational structure should be determined by the strategic plan (i.e., what organizational structure best allows us to achieve our vision?)
• *Types of structures**
• Matrix: Usually used in conjunction with a function-based hierarchy; matrixed teams work across the departments (e.g., a surveillance unit that provides services to a health protection and health promotion department)

Pros: flexible team, favors communication, allows partnerships

Cons: ambiguity around roles+authority, potential conflict between 2 managers.

• Functional/Function-based hierarchy (aka departmentalization): Departments/silos divided according to the tasks performed. Best practice, every employee reports one level up (i.e., employees
  should not report to a manager in the same level or >1 level up)

Pros: absence coverage, clear lines of accountability

Negs: complex problem resolution, less horizontal communication.

• Geographic: Replication of organizational structures in adjacent geographic zones
• Project-based
• Autonomous business unit: A department that sits outside of the usual organizational structure and usually reports directly to senior management; created to perform a specific, often disruptive, task and may be disbanded after that task is achieved

Pros: clear accountability + responsibility, multi-disciplinary

Cons: competition for resource within organization

• Line authority: The authority to issue a command, according to an organizational
  structure (e.g., a manager has line authority over a staff person)
• Span of control: The number of staff people a manager has direct line authority over
• Larger span of control acceptable for highly capable, independent staff or staff
  who all perform the same function
• Smaller span of control required for geographically dispersed staff, large number
  of administrative duties associated with each team member, high volume of
  training or one-on-one supervision required

- _Delegation of authority_: Mechanism by which accountability and authority are moved
downwards through an organization (e.g., the Board delegates to the CEO, the CEO
delegates to a director, and so on); delegation of authority does not absolve an individual
from accountability (i.e., if you delegate a task, you are still accountable for the
completion of the task; the individual you delegated the task to now also is accountable)
- _Responsibility_: The duty to get something done (can be delegated)
- _Accountability_: The requirement to ensure something is done (cannot be delegated)

Question 291

What is a confounder and how can it be controlled for?

What is effect modification and how is it explored?

Answer 291

Confounding and effect modification
Confounding: Factor that distorts the relationship between an exposure
and an outcome due to a mutual relationship with an extraneous factor (where the extraneous
factor is a risk factor for the outcome of interest); I.e., There may or may not be a real
relationship between the exposure and the outcome; the relationship is obscured by the
confounder
- A confounder must be associated with the exposure and must also be a risk factor for, or
affect the probability of recognizing, the outcome
- A confounder is not on the causal pathway

• Control for confounding through:
• Design: Randomization, restriction (based on known confounders), matching
• Analysis: Stratification, multivariate analysis, standardization

Effect modification: The effect of the risk factor on the outcome differs by the level of another
factor, the effect modifier; I.e., There is a real relationship between the exposure and the
outcome; the relationship is just modified by some third variable (note: effect modification is
basically the same thing as interaction, but the former is a biological phenomenon while the
latter is a statistical phenomenon); effect modification may be:
- Synergistic: Positive interaction
- Antagonistic: Negative interaction

Stratification: Method used to determine whether or not a the relationship between an
exposure and an outcome is due to a confounder or impacted by an effect modifier; stratify the
exposure and outcome by the potential confounder/effect modifier
- If the relationship is not due to the confounder, then the incidence of the outcome will be
higher in the exposed than in the unexposed in every stratum and the strength of the
association will be similar in every stratum
- If the relationship is impacted by an effect modifier, then the strength of the association
will be different in every stratum
- Proceed with an adjusted OR or RR as follows:
- Can calculate the pooled OR using the Mantel-Haenszel method (essentially a weighted
average of the stratum-specific ORs)

Question 292

What are health technology assessments and what entity performs them in Canada?

Answer 292

Health technology assessment
Definition:“the systematic evaluation of properties, effects and/or impacts of health technologies and interventions. It covers both the direct, intended consequences of technologies and interventions and their indirect, unintended consequences” (WHO)

• Federally, CADTH (Canadian Agency for Drugs and Technologies in Health) produces HTAs for topics of pan-Canadian interest
• In Ontario, the Ontario Health Technology Advisory Committee recommends to the MOHLTC whether health interventions should be publicly funded or not, based on HTAs performed by Health Quality Ontario

OAE³: Organization compatibility, acceptability, ethical, economic, efficacy

Question 293

Describe and provide examples of AEFI (5 types of adverse events following immunizations)

When should AEFI be reported?

Answer 293

AEFI: Any untoward medical occurrence that follows immunization; may be coincidental or causally linked to the vaccine

In summary:

Vaccine product ^(expected), quality ^(unexpected)

Immunization anxiety ^(expected), error ^(unexpected)

Coincidence ^(unexpected)

AEFIs should be reported when the event:

• Has a temporal association with a vaccine;
• Has no other clear cause at the time of reporting

Of particular interest are those AEFIs which:

• Meet one or more of the seriousness criteria:
• Are unexpected regardless of seriousness:
• Expected AEFI: Included in the product monograph (e.g., pain, febrile seizures,
  anaphylaxis); important to assess changes in expected AEFIs (e.g., associated with a
  particular lot?)
• Vaccine product-related reaction: Due to one or more of the inherent
  properties of the vaccine product (e.g., extensive limb swelling following DTaP)
• Immunization anxiety-related reaction: Due to anxiety about the immunization
  (e.g., vasovagal syncope, hyperventilation, vomiting)
• Unexpected AEFI: AEFI that is not included in the official product monograph
• Vaccine quality defect-related reaction: Due to one or more quality defects in the vaccine or its administration device (e.g., failure to inactivate a lot of IPV)
• Immunization error-related event: Due to inappropriate vaccine handling, prescribing, or administration (e.g., infection from contaminated multidose vial)
• Coincidental event: Due to something other than the vaccine product, immunization error, or immunization anxiety
• Serious adverse event: AEFI that is life-threatening or that results in hospitalization, permanent disability, congenital abnormality, or death; may fit in any of the above categories

Question 294

Compare and contrast process and outcome evaluations?

What are the 5 elements to asses to evaluate if a program is ready for an outcome evaluation (evaluability assessment)?

Describe 2 program evaluation frameworks:

• CDC program evaluation framework
• RE-AIM framework

Answer 294

Program evaluation

Types of evaluations
- Implementation/process (aka formative) evaluations: Used to determine whether a program has been implemented as intended (e.g., how many people are being reached? Is the quality of the service sufficient?)
- Effectiveness/outcome (aka summative) evaluations: Used to determine whether a program is achieving the short-term, intermediate, or long-term outcomes it was intended to create (e.g., are mortality rates declining? Are protective behaviours
increasing?)
- Efficiency evaluations: Used to determine whether a program’s outcomes are being produced with the minimum necessary resources (e.g., what is the staff time per outcome?)
- Cost-effectiveness evaluations: Used to determine the cost per outcome of the program
- Attribution evaluations: Used to determine whether outcomes are attributable to your program or other secular changes

Which type of evaluation should I choose? Considerations:

• Utility: What is the purpose of the evaluation? Who will use the evaluation results? How will they use the results?
• Feasibility: What is the stage of development of the program? What are the potential resource and logistic challenges? How intensive is the program?

Is the program ready for an outcome evaluation (evaluability assessment)? Yes, if: [mnemonic ##SSFDR]

• Sustainable: The program will continue to exist during the evaluation
• Fidelity: The program is implemented in a way that matches the intended implementation
• Stability: The program is unlikely to change during the evaluation
• Reach: The program is reaching a sufficient number of clients
• Dosage: Clients have had sufficient exposure to the program

CDC program evaluation framework:

• Engage stakeholders Those involved, those affected, primary intended users
• Describe the program Need, expected effects, activities, resources, stage, context, logic model
• Focus the evaluation design Purpose, users, uses, questions, methods, agreements
• Gather credible evidence Indicators, sources, quality, quantity, logistics
• Justify conclusions Standards, analysis/synthesis, interpretation, judgment, recommendations
• Ensure use and share lessons learned Design, preparation, feedback, follow-up, dissemination

Standards for Effective Evaluation: Utility, Feasibility, Propriety, Accuracy

RE-AIM evaluation framework
The RE-AIM framework was developed to assess the impact of evidence-based interventions
on public health. It can be applied to either program design or evaluation. The creators of the
RE-AIM framework intend for it to be used with hard indicator metrics

Question 295

What is radon, why is it a public health concern and what can be done about it?

How does radon enter a home?

Answer 295

Radon (hot topic)
- Definition: Odourless radioactive gas formed by naturally occurring uranium. Radon in the ground, groundwater, or building materials enters working and living spaces and disintegrates into its decay products, releasing alpha particles.
- Source: Released from rocks and soil
- Can also be released from granite countertops, but because countertops are typically installed in well-ventilated rooms like bathrooms and kitchens, and granite is relatively non-porous and releases radon slowly, the health risk is much less than that due to radon in basements from soil
- Exposure: Can seep into buildings through dirt floor, basement window, floor drains, sumps, or gaps/cracks in foundation and building materials where it can build up to high levels (pressure inside houses is usually lower than pressure around the foundation). If it is released into the atmosphere, it is diluted
and does not pose a health risk. Radon levels are typically highest in basements and during the winter.

• Health effects: Radon’s radioactive progeny tend to attach to dust, which are then
  deposited in the lungs if inhaled –> direct exposure of the lung tissue to alpha radiation
  and can result in lung cancer. Smokers and those exposed to second-hand smoke are
  at a higher risk of developing radon-related lung cancer than non-smokers.
• Radon is the second-leading cause of lung cancer after tobacco smoke (16% of
  lung cancers in Canada are attributable to radon)
• In Canada, radon represents almost 50% of a person’s lifetime radiation
  exposure
• Most radon-related lung cancers (85%) occur in ever-smokers
• Canadian guidelines: Recommend that remedial action be implemented if average
  radon levels exceed 200 Bq/m3 in areas of a dwelling where people spend more than
  four hours per day.
• WHO recommends levels remain below 100 Bq/m3
• Most radon-related lung cancers in Ontario (90%) are attributable to exposures
  below 200 Bq/m3 (i.e., is testing and remediation the best policy option?)
• Measuring radon levels: Radon levels fluctuate widely, so it is preferable to measure
  radon levels over a long period of time, such as one year. Measurements should be
  taken in the lowest level of the home that is used regularly (i.e., not in bathrooms,
  closets, or unfinished basements).
• Remediation:
• Depressurization
• Increase ventilation (limited effectiveness)
• Seal major entry routes (limited effectiveness)

Question 296

What are HIV transmission risks per different acts?

Answer 296

Blood transfusion 93%

IVDU Needle sharing 0.6%

Needlestick 0.2%

Receptive anal intercourse 1.4%

Insertive anal intercourse 0.1%

Other sexual intercourses <0.1%

Question 297

What is implementation science and knowledge translation?

Contrast knowledge diffusion with knowledge dissemination.

Describe the awareness-to-adherence model (4As).

Answer 297

Implementation science
Definition: “_Implementation Science is the study of factors that influence the full and effective
use of innovations in practice._The goal is not to answer factual questions about what is, but
rather to determine what is required.” (NIRN, 2015)
*Recognizes that publishing evidence supporting an intervention or telling organizations/
practitioners to change their behaviour is not sufficient for translating evidence to practice, and
that, once change is initiated, it is often not sustained or deviates from evidence-based practice
over time

Areas of implementation science research:
- Diffusion of innovation (“Letting it happen”): How does information about innovation
diffuse? What factors determine whether or not an organization will choose to
implement an innovation?
- Dissemination of innovation (“Helping it happen”): How can information about an
innovation be actively disseminated in a way that results in more organizations
implementing an innovation?
- Implementation of innovation (“Making it happen”): How are innovations implemented in
organizations? How can innovative programs be maintained and delivered in a highfidelity
way?

Active implementation framework:
(Factors that determine whether or not an intervention will be effective)
- What needs to be done (the intervention must be effective)
- How to establish the intervention in practice (the implementation must be effective)
- Who will implement the intervention and where they will implement the intervention (the
context must be enabling)

Knowledge translation
Definitions
- Knowledge translation: “a dynamic and iterative process that includes synthesis,
dissemination, exchange and ethically sound application of knowledge to improve the
health of Canadians, provide more effective health services and products and strengthen
the health care system.” (CIHR definition)
- KT is required because more than a third of patients do not receive evidencebased
care, but the premature adoption of some interventions can lead to harm
- “Knowledge translation” sometimes used as a synonym for “implementation
science”
- Knowledge transfer: “Process of getting knowledge used by stakeholders”; “criticized
for suggesting that the process is unidirectional” (Graham et al., 2006)
- Knowledge exchange: Process of bringing together researchers and decisionmakers
and facilitating their interaction, which starts with collaborating on determining the
research question” (Graham et al., 2006)
- Knowledge implementation: “scientific study of methods to promote the systematic
uptake of clinical research findings and other evidence-based practices into routine
practice” (Graham et al., 2006) (see also: Implementation science)
- Knowledge diffusion: “passive unplanned efforts such as publishing an article in a
journal” (Graham et al., 2006)
- Knowledge dissemination: “tailoring the message and targeting it to a particular
audience” (Graham et al., 2006)

Awareness-to-adherence model
- Model developed to explain why physicians are unaware of, or do not use, clinical
guidelines
- Proposes that physicians “must first become Aware of [a specific guideline], then
intellectually Agree with it, then decide to follow it in their practice (Adopt it), then actually
succeed in following it at appropriate times (Adhere to it)
- “Interventions to improve guideline compliance are likely to miss their target and thus
prove ineffective if they do not recognize that guideline compliance can fail at any of four
steps. Redoubling guideline dissemination efforts when compliance is low–historically
the most common intervention to promote guideline adherence–may be helpful…where
significant numbers of physicians were unaware of or did not understand the
recommendations. On the other hand, [when physicians already know about the
guidelines], intensifying dissemination efforts will not improve adherence.”

Question 298

What are the 6 elements of the chain of transmission?

Answer 298

• Infectious agent: Bacteria, viruses, and fungi
• Reservoir: Ex. humans, animals, insects, water, food
• Portal of exit: How the infectious agent leaves the reservoir (e.g., sneeze)
• Mode of transmission: Contact, droplet, or airborne
• Portal of entry: How the infectious agent enters the host
• Susceptible host

Question 299

What are 4 federal laws relevant to public health emergency management?

What are 2 federal laws related to smoking?

Answer 299

• Canada Labour Code: Similar to the Ontario Labour Standards, except that the code
  applies only to federally regulated businesses and industries (e.g., banks, airports,
  telephones, uranium mining); outlines labour rights and responsibilities of employers and
  employees in these industries
• Canadian Human Rights Act: Protects individuals working for the federal government or
  receiving services from the federal government from discrimination based on race,
  national or ethnic origin, colour, religion, age, sex, sexual orientation, marital status,
  family status, disability, or a conviction for which a pardon has been granted
• Emergency Act (Canada): What used to be the War Measures Act; gives the federal
  government powers to regulate travel and evacuation, and establish emergency
  hospitals; no power to compel action to prevent the spread of disease
• Emergency Management Act (Canada): Assigns responsibility for federal-level
  emergency management and F/P/T emergency coordination to the Minister of Public
  Safety (basically, tells the federal government to cooperate with the provinces); requires
  federal institutions to develop emergency management plans
• Public Safety Act (Canada): Empowers the Minister of Public Safety and Emergency
  preparedness to issue interim orders if there is a significant risk to health or safety
• Quarantine Act (Canada): Authorizes the Minister of Health to establish quarantine
  stations that can be used to quarantine travellers or cargo that may spread a
  communicable disease; the Governor-General can make emergency orders prohibiting a
  people from a specific country entry into Canada using the Act
• Human Pathogens and Toxins Act (Canada): Applies to individuals conducting activities
  with human pathogens; bans activities with schedule 5 pathogens and toxins (currently,
  only smallpox); specifies training, audits, etc. required to work with human pathogens
  and toxins; enforced by PHAC
• Non-smokers’ Health Act (Canada): Like the Smoke-Free Ontario Act, but for federal
  workplaces
• Tobacco Act (Canada): Provides tobacco product standards; requires specific packaging
  on tobacco products and signage for retailers selling tobacco products; prohibits tobacco
  promotion

ONTARIO-SPECIFIC

• Accessibility for Ontarians with Disabilities Act (Ontario): Outlines the process for developing and enforcing accessibility standards; standards will be completed rolled out by 2025
• Emergency Management and Civil Protection Act (Ontario): Requires Ontario
  municipalities to develop, implement, and maintain an emergency management plans;
  allows for the declaration of a provincial emergency
• Human Rights Code (Ontario): Prohibits discrimination against individuals based on a
  protected ground (age, ancestry, citizenship, ethnic origin, place of origin, creed,
  disability, family status, marital status, gender identity, receipt of public assistance,
  record of offences, sex, and sexual orientation) in a protected social area
  (accommodation, contracts, employment, goods and services, memberships in unions or
  professional associations)
• Immunization of School Pupils Act (Ontario): Requires that all children attending school
  to have proof of age-appropriate immunization against diphtheria, tetanus, polio,
  measles, mumps, rubella, meningococcal disease, pertussis, and varicella
• Mandatory Blood Testing Act (Ontario): Allows anyone who comes into contact with
  bodily fluids as a result of being a victim of a crime, providing emergency health care
  services, or while working as a correctional officer, police officer, firefighter, paramedic,
  or nurse to apply to the MOH to require the source of the bodily fluids to be tested for
  HIV, HBV, and HCV
• Milk Act (Ontario): Controls milk advertising and production within Ontario; provides
  regulation for milk and milk product quality
• Occupational Health and Safety Act (Ontario): Defines the rights and duties for all parties
  in the workplace with respect to health and safety (see Occupational Health section)
• Ontario Building Code Act: Governs the construction, renovation, change of use, and
  demolition of buildings; the Ontario Building Code is a regulation under the Act that
  ensures public safety in newly constructed buildings

- ***Ontario Labour Relations Act***: Facilitates collective bargaining between employers and
trade unions; applies to all workplaces in Ontario except those that are covered by
another act (e.g., Fire Protection and Prevention Act, Canada Labour Code) or those
who do not belong to a collective bargaining unit

• Pay Equity Act (Ontario): Describes the requirements from ensuring that an employer’s
  compensation practices are equitable between male and female job classes; redresses
  systemic gender discrimination against women
• Smoke-Free Ontario Act: Bans smoking in enclosed work- and public places, and some
  outdoor spaces; requires that “No Smoking” signs be posted at all entrances, exits, and
  washrooms of designated facilities; enforced by local public health agencies

Question 300

Explain the LEADS framework.

Answer 300

LEADS Framework
- Framework developed by the LEADS Collaborative for healthcare leaders in Canada
- Sponsored by the Canadian College of Health Leaders, Royal Roads University,
and the Canadian Health Leadership Network
- Used by (for example) Accreditation Canada and the CMA’s Physician Manager
Institute
- “The underlying assumption of this framework is that effective personal leadership is
associated with a set of definable skill sets or capabilities that can be learned by
conscious and intentional effort”

Lead self:
- Self-aware: Be aware of your assumptions,values, principles, strengths, and limitations
- Manages self: Regulate the expression and experience of emotions, develop personal
mastery, achieve life balance (or work-life integration)
- Develop self: Develop soft skills (e.g., communication skills) and be a life-long learner
- Demonstrate character: Achieve personal integrity (trust, courage, authenticity, virtue)
and emotional resiliency

Engage others:
- Foster development of others: Support and challenge others to achieve personal and
professional goals
- Contribute to the creation of healthy organizations: Create an engaging environment
where others have meaningful opportunities to contribute and the resources to fulfill their
expected responsibilities
- Communicate effectively: Listen well and encourage an open exchange of information
and ideas using appropriate communication media (including “walking the talk”; one-onone
dialogue is the most effective method of communication)
- Build teams: Facilitate an environment of collaboration and cooperation to achieve
results
- Focusing solely on achieving tasks and goals can be detrimental; this focus
spurs overachievers to command and coerce, rather than coach and collaborate,
stifling team performance and future productivity

Achieve results:
- Set direction: Inspire vision by identifying, establishing, and communicating clear and
meaningful expectations and outcomes
- Vision should be a challenging, but realistic, future ideal about what the
organization can become
- Strategically align decisions with vision, values, and evidence: Integrate organizational
mission, values, and reliable, valid evidence to make decisions
- Take action to implement decisions: Act in a manner consistent with the organizational
values to yield effective, efficient, public-centred service
- Assess and evaluate: Measure and evaluate outcomes; hold yourself and others
accountable for results achieved against benchmarks and correct the course as
appropriate

Develop coalitions:
- Purposefully build partnerships and networks to create results: Create connections, trust,
and shared meaning with individuals and groups
- Mobilize knowledge: Employ methods to gather intelligence, encourage open exchange
of information, and use quality evidence to influence action across the system
- Exploring an environment for potential collaborations: Spot and monitor trends
(use multiple information sources); future search (create scenarios of alternative,
parallel futures); learn from others (what are other organizations doing?)
- Mobilize knowledge between organizations: Create porous boundaries (be open
to new ideas); scan broadly (look at organizations unlike yours); provide for
continuous interaction; nurture gatekeepers and boundary-spanners (individuals
with extensive internal and external networks); fight not-invented-here syndrome
- Demonstrate commitment to customers and service: Facilitate collaboration, cooperation
and coalitions among diverse groups and perspectives aimed at learning to improve
service
- Navigate socio-political environments: Be politically astute; negotiate through conflict
and mobilize change

Systems transformation:
- Demonstrate systems/critical thinking: Think analytically and conceptually, questioning
and challenging the status quo, to identify issues, solve problems, and design and
implement effective processes across systems and stakeholders
- Encourage and support innovation: Create a climate of continuous improvement and
creativity aimed at systemic change
- E.g., Plan-do-study-act, Lean management, force field analysis
- Orient strategically to the future: Scan the environment for ideas, best practices, and
emerging trends that will shape the system
- Champion and orchestrate change: Actively contribute to change processes that
improve health service delivery

Question 301

How is syphilis treated?

Answer 301

Case management:

Abstain from unprotected sex until adequate serological response is
attained; monitor serological response (e.g., RPR) until adequate serological response is attained (e.g., 4-fold drop at 12 months for early latent)

• Primary, secondary, early latent: Benzathine penicillin G, 2.4 million U IM x 1
• Late latent: Benzathine penicillin G, 2.4 million units IM q 1 week x 3 weeks
• Neurosyphilis, infants, penicillin allergies, pregnant women, HIV+ patients all get alternative courses to what is listed above
• *Contact management:**
• Empiric benzathine penicillin G, 2.4 million units IM x 1 for all sexual contacts of an infectious case, where contact occurred in the preceding 90 days
• Offer testing to all partners in the following time frames and treat if positive:
• Primary: 3 months
• Secondary: 6 months
• Early latent: 1 year
• Late latent and tertiary: Long-term partners and children
• Congenital: Mother and her sexual partners

Recommended Regimens for infants:

Aqueous crystalline penicillin G 100,000–150,000 units/kg/day, administered as 50,000 units/kg/dose IV every 12 hours during the first 7 days of life and every 8 hours thereafter for a total of 10 days
OR

Procaine penicillin G 50,000 units/kg/dose IM in a single daily dose for 10 days
OR

Benzathine penicillin G 50,000 units/kg/dose IM in a single dose

Data to support use of alternatives to penicillin in the treatment of primary and secondary syphilis are limited. However, several therapies might be effective in nonpregnant, penicillin-allergic persons who have primary or secondary syphilis. Regimens of doxycycline 100 mg orally twice daily for 14 days (411,412) and tetracycline (500 mg four times daily for 14 days) have been used for many years.

The only acceptable alternatives for the treatment of latent syphilis are doxycycline (100 mg orally twice daily) or tetracycline (500 mg orally four times daily), each for 28 days.

Pregnant women with primary or secondary syphilis who are allergic to penicillin should be desensitized and treated with penicillin.

Question 302

Describe the behavior change model: Theory of reasoned action and planned behavior

Answer 302

Theory of reasoned action and planned behaviour
- Theory of reasoned action was initially developed by Azjen and Fishbein; revised to the
theory of planned behaviour by Bandura to include self-efficacy
- Assumes people are rational (individual’s behaviour proceeds logically from their
beliefs); assumes intention to act is the most immediate determinant of behaviour

• Whether or not an individual’s behaviour will change is based on the following
  constructs:
• Behavioral intention (a person’s readiness to perform a behaviour)
• Attitude (toward the behaviour)
• Subjective norms (individual’s perceptions of societal norms; how much an
  individual wants to be like others; social desirability)
• Perceived behavioral control (how hard or easy the individual believes it is to
  change; self-judgement)
• Applying the theory:
  1. Define and describe the target behaviour, specifying the action, target, context,
  and time
  2. Determine how willing the individual is to engage in the target behaviour (e.g.,
  “how likely are you to…?”)
  3. Identify beliefs that need to be changed or strengthened to change or reinforce
  behaviour

Question 303

Describe the hierachy of food recalls

Answer 303

• *Mandatory food recalls** (removal of a food from all tiers of the affected distribution
  system) issued by CFIA and based on health risk:
• Health risk category 1: Reasonable probability food will lead to adverse serious, life threatening health consequences or an outbreak
• Health risk category 2: Reasonable probability food will lead to temporary or nonthreatening health consequences
• Health risk category 3: Reasonable probability food will not result in health consequences, but analysis suggests there was a breakdown in Good Manufacturing Practices, Good Agricultural Practices, or Good Practices in Veterinary Medicine
• Precautionary recall
• No recall, but continue investigation
• Voluntary recall = Recall initiated and carrying out by a company without a Ministerial Order

Question 304

What is Haddon’s matrix?

What are Haddon’s 10 injury prevention countermeasures?

Differentiate active and passive injury prevention

Answer 304

Haddon’s matrix

Analyzes:
“pre-event” factors
“event” factors
“post event” factors

Against:
“host/human” factors
“agent/vehicle” factors
“environment (physical and social)” conditions

Population-level interventions
Haddon’s countermeasures
1. Prevent the creation of the hazard (e.g., banning bodychecking in hockey for children 12
years and under)
2. Reduce the amount of the hazard created (e.g., catalytic converters)
3. Prevent the release of the hazard that already exists (e.g., milk pasteurization)
4. Modify the rate of release of the hazard from its source (e.g., nuclear reactor control
rods)
5. Separate, in time or space, the hazard and the individual (e.g., isolation of individuals
with communicable diseases from susceptible individuals)
6. Separate the hazard and the individual using a material barrier (e.g., childproofing)
7. Modify the hazard to make it less hazardous (e.g., reducing the space between crib
slats)
8. Make individual at risk more resistant to the hazard (e.g., immunization)
9. Counter the damage already done by a hazard (e.g., rescue operations)
10. Stabilize, rehabilitate, or repair damaged objects (e.g., rebuilding)

Active vs. passive prevention
- Active prevention: Prevention measures that require significant action on the part of
individuals; e.g. falls prevention for older adults
- Passive prevention: Prevention measures that require no action on the part of
individuals; measures that do not require the continued, active cooperation of an
individual are more effective than those that do; e.g., child-proof cigarette lighters, smoke alarms

Question 305

Describe basic facts about lead

Answer 305

Lead (*)

Testing: Test symptomatic patients and screen high-risk children. Counsel patients with BLL ≥0.5 μmol/L (≥10 μg/dL) to reduce exposure and repeat BLL in six months. Refer patients with BLL ≥2
μmol/L (≥45 μg/dL) for treatment; recommend diet high in iron (competitive Hgb binding), calcium, vit C (increases renal excretion)

Common sources:

• Lead plumbing (lead pipes used until 1920s; lead solder used until 1980s; run taps x 2 min or install
  filtration system)
• Contaminated soil and food (tetraethyl lead banned from road vehicles in Canada in 1989; wash hands, don’t play in dirt),
• house paint applied before the 1970s,
• work and hobbies (e.g., shooting ranges, stain glass, lead smelting, jewelry), and some imported products (e.g., Ayurvedic medicines)

Short-term effects:

Acute lead poisoning in Canada is rare; colicky abdo pain, anemia, headache, memory loss (usually BLL >> 60 μg/dL)

Long-term effects:

Neurotoxic: Intellectual deficits, behavioural problem (no threshold for adverse effects); can
cause encephalopathy and death
Microcytic anemia
Nephropathy (decreased GFR, increased sBP→HTN)
Neuropathy
Inorganic lead → IARC 2A
Organic lead → IARC 3

Question 306

Describe basic facts about trichinosis

Organism, Reservoir, Mode of transmission

Incubation period, infectious period

Epidemiology

Presentation, Testing

Case management, Contact management

+/- Immunization

Answer 306

Trichinosis (reportable)
- Organism: Trichinella spp. (roundworm)
- Reservoir: Lots of animals (pigs, dogs, cats, horses, bears, crocodiles, lions, Arctic
marine mammals)
- Mode of transmission: Consumption of raw or insufficiently cooked meat containing
viable larvae

• Epidemiology:
• Occurs worldwide, but human trichinellosis associated with pork from routinely inspected
  abattoirs is rare
• In Canada, the primary risk factors for trichinellosis are the consumption of
  undercooked or raw wild game, especially bear and walrus
• Presentation: Severity depends on number of larvae ingested; classically, myalgia +
  fever + periorbital/facial swelling that may be followed by subconjunctival or retinal
  hemorrhages, photophobia, thirst, weakness, and eosinophilia +/- GI, cardiac, or
  neurological involvement
• Incubation period: 8-45 days
• Testing: Serology + eosinophilia +/- muscle bx
• Case management: Albendazole or mebendazole +/- corticosteroids (however, viable
  larvae may survive in muscle tissue if dx and tx is not prompt)
• Contact management: If infectious meat is known to have been consumed, an individual
  can be given PEP with antihelminthic medication
• Other: Cooking, freezing, or irradiating meat kills the larvae (exception: Trichinella spp.
  that infect wild game in Canada are not consistently killed by freezing); all pork and wild
  game should be cooked until 71 C; curing, drying, and smoking meat does not
  consistently kill Trichinella larvae

Question 307

Describe a risk management process?

Answer 307

Steps in risk management (mnemonic PRODAE)

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
5. Take Actions to implement the decisions (see also: Risk communication)
6. Conduct an Evaluation of the actions
   Conduct all steps of risk management in collaboration with stakeholders

Question 308

Name 4 vaccines contraindicated in patients with severe immune suppression?

Answer 308

OPV, YF, MMR, BCG

Question 309

Define surveillance.

What type of health events are conducive to surveillance?

What are reasons to conduct surveillance?

What are the process steps of surveillance?

What are criteria to evaluate surveillance systems?

What are the process steps in evaluating surveillance systems?

Name examples of Canadian surveillance systems for flu, global/travel health, antimicrobial resistance, chronic diseases, immunization monitoring, enterics, injury, perinatal.

Answer 309

Public health surveillance
Definitions
- WHO definition: “the continuous, systematic _collection, analysis and interpretatio_n of health-related data needed for the planning, implementation, and evaluation of public health practice”
- CDC definition: “Public health surveillance is the ongoing, systematic collection, analysis, and interpretation of health data, essential to the planning, implementation and evaluation of public health practice, closely integrated with the dissemination of these
data to those who need to know and linked to prevention and control.”
- Surveillance may be performed on any point of the epidemiological triangle or disease pathway: Agent, environment, vector, exposure, disease, medical care, death

Types of surveillance systems
- Active: Public health plays an active role in gathering data; usually for specific, timelimited surveillance (e.g., enhanced surveillance following passive case identification)
- Passive: Public health plays a passive role (burden is on the reporter) (e.g., reportablediseases)
- Sentinel: Disease reporting for a limited network of limited sites; helpful for early identification of common diseases; not generalizable (e.g., sentinel influenza surveillance)
- Syndromic: A real-time or near real-time collection, analysis, interpretation, and dissemination of non-specific health indicators (e.g., clinical signs, symptoms, measures of absenteeism, drug sales, etc) that are automatically generated with
little to no reporting burden; offer assurance that nothing is happening, but thesetype of systems are largely untested (“Criticism and concern have arisen regarding the associated costs and the number of false alarms that will be fruitlessly pursued and whether syndromic surveillance will work to detect outbreaks” - CDC)
- Online surveillance cohorts (e.g., Flu Near You) (issue: attrition)
- Search-term trend surveillance (e.g., the now-defunct Google Flu Trends)
- Event-based (e.g., GPHIN (Global Public Health Intelligence Network based in Ottawa), HealthMap)

Characteristics of health events conducive to surveillance
- Important public health problem (e.g., as measured by incidence, mortality, severity,
socioeconomic impact)
- Preventable or controllable (i.e., prevention, treatment, or control measures are
available)
- Health system has the capacity to respond

Reasons to conduct PH surveillance activities

Estimate the burden of a health problem
Determine the distribution of an event and its determinants
Monitor trends in disease occurrence
Detect outbreaks and epidemics
Stimulate research
Detect changes in health services utilization
Facilitate program planning, monitoring, or evaluation

• *Steps in surveillance**
  1. Defining the purpose of the surveillance: Hazard, exposure, or outcome surveillance?
  2. Data collection
  3. Data analysis
  4. Interpretation (creating information from data)
  5. Dissemination to those who need to know
  6. Action to prevent disease or injury

Characteristics of well-conducted surveillance:
PS-FARTS + SVQ
- Positive predictive value: High proportion of positives are actually cases
- Sensitivity: Ability of the surveillance system to detect the health problem it was
intended to detect
- Flexibility: Ability of the surveillance system to accommodate changes in the operating
conditions
- Acceptability: To individuals and organizations who must participate
- Representativeness: Extent to which surveillance findings accurately portray the event
- Timeliness: Data available rapidly enough for public health authorities to take action
- Simplicity: Ease of operation
- Stability: Reliability of resources, personnel, and technology required to support the
surveillance system
- Validity: Surveillance data are measuring what they are intended to measure
- Quality: Complete and valid data

Evaluating surveillance systems
1. Engage stakeholder in the evaluation
2. Describe the surveillance system: Purpose, stakeholders, operation
a. Describe the public health importance of the health event under surveillance
(e.g., QALYs, case-fatality ratio, preventability, public interest)
b. Describe the purpose and operation of the surveillance system
c. Describe the resources used to operate the surveillance system (e.g., cost,
personnel, training, supplies, etc.)
3. Design the evaluation (what do you want to know and what is the most efficient way to
find out?)
4. Describe the performance of the surveillance system
a. How useful is the system?
b. Describe the system according to the characteristics of well-conducted
surveillance (above)
5. Justify and state conclusions/recommendations

Examples of surveillance systems
FluWatch: Positive lab reports of influenza and other respiratory viruses, lab-confirmed
outbreak reports, antiviral sales, influenza-associated deaths, and influenza-associated
hospitalizations from across Canada, by week, as well as strain characteristics and provincespecific
incidence (PHAC)

Global Public Health Intelligence Network: Geo-referenced reports of potential health threats
based on active monitoring of websites (not publicly available) (PHAC)

Canadian Integrated Program for Antimicrobial Resistance Surveillance (CIPARS): A mixed
passive and active surveillance system collecting data from physician diagnoses, hospital
purchasing, pharmacy sales, sentinel farms, and the Canadian Animal Health Institute on
antimicrobial use (PHAC)

Canadian Chronic Diseases Surveillance System (CCDSS): Prevalence, incidence, mortality, complications, co-morbid conditions, and health services utilization of chronic diseases, based on provincial and territorial health administration databases; not timely (PHAC)

Data sources:

• health insurance registry
• hospitalization databases
• physician billing claims databases
• prescription drug databases

Canadian Immunization Monitoring Program Active (IMPACT): Pediatric hospital-based active
surveillance system that monitors for adverse events following immunization

National Enteric Surveillance Program (NESP): Reports of lab-confirmed enteric illnesses
from P/Ts are submitted to the National Microbiology Lab, which reviews the reports for
trends and potential outbreaks; weekly summary of data is available to the provinces

PulseNet: National database of pulse-field gel electrophoresis patterns of all cases of E. coli
and most cases of Salmonella; used to detect related cases across large geographical areas;
system based on and shared with the CDC’s PulseNet USA (NML National Microbiology Laboratory - Canada)

Canadian Travel Medicine Network (CanTravNet): Network of travel and tropical medicine
clinics; sentinel surveillance program for illness in returned Canadian travellers and new
immigrants; the sites are a subset of the GeoSentinel Surveillance Network (ISTM - International Society of Travel Medicine_)_

Canadian Influenza Sentinel Practitioner Surveillance Network (CSPSN): Sentinel healthcare
practitioners obtain laboratory specimens, patient history, and vaccination status for all
influenza-like illnesses to determine influenza vaccine effectiveness using the “test-negative”
design (led by the BC Influenza Sentinel Practitioner Surveillance Network)

FoodNet Canada: Sentinel local public health units and provincial public health laboratories
report cases of food- and waterborne illnesses, along with an in-depth investigation of each
case, + sampling of retail, farm, and water sources (PHAC)

Canadian Perinatal Surveillance System (CPSS): Extracts 27 perinatal health indicators (e.g.,
breastfeeding rate, c-section rate, maternal mortality, multiple birth rate) from 6 data sources
(Vital Statistics, CIHI DAD, MED-ECHO, Dalhousie University, Manitoba Hospital Abstract
System, and the NLSCY); includes the Canadian Congenital Anomalies Surveillance Network
(CCASN)

Federally Reportable Diseases in Animals: Animal owners, veterinarians and laboratories are
required to immediately report confirmed or suspected cases of 31 diseases to the CFIA

Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP): Injury and poisoning
surveillance system; collects pre-event information (what was the person doing when they
were injured? what went wrong? where did the injury occur?) from individuals presenting with
injuries to 11 pediatric hospitals and 6 general hospitals

Question 310

Describe the canadian and global epidemiology of HIV?

Answer 310

Epidemiology:
Canadian epidemiology
- Prevalence in Canada = 0.2%; of the prevalent cases, 50% are MSM, 20% are PWID,
33% are heterosexual men and women, 9% are Indigenous, and 23% are women
- Prevalence in MSM = 16%
- Prevalence in federally incarcerated prisoners = 8% (F), 5% (M)
- Incidence in Canada = ~3,000 new infections/year

Global epidemiology
- Worldwide, an estimated 35 million people have HIV
- Prevalence has stabilized or is decreasing in most countries
- Fastest growing HIV epidemic = PWID in Eastern Europe
- Most people with HIV/AIDS (70%) live in sub-Saharan Africa; most people with
HIV/AIDS in sub-Saharan Africa are women (58%)
- Predominant modes of transmission:
- Sub-Saharan Africa and Southeast Asia: Heterosexual sex
- Eastern and Central Europe: Injection drug use
- South America: Sex work and MSM
- North America, Western Europe, and Australia: Injection drug use and MSM

Question 311

What is the federal framework around antibiotic resistance?

What are 2 surveillance programs for antimicrobial resistance?

What are reasons for antimicrobial resistance?

Answer 311

Antimicrobial Resistance and Use in Canada: A Federal Framework
- Surveillance: Detect and monitor antimicrobial resistance trends
- Canadian Nosocomial Infection Surveillance Program (CNISP): Monitors antimicrobial use and resistance in hospitalized patients
- Canadian integrated Program for Antimicrobial Resistance Surveillance
(CIPARS): Monitors antimicrobial use and resistance in humans, animals, and the food supply
- Stewardship: IPAC guidelines, education, regulations, and oversight in human and
veterinary medicine
- Innovation: Health research to combat antimicrobial resistance and improve antimicrobial use

Reasons for antimicrobial resistance: Use in vet medicine and agriculture, over-prescribing, OTC, inadequate IPC, global travel

Question 312

According to Ontario HPPA,

what are the responsibilities of a Medical Officer of health (MOH)?

Answer 312

Qualifications, roles, and responsibilities of public health professionals according to the Ontario HPPA

Medical officer of health
- Must be a PHPM physician (not applicable to MOHs employed on or prior to 1984) or is
a physician with some academic public health training (e.g., MPH)
- “Is responsible to the board for the management of the public health programs and
services;
- “Directs staff of the board of health (who are responsible to the medical officer of health)
if their duties relate to the delivery of public health programs or services;
- “Has authority that is limited to the health unit served by the board of health; and
- “Is entitled to attend each meeting of the board and its committees (except as relates to
the performance and remuneration of the medical officer of health).” (OPHS)

Business administrators
- Must have knowledge and experience equivalent to a BA in business administration or
commerce + 3 years experience in business management and administration

• *Public health dentists**
• Must have a specialty certificate in public health dentistry or completed equivalent training

Public health inspectors
- Must be certified by CIPHI or must be veterinarians with a certificate in veterinary public
health
- May issue a section 13 order, requiring “a person to take or to refrain from taking any
action that is specified in the order in respect of a health hazard”
- Under section 19 of the HPPA, may seize or destroy any “substance, thing, plant, or
animal other than man” that is a health hazard
- Under section 41, has rights of entry and powers of inspection

Public health nurses
- Must have a nursing degree that included “preparation in public health nursing”
- No delegated powers under the HPPA
- Section 71 of the HPPA: Every board of health must employ persons necessary to carry
out the board’s functions, including PHNs

• *Public health nutritionists**
• Must have a Masters degree in public health or community nutrition
• Nutrition services are a mandatory program under section 5 of the HPPA

IPAC professionals, health promoters, epidemiologists, and biostatisticians do not have
specifically legislated or regulated qualifications, roles, or responsibilities

Question 313

Describe basic facts about cholera

Organism, Reservoir, Mode of transmission

Incubation period, infectious period

Epidemiology

Presentation, Testing

Case management, Contact management

+/- Immunization

Answer 313

Cholera
Organism: Vibrio cholerae serogroups O1 and O139
Reservoirs: Humans, copepods, other zooplankton
Transmission: Fecal-oral; ingestion of infected organism
Presentation: Most cases are asymptomatic, but can cause severe, sudden onset, profuse, watery stools causing rapid dehydration and death
Case management: Cases require enteric precautions
Tx = Rehydration, doxycycline in moderate or severe cases
Public health interventions: Safe water, hand washing, safe food preparation, vaccination, sanitation
systems, disinfection of case feces and vomit in regions without sanitation systems

Question 314

Describe common pesticides and their potential health impacts on at-risk populations

Answer 314

Categories (5): insecticide, herbicide, fungicide, rodenticide, fumigants

• Glyphosate (organophosphate):Most widely-used herbicide in the world; classified as a IARC 2A in 2015 (non-Hodgkin’s lymphoma)
• Malathion (organophosphate): Widely-used insecticide; IARC 2A (prostate cancer)
• Neonicotinoids: Insecticide, highly toxic to bees and other beneficial pollinators (ecological harm); Health Canada proposed, but has not yet enacted, a ban
• Permethrin: Used in agriculture, public health (impregnated bed nets and clothing), clinical treatment (scabies and lice); neurotoxin, but less than 1% is absorbed through skin in humans (so not toxic if used correctly)
• Organophosphates: Acute exposure results in a cholinergic toxidrome (MUDDLESS miosis, urination, diaphoresis, diarrhea, lacrimation, emesis, excitation, salivation, seizures); can result in death via bronchospasm, bronchorrhea, and bradycardia. Antidote = pralidoxime, carbamate, anticholinergic
• Dichloro-diphenyl-trichloroethane (DDT) (organochloride): Commonly used organochlorine insecticide in the 1940s; excellent at controlling malaria and typhus; restricted as a Persitent Organic Pollutant under the Stockholm Convention (may only be used for malaria control); IARC 2B (liver cancer)
• Bacillus thuringiensis: Biological pesticide
• Atrazine: Herbicide (very environmentally persistent, but does not biomagnify); exposure is uncommon, except in individuals who work with or live near areas where atrazine is applied; in acute exposure, slightly to moderately toxic (irritation of the mucous membranes, N/V/D); long-term exposure can result in pre-term delivery;
  teratogenesis; IARC, group 3
• *Routes of exposure:**
• Oral: Accidental or intentional ingestions (acute toxicity), hand-mouth behaviour, food surfaces, well water
• Dermatologic: Spills (acute toxicity), children playing outdoors
• Respiratory: Aerial drift (indoor and outdoor air)
• *Risk groups:**
• Applicators
• Children
• Well water users
• Individuals living in areas with aerial spray drift

Question 315

What is an emergency response plan and what are its components (13).

What is a continuity of operations plan (COOP), what are some of its components and give an example of a plan.

Answer 315

In summary, common elements or ERP + COOP:

- Aim, scope, purpose

- Trigger for activation/demobilization

- Notification procedures, communication standards

- Roles + responsibilities, essential functions

- Structures, processes

- Partners, coordination

- Occ health + safety

Emergency response plan
Definition: Plan that defines the initiation and and conduction of an emergency response;
defines how the organization mobilizes to address an emergency (outward-looking)
- All-hazard plan: Plan can be applied to any emergency (aka emergency operations
plan) (e.g., Province of Ontario Emergency Response Plan)
- Incident-specific plan: Plan is specific to one type of emergency; may be an annex to
an all-hazard plan or a stand-alone plan (e.g., Ontario Health Plan for an Influenza
Pandemic); incident-specific plans are usually developed for high-risk hazards identified
through the HIRA
- Incident action plan: Component of IMS; verbal or written plan identifying specific
objectives to be achieved that are developed during the emergency response; consistent
with the ERP (Emergency response plan)

Components of an ERP:
1. Aim
2. Authority
3. Relationship to other plans
4. Plan activation and demobilization
a. In Ontario, the ERP is activated when the regional Incident Management Group
is activated
5. Notification procedures
a. Internal (staff)
b. External (partners and stakeholders)
6. Roles and responsibilities (aligned with the IMS)
7. Public health emergency control group or equivalent
8. Emergency operations centre
9. Crisis communication
10. Occupational health and safety
a. Evacuation procedures
b. Accommodation during an emergency
11. Arrangements for psychosocial supports for board of health staff
12. Coordination with other agencies
13. Tools, structures and processes to be utilized in emergency response.

Continuity of Operations Plan (COOP)
Definition: Plan that defines how organizational interests will be protected and essential
operations will be sustained during an emergency (aka business continuity plan); defines how
an organization mobilizes to sustain its essential functions during an emergency (inwardlooking)

Common components of a COOP
Background: Assumptions underlying COOP, integration of COOP with those of other
departments or organizations, purpose and scope of COOP, and situation overview (why is
the COOP necessary?)
Alternate operating facility description (e.g., number of electrical outlets), map/driving
directions, and address
Alternate site check-in procedure
Alternative vendors and suppliers
Alternative work arrangements (e.g., shift work, telework)
COOP activation notification or staff recall procedure (e.g., automated dialling notification
system)
COOP condition alert levels (i.e., how quickly should we be able to activate the COOP?)
COOP implementation plan (“Concept of Operations”)
COOP maintenance schedule
Description of backup systems for vital records, records, databases
Description of budgeting and acquisition of resources during an emergency
Description of dependencies (what organizations or services does your organization rely on to
perform essential functions?)
Description of essential equipment and back-ups
Description of essential organizational functions
Description of the loss of resources on essential functions
Drive-away kits/go bags
Employee COOP training schedule
Employee responsibilities during COOP activation
Employees required for essential functions (list)
External contact list
Memoranda of understanding/mutual aid agreements
Order of succession
Pre-delegation of emergency authority
Procedure: Devolution/ reconstitution/ return to normal operations
Procedure: Relocation
Recovery point objective for essential functions (i.e., amount of data that can be lost)
Recovery time objective for essential functions
Site vulnerability analysis
Triggers for COOP activation/step-down
Common COOP scenarios
- Strike contingency planning
- Loss of access to a facility
- Loss of services due to equipment or system failure
- Natural disaster
- Pandemic influenza

Case study: Strike contingency planning
1. Identify and prioritize critical functions of the organization
2. Identify the minimum number of staff and the minimum skill set required to maintain the
critical functions (can these functions be temporarily filled by management?
contractors?)

3. Develop strategies to reduce the impact of the strike on critical functions (e.g.,
   alternative work locations, site closures)
4. Determine how the organization will proceed with non-critical functions during a strike
   (e.g., temporarily cease the function, reduce function)
5. Develop strategies to address the following during the strike:
   a. Security (e.g., how will you ensure safety of staff who continue to come to work?)
   b. Staff redeployment
   c. Replacement workers/contractors
   d. Picket line monitoring
   e. Communication (external and internal)
   f. IT (e.g., can striking staff access their voicemail, e-mail, etc.?)
   g. Payroll
   h. Human resources
6. Based on steps 1-5, write a strike contingency plan
7. Train management staff to deploy the strike contingency plan

Question 316

What are important considerations to get a communication plan right?

Answer 316

Types of public health communications
Health education -> Individual, family
Social marketing -> Community, population
Mass media campaign -> Population
Media advocacy ->Population, policymakers

Communications plan: Description of how to convey the right message from the right
communicator to the right audience through the right channel at the right time; includes most of
the same components as a health communication campaign; considerations: SAMM (speaker,
audience, medium, message)

Timing of communications plans:
1. Proactive: Usually tied to release of known information; advance planning; follows a
known cycle (e.g., West Nile in the summer, influenza in the fall)
2. Reactive: Usually tied to issues management; little to no advance planning; may still
follow a known cycle (e.g., influence outbreak in early winter) (see also: Crisis
communication)

Question 317

In survival analyses, what is the censoring and truncation?

Answer 317

Survival analysis
Answers the question: Is survival time between two groups different?
Why do you have to do a difficult survival analysis instead of just using a Poisson analysis?
Because following people is complicated:
- Censoring: “Phenomenon of unobserved values of the response measurement”;
“particular characteristic of time-to-event data that has led to the development of
statistical tools specific to this type of response measurement”; the individual has been
counted, but the outcome is unknown
- Right-censoring: Study ends before all survival times known (e.g., most deaths
occur after the study ends)
- Left-censoring: Death occurred before the study period began, but unknown
when the death occurred

• Truncation: “Condition that screens or excludes units from the study population”; the
  individual has not been counted and the outcome is unknown
• Left truncation: “Individuals are excluded because their response is too small”
• Right truncation: “Individuals are excluded because their time-to-response time
  is too large”
  *Survival data are usually right-censored and left-truncated
• Possible approaches:
• Parametric
• Semi-parametric: Proportional hazard/Cox regression (hazard ratios)
• Non-parametric: Kaplan-Meier
• Log-rank
• Mantel-Haenszel
• Hazard regression

Question 318

List 7 infectious diseases that are screened for in pregnancy

Answer 318

Infectious disease screening in pregnancy
- Syphilis: Can cross the placenta after 18 weeks GA; maternal syphilis can cause
congenital syphilis (hepatosplenomegaly, osteochondritis, CNS malformation) and
increases the risk of vertical perinatal HIV transmission
- Rubella: Maternal rubella infection in the first trimester can cause congenital rubella
syndrome (cataracts, hepatosplenomegaly, congenital heart disease, MR, IUGR)
- Gonorrhea and chlamydia: Untreated GC or CT can cause ophthalmia neonatorum;
untreated CT can cause chlamydial pneumonia in the newborn; untreated GC can cause
PROM, chorioamnionitis, and perinatal mortality
- Hepatitis B (surface antigen): Infants of mothers who are HBsAG + require HBV vaccine
and HBIG
- HIV: Mother-to-child transmission accounts for most pediatric HIV infections; in 80% of
cases, the virus is transmitted after 36 weeks; transmission can be prevented with
maternal treatment
- Group B strep: Major cause of newborn sepsis; GBS colonization occurs in 1-30% of
births; testing is recommended at 35-37 weeks GA, with intrapartum chemoprophylaxis
for mothers who test positive
*Toxoplasmosis: Not recommended as part of routine obstetrical care; recommend avoiding
contact with cat feces
*Parvovirus: Not recommended as part of routine obstetrical care; test women who may have
been exposed (approx 60% of adults are immune)
*Cytomegalovirus: Not recommended as part of routine obstetrical care; maternal immunity
does not prevent congenital infection
*Hepatitis C (antibody): Testing recommended for only women at high risk
*Varicella: Testing recommended only in women without a definite history of prior chickenpox or
immunization against chickenpox

Question 319

Describe the behiavor change model: Social cognitive theory

Answer 319

Social cognitive theory
- Whether or not an individual’s behaviour will change is based on: When an individual
observes others performing a behaviour, whether or not others are rewarded for that
behaviour determines whether or not the individual will replicate that behaviour

• Constructs:
• Reciprocal determinism: Interaction between the individual, behaviour, and
  environment
• Behavioral capability: Knowledge and skill to perform a given behaviour
• Expectations: Anticipated outcomes of a behaviour
• Self-efficacy: Confidence in one’s ability to take action and overcome barriers
• Observational learning/modelling: Behavioural acquisition that occurs by
  watching the actions and outcomes of others’ behaviours
• Reinforcement: Punishment/reward in response to a person’s behaviour that
  increase or decrease the probability of recurrence

Question 320

What are routine IPC precautions?

Answer 320

Routine practices: Practices used with every patient, every time, regardless of their infection
status; protects providers and patients from unknown infectious agents (basically: assume all
blood, bodily fluid, body secretion, mucous membranes, non-intact skin, and soiled items are
infectious); includes brief risk assessment, hand hygiene, waste management, and the use of
appropriate PPE

Question 321

What are the indications for HIV PrEP?

Answer 321

Individuals at high risk of HIV infection:

• engages in condomless sexual activity with an HIV-positive partner who is not on treatment or whose viral load* is ≥ 200 copies/ml
• engages in condomless sexual activity with a partner whose HIV status is unknown
• engages in sexual activity that involves: • no or inconsistent condom use • exchange of sex for drugs or money
• use of illicit drugs or alcohol dependence • shared drug use equipment
• have a diagnosis of sexually transmitted infections (STI)
• prison experience

In addition, PrEP should be considered for individuals who have taken PEP (i.e., who are at ongoing, high risk of infection).

Truvada (tenofovir-emtricitabine)

Question 322

How are powers divided between federal and provincial governments?

Answer 322

Federated system and division of powers
- Parliament can make laws governing all of Canada, for matters specifically assigned to it
under the Constitution and related to the country as a whole: criminal law, national
defence, foreign affairs, interprovincial trade, “POGG” (peace, order and good
government)
- P/Ts can make laws that apply only within provincial boundaries: hospitals, civil rights,
municipalities, education, administration of justice

• Neither the federal government nor the P/Ts have specific or exclusive power for health,
  with the exception of:
• Federal government responsible for quarantine and marine hospitals
• P/Ts responsible for other hospitals
• Federal government responsible for POGG and therefore public health emergencies
• Federal jurisdiction over drugs, food, controlled substances, medical devices, tobacco,
  cosmetics, consumer products, radiation emitting devices, etc. emerges through criminal
  law
• Municipalities have no lawmaking power under the Constitution
• Municipalities are created by provinces; their power is delegated by the provincial
  legislature
• Municipalities may enact bylaws that address municipal issues; bylaws may not conflict
  with provincial or federal legislation

Question 323

What entity approves vaccines in Canada?

Answer 323

Health Canada, Biologics and Genetic Therapies Directorate verifies the safety and efficacy of
the vaccine
- Issues Notice of Compliance (once this issued, vaccine is available for private purchase)
- Inspect and regulates manufacturing plants
- Reviews and assesses the data provided by the manufacturer from clinical trials (product
monograph)
- Tests every lot of vaccine
- Does not make recommendations

Question 324

Define health promotion.

What are prerequisites for health?

What are health promotion values/principles?

What are health promotion skills, actions?

Answer 324

• *Health promotion**: Process of enabling people to increase control over, and to improve, their health
• “To reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical
  capacities. Therefore, health promotion is not just the responsibility of the health sector, but goes beyond healthy life-styles to well-being.”
• Prerequisites for health: Peace, shelter, education, food, income, a
• *Health promotion values/principles**:
• Inclusion/participation: Everyone is heard
• Social justice and equity: Resources are allocated based on need
• Respect: Recognition of the worth of individuals and communities
• Empowerment: Creating environments that support the ability for individuals or communities to take control over their own health
• Holistic – taking account of the separate influences on health and the interaction of these dimensions..
• Intersectoral, multi-strategy – working in partnership with other relevant agencies/organisations.
• Sustainable – ensuring that the outcomes of health promotion activities are sustainable in the long term.
• Health promotion skills:
• Advocate: Advocate for political, economic, social, cultural, environmental, behavioural and biological conditions that are favourable to health
• Enable: Enable people to take control of the determinants of their health, with the goal of achieving equity in health
• Mediate: Professionals, social groups, health personnel have a responsibility to mediate between differing societal interests
• Health promotion actions (mnemonic: cool people reject horrible sweatpants):
• Strengthen community actions: Empower community action to improve social support and public participation
• Develop personal skills: To cope with illness and injury, to make healthy choices, and to exercise control over their own health and environment
• Reorient health services: Expand the mandate of health services beyond clinical and curative services to support individuals and communities to provide for the whole person
• Build healthy public policy: Legislation, fiscal measures, taxation, and
  organizational change should improve health equity and make healthier choices easier
• Create supportive environments: Refers to the “socioecological environment”; Care for our communities and our natural environment by conserving resources, healthy working conditions, and considering the health impact of environmental changes

Question 325

What are the benefits and risks of breastfeeding?

What are medical indications for formula?

Name elements of the baby-friendly hospitals and the International Code of Marketing Breastmilk Substitutes

Answer 325

Lactation and breastfeeding
Joint statement of Health Canada, the Canadian Paediatric Society, Dietitians of Canada and the Breastfeeding Committee for Canada (2013): “Breastfeeding - exclusively for the first six
months, and sustained for up to two years or longer with appropriate complementary feeding - is important for the nutrition, immunologic protection, growth, and development of infants and
toddlers.”

• *Breastfeeding epidemiology**
• 90% of women begin breastfeeding their babies; 25% of women are exclusively breastfeeding their babies by 6 months
• Mothers who breastfeed exclusively for 6+ months are more likely to be 30+ years old, have postsecondary education, and be in a relationship
• Most commonly reported reasons for not breastfeeding or stopping breastfeeding before 6 months:
• Bottle feeding is easier
• Medical condition in mother or baby
• Not enough breast milk
• Difficulty with breastfeeding technique
• Baby ready for solids
• Return to work or school
• 80% of exclusively-breastfed babies receive vitamin D supplementation
• *Evidence-based benefits of breastfeeding**
• Improved immunity (reduced incidence of RTI, GE, OM) in the first two years of life
• IgA from human milk coats the gut, but is not absorbed into the bloodstream
• Reduced risk of maternal breast cancer
• Reduced risk of SIDS (small ARR; supine sleeping is much more effective)
• Enhanced maternal weight loss (this is a harm in undernourished populations)
• Prevention of dental fluorosis
• Decreased risk of dental malocclusions
• Delay in return of fertility

- Decreased postpartum bleeding

• *Potential benefits of breastfeeding** (insufficient or mixed evidence)
• Reduced incidence of metabolic syndrome, obesity, diabetes, hypertension, hyperlipidemia, NEC, eczema
• Improved speech-language development
• Reduced risk of maternal ovarian cancer

Purported benefits of breastfeeding that are not supported by evidence

• Free (feeding q2-3h x 30-45min = 4-9h/day is not free!)
• Increased intelligence
• Reduced risk of childhood cancers
• Protection against allergic disorders
• *Risks and harms of breastfeeding**
• Increased risk of dental caries if breastfeeding > 1 year
• Iron-deficiency anemia (prevent with supplementation or introduction of complementary iron-rich foods; infants usually have sufficient iron stores for the first 4-6 months)
• Mastitis, cracked nipples, and thrush
• Health inequity (prevent with better parental leave and income support policies)

Medical indications for formula (WHO, UNICEF, 2009)
- HIV
- Severe maternal illness
- HSV-1 lesions on mother’s breast
- Certain maternal medications (e.g., radioactive iodine-131, cytotoxic chemotherapy)
Note: Breastfeeding can still continue if a mother is misusing substances (e.g., alcohol, cocaine, nicotine), but these may have negative impacts on the infant

Baby-Friendly Initiative: Practice Outcome Indicators
1. Have a written breastfeeding policy that is routinely communicated to all health care providers and volunteers.
2. Ensure all health care providers have the knowledge and skills necessary to implement the breastfeeding policy.
3. Inform pregnant women and their families about the importance and process of breastfeeding.
4. Place babies in _uninterrupted skin-to-skin c_ontact with their mothers immediately following birth for at least an hour or until completion of the first feeding or as long as the
mother wishes. Encourage mothers to recognize when their babies are ready to feed, offering help as needed.
5. Assist mothers to breastfeed and maintain lactation should they face challenges including separation from their infants.
6. Support mothers to exclusively breastfeed for the first six months, unless supplements are medically indicated.
7. Facilitate 24-hour rooming-in for all mother-infant dyads: mothers and infants remain together.
8. Encourage baby-led or cue-based breastfeeding. Encourage sustained breastfeeding beyond six months with appropriate introduction of complementary foods.
9. Support mothers to feed and care for their breastfeeding babies without the use of artificial teats or pacifiers (dummies or soothers).
10. Provide a seamless transition between the services provided by the hospital, community health services and peer support programs. Apply principles of Primary Health Care and Population Health to support the continuum of care and implement strategies that affect
the broad determinants that will improve breastfeeding outcomes.

• *International Code of Marketing Breastmilk Substitutes (WHO**)
• Educational materials about infant feeding must include the benefits and superiority of breastfeeding and the difficulty of reversing the decision not to breastfeed
• Formula manufacturers must not provide pregnant women with formula samples or items that promote the use of formula
• Hospitals may not display formula or advertising for formula
• Healthcare workers should encourage breastfeeding
• Volume of sales incentives should not be used for formula
• Formula labels must not discourage breastfeeding and must state that breastfeeding is superior
• Formula labels must warn of the risks of inappropriate preparation
• Formula labels must not have pictures of infants or anything that idealizes the use of formula
• Governments must monitor the effectiveness of policy implementation related to this code

Baby-friendly requirements:

Achieve accreditation
Apply WHO code for marketing
Apply 10 principles
Achieve program-defined targets

Question 326

What are 4 assumptions of the SIR infectious disease model?

Answer 326

Assumptions of the basic SIR model:

• The population is closed (no one is immigrating, dying, or being born) )okay for outbreaks that are occurring so quickly that they are not affected by demographics)
• Every person in the population has an equal chance of interacting with anyone else in the population
• The transmission rate doesn’t change
• Individuals in the recovered compartment are immune

Question 327

What is HACCP and what are its 7 principles?

Answer 327

Hazard Analysis Critical Control Point (HACCP): A food safety management system developed
by freakin’ NASA and Pillsbury company that consists of the following seven principles:
1. Assess the hazards and risks associated with growing, harvesting, raw materials,
ingredients processing, manufacturing, distribution, marketing, preparation and
consumption of the food in question
2. Determine the critical control points required to control the identified hazards
3. Establish the critical limits that must be met at each identified CCP
4. Establish procedures to monitor the CCP
5. Establish corrective actions to be taken when there is a deviation identified by monitoring
a given CCP
6. Establish procedures for verification that the HACCP system is working correctly
7. Establish effective record-keeping systems that document the HACCP plan

HACCP uses a systems theory and multi-barrier approach (“Farm to Fork”)
- Considers the dynamic and sometimes self-reinforcing behaviours of systems when
investigating or trying to prevent foodborne outbreaks (Inputs, processes, outputs, feedback)
- Also considers systems within systems (e.g., food workers, equipment, and economics
of a restaurant). Points of intervention (each are systems within system): source, rocessing/manufacturing, distribution, point of final service

Question 328

Describe the different types of water advisories (boil water, water avoidance)

Answer 328

Water advisories
- Most water advisories are issued on a precautionary basis (i.e., due to the possibility of
water contamination, rather than because of actual contamination)
- Boil water advisory (BWA): Issued by LPHA or the water utility because there is
evidence that the water is/may be biologically contaminated; either: 1. The water is
contaminated (unacceptable levels of microorganisms OR unacceptable levels of
turbidity) or 2. The water may become contaminated (e.g., emergency repairs)
- BWA may be issued on a precautionary or emergency basis
- Precautionary BWA: Issued in response to a risk of water contamination
without detection of E. coli (e.g., significant pressure drop, minor
equipment malfunction, unexpected turbidity)
- Emergency BWA: Issued in response to confirmed detection of E. coli in
the water(see flow chart below) (only 5% of BWAs in Canada are
emergency BWAs)
- In Ontario, the Ontario Drinking Water Quality Standards determine when BWA
must be issued
- Water must be boiled for at least 1 min
- Boil all water used to drink or for food preparation (e.g., water used to
wash veggies or make ice cubes)
- Water can be used without boiling to wash dishes, do laundry, or bathe
- People who will drink bathing water (e.g., infants) should be spongebathed
- Drinking water advisories (DWA)/Water avoidance advisories: Issued by LPHA
when there is evidence that water may be chemically contaminated and boiling the water
will not reduce the risk (boiling the water will increase the risk because it will concentrate
the chemical of concern); DWA are rare in Canada (account for only 2% of drinking
water advisories)
- 2 types of DWA: 1. Do not use DWA; 2. Do not consume DWA
- In Ontario, the Ontario Drinking Water Quality Standards determine when DWA
must be issued

Question 329

Name 8 principles of incident management systems.

What are the IMS personnel roles [ncident commander, command staff (3), general staff (4)]?

Answer 329

Incident Management System (IMS)

In summary:

Simple, modular, flexible, scalable

Standardized

Interoperable

Unity of command

Integrated comms

IMS staff: mnemonic = ESL - FLOP

Emergency info, Safety, Liaison - Finance, Logistics, Operations, Planning

Principles:
- Modular: Composed of discrete but interrelated components
- Standardized: Shared management structures and terminology
- Interoperable: The functional and technological ability for responders from different
jurisdictions and organizations to work together (e.g., by sharing the same procedures
and communications technologies)
- Unity of command: Each person, at every level, reports to only one clearly designated
supervisor
- Simple: Elements are eliminated when no longer needed
- Flexible and scalable: Can be expanded to address any size of incident; a single
person can act alone as an the entire incident management system (i.e., if one person is
sufficient to address all needs, then there is no need to establish a command or general
staff); as needs change, system can be scaled up
- Integrated communications

Components
Concepts
- Incident Command: The authority and responsibility for all incident responses; only one
person, the incident commander, exercises these functions
- Single command: Incident decision-making involves only one jurisdiction
- Unified command: Required when decision-making regarding the incident must
be interjurisdictional; joint decisions are made within the unified command and
announced by a single spokesperson

• Incident Action Plan: Verbal or written plan identifying specific objectives to be
  achieved
• Operational period: Period of time assigned to complete the objectives of the
  IAP; usually less than 24 h
• Supporting plans: Plans developed in support of the IAP; like the IAP, may be
  verbal for simple incidents; examples include:
• Incidence Medical Plan: Details plan for medical access for responders
• Incident Telecommunications Plan: Details telecommunication methods to
  be used during the response
• Span of control: In IMS, effective span of control is 3 to 7 components, with 5
  components being preferred; span of control must be maintained by expand or
  contracting components
• Operational briefing: A meeting attended by all supervisory personnel; IAP is
  distributed; tasks are assigned
• Organizational chart: Organized into Sections, Branches, and Groups or Units
• Contraction: When an organizational unit is no longer required, it is eliminated from the
  organizational structure
• After-action report: Documents the tasks performed to manage the incident and can
  recommend improvements; written by the Incident Command

Locations
- Incident command post: Headquarters of the Incident Command
- Staging area: Temporary location where available resources (personnel and equipment)
wait to be assigned
- Emergency information centre: Location where media inquiries are addressed
- Emergency operations centre: Facility from which support to the Incident Command is
organized and coordinated (e.g., location with a back-up generator, multiple phone lines,
and meeting space); does not need to be activated for simple incidents
- Base: Location from which logistical and administrative functions are coordinated; may
serve as a place to eat, sleep, or repair items; only 1 base/incidence
- Camp: Like a small, temporary base where responders can eat and sleep
- Airbase: Location from which fixed wing and rotary wing aircraft operate

IMS personnel
- Incident commander: Person or team responsible for managing all responses to an
incident
- In public health, this may be split into two roles, the executive lead (authorizes)
and the incident manager (manages)

• Command staff: For complex incidents, the command staff take on some of the
  responsibilities that initially rested with the incident command; command staff usually
  includes an emergency information officer, a safety officer, and a liaison officer, and may
  include other subject matter experts
• Emergency information officer: Responsible for the development and release
  of emergency information to the public and media
• Safety officer: Responsible for processes and procedures that ensure the safety
  and overall health of responders
• Liaison officer: Responsible for coordinating cooperation with and support from
  outside organizations (e.g., NGOs, industry)
• General staff: Responsible for supporting the incident command by carrying out FLOP:
  finance/administration, logistics, operations, and planning
  (“pays/gets/implements/prepares”)
• Operations Section Chief: Responsible for organizing and supervising all resources
  assigned to an incident, including air operations and staging area; individuals reporting
  to the Operations Section Chief may be organized into:
• Single resource: One person or one piece of equipment + crew
• Strike team: Resources of the same kind and type assembled for a particular
  purpose (e.g., firefighters tasked with fighting a fire)
• Task force: An organizational component of mixed resources assembled for a
  particular purpose; must have shared communications (e.g., firefighters + road
  graders tasked with fighting a fire) (task-based)
• Group: An organizational component that report to the same supervisor; that
  supervisor reports to the Operations Section Chief (e.g., police officers reporting
  to the same supervisor) (occupation-based)
• Division: An organizational component assigned to a specific geographical area,
  lead by a supervisor (geography-based)
• Planning Section Chief: Responsible for coordinating the development of Incident
  Action Plans, as well as long-range/contingency plans and tracking all resources;
  individuals reporting to the Planning Section Chief may be organized into:
• Resources Unit: Responsible for maintaining the status of all assigned resources
• Documentation Unit: Responsible for maintaining incident files
• Demobilization Unit: Responsible for returning resources to their original condition
• Logistics Section Chief: Responsible for the provision of all supporting resources (e.g.,
  facilities, medical services, food) required to implement the IAP
• Finance and Administration Section Chief: Responsible for tracking and reporting
  spending, reimbursing expenses, and negotiating contracts; individuals reporting to the
  Planning Section Chief may be organized into:
• Procurement unit
• Time unit
• Cost unit
• Compensation/claims unit

Question 330

Describe the behavior change model: Transtheoretical/Stages of change model

Answer 330

Transtheoretical/Stages of Change model
- Whether or not an individual’s behaviour will change is based on: Motivation and
readiness to change

• Stages:
  1. Precontemplation: Has no intention of taking action within the next six months
  2. Contemplation: Intends to take action in the next six months
  3. Preparation/Decision: Intends to take action within the next 30 days and has
  taken some behavioral steps in this direction
  4. Action: Has changed behaviour for < 6 months
  5. Maintenance: Has maintained changed behaviour for > 6 months

Question 331

What are persitent organic pollutants?

Answer 331

Persistent organic pollutants
- POPs: Lipophilic synthetic compounds that are subject to long-range transmission and
adversely affect human health and the environment; POPs persist in the environment
and biomagnify through the food chain in human and animal fatty tissues; most POPs
can be detected in breast milk and cross the placental barrier
- POPs also bioaccumulate (bioaccumulate = accumulation within one organism;
biomagnify = increasing concentrations up the food chain)
- S_tockholm Convention on Persistent Organic Pollutants: A UN treaty adopted in
2001 and entered into force in 2004 that lists 12 POPs_ that signatory governments will
reduce or eliminate the production, use, or release of; POPs persist for years in the
environment, so POPs generated in one country can affect people and the environment
in other countries, necessitating an international treaty
- Beginning in 2009, additional POPs are added to the Stockholm convention
every other year
- At-risk populations: Indigenous people whose diets primarily comprise country foods,
children, the elderly, and individuals of childbearing age
- POP levels in Canadian Inuit in Nunavut are generally below guideline levels of
concern
- International efforts to reduce or ban POPs have resulted in a decline in legacy
POP concentrations in the Canadian Arctic

Examples of POPs include the following pesticides:

Aldrin. This has been used to kill insects like termites and grasshoppers.

Chlordane. This chemical can also be used to kill termites.

DDT. This is an infamous chemical that has been used against mosquitoes.

Dieldrin. Its main use is for termite control.

Endrin. While it’s an insecticide, it’s also used to kill rodents.

Heptachlor. This can be used to kill everything from termites to grasshoppers to mosquitoes.

Hexachlorobenzene. This compound has been used to kill fungi that may damage food crops.

Mirex. This is used to control fire ants and termites.

Toxaphene. This kills insects on produce, cotton, as well as ticks and mites on livestock.

DDT

Other POPs include:

Polychlorinated biphenyls, betters known as PCBs. PCBs are used in everything from paint to heat exchange fluids to plastics.

Polychlorinated dibenzo-p-dioxins, or PCDDs. These are produced as byproduct of various manufacturing processes, including those of pesticides. They can also be emitted when everything from municipal to hospital waste to gasoline to wood is burned.

Polychlorinated dibenzofurans, PCDFs. These can be found emitted from automobiles and from the burning of waste. They are also byproducts of the manufacture of PCBs.

Other POPs include Alpha hexachlorocyclohexane, Beta hexachlorocyclohexane, Chlordecone, Decabromodiphenyl ether, Hexabromobiphenyl, Hexabromocyclododecane, Hexachlorobutadiene, Lindane, Pentachlorobenzene, Pentachlorophenol, Perfluorooctane sulfonic acid, perfluorooctane sulfonyl fluoride, Polychlorinated naphthalenes, Short-chain chlorinated paraffins (SCCPs), Technical endosulfan, Tetrabromodiphenyl ether and pentabromodiphenyl ether.

Question 332

Describe the SDOH ecological model

Answer 332

Ecological model

• Health behaviours, and ultimately health outcomes, are the result of complex interactions between individual (behavior choice), interpersonal (family/friends), organizations (work/school), community (neighborhood), and societal (public policy)
• Multiple-level interventions are most effective

Question 333

What is the routine childhood immunization schedule?

[to verify if updates]

Answer 333

Question 334

Describe core principles of foodborne illness outbreak investigations.

What are pathogens associated with foodborne illnesses?

Answer 334

Food-borne illness outbreak investigation
- Foodborne outbreak = 2+ persons from different households experience a similar illness after a common source of exposure
- Suspected foodborne outbreak → collect food and stool samples → test for foodborne pathogens → compare pathogens from food to pathogens from stool
- *must demonstrate that the isolate causing human illness is the same as the isolate from the implicated food; usually use PFGE patterns
- Matches between common PFGE patterns (i.e., organism with low PFGE diversity) offer weak evidence
- Only foods implicated on epidemiological groups (e.g., food-specific attack rates) should be submitted for analysis immediately; other foods can be collected and stored, then submitted to the laboratory if initial results do not identify an etiological agent
- Collecting feces specimens for outbreak investigation (Ontario-specific): Use Enteric Outbreak Kit (contains three vials: bacterial, parasitology, viral and toxin) x the first 10-15 specimens; if the outbreak is most likely bacterial or viral, parasitology vials do not need to be collected
- Coring = Technique used to acquire an uncontaminated sample from an nonintact (package open) sample that is suspected of causing (otherwise, difficult to assess whether the pathogen was introduced by the consumer or by the manufacturer)
- Suspected foodborne outbreak → collect food histories from cases and controls → assess for statistically significant association between a single food product and illness
- Consider adapted Bradford Hill criteria:
1. Plausibility: Pathogen has been previously implicated in similar outbreaks
2. Consistency (food): Consumption of specific food item reported by most cases
3. Consistency (temporal/spatial): Tight temporal and spatial clustering
4. Specificity: Single food product implicated
5. Strength of association: Case-control or cohort study demonstrates statistically
significant association
6. Temporal: Food consumed within incubation period
7. Dose-response: The more of the item that is eaten, the more likely the individual
becomes ill (often impractical to perform)
8. PFGE: Consistent with epi
9. Alternative explanations: None are consistent
- Traceback: Identify where food originated from
- Traceforward: Identify where the food was distributed to
- For both traceback and traceforward, consider farm → importer → processor →
manufacturer → distributor → point of purchase → consumer’s home
- Can use packaging, UPC codes, receipts, credit card records,
membership/loyalty cards, invoices

Pathogens associated with foodborne illnesses:

Campylobacteriosis

Clostridium perfringens

Listeria

Salmonella

E. coli (Escherichia coli) infection

Clostridium botulinum

Shigella

Norovirus

Question 335

Regardin red and processed meats, describe:

health impacts

and recommendations.

Answer 335

Case study: Red meat (hot topic)
- In 2015, IARC classified red meat as Group 2A, probably carcinogenic to humans and
processed meat as Group 1, carcinogenic to humans
- Diet high in red meat and processed meat are linked with higher risk of colorectal
cancer; there is also evidence that red meat is linked to pancreatic and prostate cancer
and processed meat is linked with stomach cancer; possible causal pathways:
- Heterocyclic amines and polycyclic aromatic hydrocarbons (carcinogens)
- Nitrates are converted to nitrosamines and nitrosamides (carcinogens)
- Dietary heme iron promotes cell growth
- Diet high in processed meat, but not red meats, is associated with a higher incidence of
CAD and DMII (RR of 1.42 of CAD for every 50 g/day of processed meat consumed)

- Recommendations:
- Canadian Cancer Society: Adults should limit their red meat intake to 3
servings/week
- WHO: Reduce the consumption of processed meat
- FAO (Food and Agriculture Organization of the UN): “Meat can be part of a balanced diet contributing valuable nutrients that are
beneficial to health. Meat and meat products contain important levels of protein,
vitamins, minerals and micronutrients which are essential for growth and
development. … Highly nutritious foods such as meat are particularly required
for HIV AIDS infected communities and also for women and children.”
- Not specifically addressed in Canada Food Guide

Question 336

What are priority drug-resistant organisms in Canada (9)?

Answer 336

- Clostridium difficile: Most frequent cause of HAI diarrhea in Canada; spreads rapidly
and has intrinsic resistance to many antimicrobials; rates have been declining since
2011
- Extended-spectrum β-lactamase (ESBL) -producing organisms: Enterobacteriaceae
spp. (Klebsiella, E. coli), Pseudomonas; many ESBL-producing organisms are also
CROs
- Carbapenem-resistant organisms (CROs): Acinetobacter, Enterobacteriaceae spp.,
Pseudomonas; Klebsiella pneumoniae carbapenemase (KPC)-producing bacteria were
the first isolated strain
- Vancomycin-resistant enterococci: Enterococcus spp. (usually E. faecalis or E.
faecium); Enterococci are intrinsically resistant to most antibiotics; Canadian rates
peaked in 2012 and are now declining

- Neisseria gonorrhoeae: >⅓ gonorrhea cases are resistant to cipro, erythromycin, and
tetracycline; some strains developing emerging resistance to azithromycin and
cephalosporins
- Drug-resistant Streptococcus: Causative agents of invasive pneumococcal disease
(S. pneumoniae) and iGAS (Group A S. pyogenes); rate of IPD has declined since the
introduction of the 13-valent pneumococcal conjugate vaccine in 2010; incidence of
iGAS in Canada is increasing, but resistance is unchanged or decreasing
- Drug-resistant Salmonella spp.: Enteric fever is usually acquired through travel, but
resistance is being monitored in Canada due to increasing fluoroquinolone resistance
worldwide; 75% of all human non-typhoidal Salmonella isolates were susceptible to all
antimicrobials in 2014
- Methicillin-resistant Staphylococcus aureus: Increasing proportion of MRSA is
acquired in the community rather than the hospital (30% in 2012 vs 10% in 1995);
highest MRSA incidence in North America is found in northern Canada
- Mycobacterium tuberculosis: Mono-resistant, MDR- , and XDR-TB; isoniazid
resistance is the most common first-line drug resistance in Canada

Question 337

How is healthcare funded in Canada?

What percentage is funded by federal vs provincial goverments?

The federal transfer payments to provinces are conditional to what conditions?

What percentage of cost is spent on hospitals, drugs and physicians?

What percentage of the GDP does healthcare spending represent?

Answer 337

Health care financing policy options

• *Current situation in Canada:**
• General taxes are used to fund health care spending
• 70% of healthcare spending in Canada is public; 30% is private
• Of the public healthcare spending, the federal government covers 22%, while the P/Ts cover 78%
• The 22% of spending from the federal government comes in the form of cash transfers to the P/Ts; this covers 37% of hospital, diagnostics, and physician services costs
• The federal transfer payment is conditional on the P/Ts abiding by the conditions in the Canada Health Act
• The federal transfer is on a per-capita basis and is increasing at 6%/year until 2017, and then will increase 3%/year after that

- Break-down of healthcare spending in Canada:
- 30% on hospitals
- 16% on drugs
- 16% on physicians

• Health care spending as a share of GDP is increasing; currently about 11.5% of GDP (2019); this is similar to other countries with the similar demographics (with the exception of the US, which spends about 17% of GDP on healthcare)
• In most cases, pharmaceutical drugs used outside of hospitals are purchased privately (although all P/Ts have some form of public pharmacare for low-income or older Canadians)
• Multiple commissions, organizations, and academics have proposed a national pharmacare strategy; universal pharmacare coverage would be cost-saving

Other policy options:
- Social insurance fund: Publicly financed system; government collects premiums from citizens specific for use in healthcare (contrast to Canada’s usage of general taxes)
- This form of financing is used to fund workers’ compensation
- Parallel public and private systems
- Co-payments: Healthcare payment is partly financed by the public sector and partly financed through either out-of-pocket payments or private insurance
- Group-based public coverage: Certain population sub-groups are eligible for publiclycovered health care; the rest of the population must pay out-of-pocket or through private insurance
- Sectoral coverage: Certain health care sectors are publicly covered, while the rest are not
Commentary:
- Countries often apply cost-containment measurements only to the public system, increasing the total healthcare system spending with multiple types of financing, The more types of financing, the higher the administrative costs
- Co-payments (aka user fees) reduce health care usage, especially for individuals with low incomes

Question 338

Regarding colorectal cancer,

what are recent epi trends?

risk factors?

CTFPHC recommendations for screening?

Answer 338

Colorectal cancer

• *Epidemiology**
• Third most common type of cancer in Canada, excluding non-melanoma skin cancers (13% of all cancer diagnoses)
• Second leading cause of cancer death in men and third leading cause of cancer death in women in Canada (12% of all cancer deaths)
• Incidence declining in older adults, but increasing in younger adults; decline in older adults attributed to colorectal cancer screening (removal of precancerous polyps)
• *Risk factors**
• Known risk factors:
• Family or personal history of colorectal cancer; personal history of breast, ovarian, or uterine cancer
• Medical conditions: Familial adenomatous polyposis, Lynch syndrome, polyps, inflammatory bowel disease, diabetes
• Lifestyle: Obesity, physical inactivity, alcohol, smoking, consumption of red and processed meats, diet low in fibre, consumption of heterocyclic amines and PAHs (created by cooking meat at high temperatures)
• Ashkenazi Jewish ancestry
• Tall adult height
• Ionizing radiation
• Possible risk factors: Asbestos, cystic fibrosis

CTFPHC screening recommendations (2016)
- We recommend screening adults aged 60 to 74 years for colorectal cancer with FOBT
(either gFOBT or FIT) every two years or flexible sigmoidoscopy every 10 years.(Strong
recommendation; moderate-quality evidence)
- We recommend screening adults aged 50 to 59 years for colorectal cancer with FOBT
(either gFOBT or FIT) every two years or flexible sigmoidoscopy every 10 years. (Weak
recommendation; moderate-quality evidence)
- We recommend not screening adults aged 75 years and older for colorectal cancer.
(Weak recommendation; low-quality evidence)
- We recommend not using colonoscopy as a screening test for colorectal cancer. (Weak
recommendation; low-quality evidence)
*FIT = fecal immunochemical testing; gFOBT = guaiac fecal occult blood testing; FIT is more
sensitive than gFOBT; all provinces use FIT except Ontario and Manitoba

Question 339

Define occupation health surveillance, occupational illness and healthy worker effect.

Name the 5 types of occupational hazards.

Answer 339

• Occupational medicine: Branch of medicine that prevents and treats health issues
  related to working environments at the individual and group level; includes the
  recognition, evaluation, control, management, and rehabilitation of occupationally related
  diseases and injuries, and any conditions that affect the ability to work
• Work-health axis: Risk assessment, control programs, independent medical
  evaluation, return-to-work planning
• Exposure-outcome axis: Screening, surveillance, causation analysis,
  compensation claims
• Occupational health surveillance: Ongoing, systematic tracking of occupational
  injuries, illnesses, hazards, and exposures; usually involves worker screening and
  workplace monitoring to identify at-risk or over-exposed workers; unlike public health
  surveillance, intervention occurs on the individual level
• Occupational illness: “A condition that results from exposure to a physical, chemical, or
  biological agent to the extent that the health of the Worker is impaired and includes an
  occupational disease for which the worker is entitled to benefits under the Workplace
  Safety and Insurance Board” (OHSA definition)
• Occupational injury: Any injury that occurs at a workplace
• Healthy worker effect: Describes the observation that workers usually have lower
  morbidity and mortality rates than the general public because individuals must be
  relatively healthy to be employable; a type of selection bias; the healthy worker effect
  can mask real excesses in morbidity and mortality due to harmful exposures in the
  workplace
• Categories of occupational hazards
  1. Biological (e.g., microorganisms, toxins)
  2. Chemical (e.g., fumes, dust)
  3. Physical (e.g., motorized vehicles/working near machinery, loud noise, radiation,
  temperature)
  4. Ergonomic (e.g., repetitive motion; slips, trips, and falls; vibration)
  5. Psychosocial (e.g., workplace violence, burnout)

Question 340

Regarding sodium,

What are recent epi trends?,

health impacts?

available interventions?

Answer 340

RDI = 1,500 mg/day for those ages 9-50 years
Tolerable upper intake level = 2,300 mg/day (on average, adult Canadians
consumer 3,400 mg/day)

Epidemiology - 85% of men and 63-83% of women in Canada have sodium intakes
exceeding the upper limit
- Sources of dietary sodium: 77% from commercially processed foods;
12% is naturally occurring; 6% added at the table; 5% added during
cooking

Health impacts Hypertension, CVD
*hypertension is the leading preventable risk factor for death worldwide; 17-
30% of hypertension can be attributed to excess dietary sodium

Prevalence of hypertension among Canadian adults = 25.5%.

Interventions - Regulation (e.g., Finland has regulated the food industry; along with
consumer education, this has resulted in 40% decrease in sodium
intake, 10 mmHg decrease in pop average BP, and 70% reduction in
CVD mortality) and food reformulation
- Food labelling (e.g., red, orange, green system used in UK food
chains)
- Collaboration with food industry: In 2010, the Sodium Working
Group, comprising representatives from food manufacturing, food
services, NGOs, the scientific and health provider communities,
consumer advocacy groups, and governments, published the Sodium
Reduction Strategy for Canada. It recommended a three-pronged
approach, plus monitoring and evaluation:
1. Voluntary reduction of sodium levels in processed food
products and foods sold in food services establishments;
2. Public education: Education and awareness of consumers,
industry, health professionals and other key stakeholders;
and
3. Research
- Salt substitution (e.g., with potassium; “Salt substitution may be a
cost-effective strategy in developing countries where the principal
source of sodium in the diet is salt added during domestic cooking”)

Question 341

How are the following vital statistics calculated:

Fetal death rate, perinatal mortality rate

Neonatal mortality rate, infant mortality rate, under-5 child mortality rate

(What are common causes of neonatal and perinatal mortality and public health interventions to reduce neonatal mortality?)

Crude birth rate, General fertility rate, Total fertility rate

Maternal mortality rate

(What are common causes of maternal mortality?)

Crude mortality rate

Dependency ratio

Answer 341

• *Vital statistics**
• Live birth: Complete expulsion/extraction of a product of conception that shows any evidence of life (breathing, heartbeat, umbilical cord pulsation, movement of voluntary muscles), irrespective of gestational age
• Stillbirth: Death prior to complete expulsion/extraction of the products of conception
• Fetal death rate: Stillbirths (per year) / total births (live births + stillbirths) (per year)
• Perinatal mortality rate: Infant or fetal deaths from 22 weeks GA to 7 days old (per year) / total births (live births + stillbirths) (per year)
• Neonatal mortality rate: Infant deaths within the 28 days of life (per year) / live births (per year) *1000
• Postneonatal mortality rate: infant deaths 28–364 days (per year)/ live births (per year) *1000
• Infant mortality rate: Deaths occurring between birth and 1 year of age (per year) / live births (per year) *1000
• Under-five child mortality rate: Deaths between birth and five years of age (per year) / live births (per year) *1000
• General fertility rate: Number of live births (per year) / mid-year female population 15 to 49 years *1000
• Total fertility rate: Mean number of children born to a woman over her lifetime (assuming all females lived to the end of their childbearing years and bore children according to the age-specific fertility rates for that area and period) (recall: refers to the total per woman)
• Population growth without immigration requires a TFR > 2.1 children/woman
• Crude birth rate: Average number of live births (per year) / mid-year population *1000 or 100,000
• The crude birth rate is usually the dominant factor in determining population growth; it depends on fertility and age structure
• Crude mortality rate: Average number of deaths (per year) / mid-year population *1000 or 100,000
• Life expectancy at birth: The number of years a newborn would live if current mortality risks for the population remain the same
• Dependency ratio: Number of children (0-14 years old) and older persons (65 years or over) (“dependents”) per 100 persons in the working-age population (15-64 years old)
• Common causes of neonatal and perinatal mortality: Major congenital anomaly (e.g., due to syphilis or maternal nutritional deficiency), low birth weight, preterm birth, birth complications (obstructed labour, fetal malpresentation, birth asphyxia), prolonged ROM, neonatal tetanus
• Key public health interventions to reduce neonatal mortality: Immunization, improved nutrition, water and sanitation, treatment for diarrheal illness and malaria
• Maternal mortality rate: Death of a woman while pregnant or within 42 days of termination of pregnancy from any cause related to pregnancy (per year) / live births (per year) *100,000
• Common causes of maternal mortality: Postpartum hemorrhage, postpartum infection,pre-eclampsia and eclampsia, delivery complications, and unsafe abortion

Question 342

Define latent period, communicable period and incubation

Answer 342

• Incubation period: Interval between initial contact with an infectious agent and the first appearance of symptoms associated with the infection (less relevant if illness is subclinical)
• Communicable period (aka period of communicability aka infectious period): Interval during which an infectious agent may be transferred directly or indirectly from another infected animal or human
• Latent period: Interval between initial contact with an infectious agent and the beginning of the communicable period; i.e., individual is not infectious during the latent period
• Symptomatic period: Period during which infected individual is symptomatic; the larger the proportion of transmissions that occur during the symptomatic period, the easier it is to control an outbreak (isolation is only possible once symptoms have developed; if transmission primarily occurs during the presymptomatic period, contact tracing +/- quarantine are required)
• Generation time: Mean time period between the infection of a primary case and the infection of a secondary case; the shorter the generation time, the more challenging it is to control an outbreak

Question 343

Describe basic facts about varicella

Organism, Reservoir, Mode of transmission

Incubation period, infectious period

Epidemiology

Presentation, Testing

Case management, Contact management

+/- Immunization

Answer 343

Varicella (reportable)
Organism: Varicella zoster virus (Herpesvirus family)
Reservoir: Humans
Mode of transmission: Airborne (varicella and disseminated HZ), direct contact with lesions
(varicella and HZ)

Epidemiology:
- Varicella:
- Occurs worldwide; seasonal in temperate areas and year-round in tropical areas
- Adults, esp pregnant women, are at increased risk of severe disease; adult
disease is more common in tropical areas; prior to immunization, most children in
temperate areas were infected prior to adolescence
- Attack rate = 65-85% in susceptible household members
- Increases risk of iGAS by 40-60x
- Herpes Zoster: Lifetime risk is up to 30% after primary infection

Presentation:
- Varicella (chickenpox): Fever, mild constitutional symptoms, pruritic rash (macule →
papule → vesicle → crusting)
- Herpes zoster (shingles): Latent VZV in sensory nerve ganglia reactivates, causing pain
and a unilateral vesicular eruption, usually in a single dermatome; most common
complication = post-herpetic neuralgia; other complications = Ramsay-Hunt Syndrome
(acute peripheral facial neuropathy), GBS
- Congenital varicella syndrome: Low birth weight, ophthalmic abnormalities, skin scarring,
limb atrophy, cerebral atrophy (risk highest between 13-19 weeks GA)

• *Incubation period**: 10-21 days (varicella)
• *Infectious period**: Varicella: 2 days before rash onset until lesions are crusted
• *Testing**: Viral culture or PCR (usually of vesicular fluid), serology

Case management: Supportive
Contact management: Susceptible close contacts of varicella or HZ should receive univalent
varicella vaccine within 72h after exposure (some benefit in reducing severity if given up to 5
days post-exposure); susceptible close contacts who are at high risk of severe varicella and for
whom the vaccine is contraindicated should receive VarIg

Vaccination:
- Varicella:
- Varicella vaccine recommended for all susceptible individuals < 50 years of age
- MMR-V has higher risk of febrile seizures than MMR + V; Quebec uses MMR-V
for all doses (cheaper), Ontario splits MMR and V in time; BC gives MMR + V
simultaneously
- Avoid salicylates for 6 weeks post-vaccination in children
- HZ vaccine: Reduces incidence of HZ and postherpetic neuralgia; recommended for all
individuals > 60 years and approved for all individuals > 50 years without
contraindications

Question 344

Describe the behavior change model: Diffusion of innovation theory

What characteristics affect innovation adoption?

Answer 344

• *Diffusion of innovation theory**
• Describes the way in which new ideas are adopted by communities
• Factors that determine the success and speed with which an innovation diffuses:
• Characteristics of the potential adopters: Innovators, early adopters, early
  majority, late majority, laggards (normally distributed; see below)
• Rate of adoption
• Nature of the social system
• Characteristics of the innovation:
• Compatibility: Does the innovation fit with the intended audience?
• Relative advantage: Is the innovation better than what it will replace?
• Cost-effectiveness
• Complexity: Is the innovation easy to use?
• Flexibility
• Reversibility/trialability: Can the innovation be tried before making a decision to adopt?
• Perceived risk
• Observability: Are the results of the innovation observable and easily measurable?
• Characteristics of change agents: E.g., role models

Stages of technological innovation: knowledge, persuasion, decision, implementation, confirmation

Question 345

What is epidemiology?

Contrast proportions, rates and ratios.

Contrast cumulative incidence and incidence density.

Calculate disease-specific mortality rate and case fatality rate.

Answer 345

Epidemiology: “Epidemiology is the study of the distribution and determinants of health-related states or events (including disease), and the application of this study to the control of diseases
and other health problems.” (WHO definition)

Measures of frequency: Incidence and prevalence
- Proportions: The fraction one quantity makes up of another quantity; the numerator isincluded in the denominator
- Rates: “a measure of the frequency with which an event occurs in a defined populationin a defined time (e.g., number of deaths per hundred thousand Canadians in one year)”;
time is included in the denominator
- Ratios: The comparison of one quantity by another (e.g., the male to female ratio in aclass), in which the numerator is not included in the denominator

• Incidence: “Number of new cases of a disease that occur during a specified period of time in a population at risk of developing the disease” (Gordis, 2009; italics, mine);
  represents the risk of developing a disease
• Cumulative incidence: Proportion of people at risk of a disease who develop a disease over some time period; new cases of condition / person at risk of condition at beginning of interval (e.g., have you ever had hepatitis C?); proportion (analogous to proportion distance travelled)
• Attack rate: Cumulative incidence of an infection over a period of time (usually an outbreak); a proportion, not a true rate (number of cases /number of contacts)
• Incidence density (aka incidence rate): New cases of a condition / person-time at risk of condition; rate (analogous to speed)
• Person-time = [(Number of people at risk at the beginning of the time interval + Number of people at risk at the end of the time interval ) / 2] x (Number of time units in the time interval)
• Prevalence: “The number of affected persons present in the population at a specific time divided by the number of persons in the population at that time” (Gordis, 2009); proportion; unitless
• Prevalence ≃incidence * duration
• Point prevalence: Prevalence of the disease at a certain point in time (e.g., do you currently have hepatitis C?)
• Period prevalence: Prevalence of the disease at any point in time over a certain time period (e.g., have you had hepatitis C in the last 10 years?)
• Mortality rate: Number of deaths in one year / number of persons in the population at midyear
• Age-specific mortality rate: Numerator and denominator restricted to a specific age group
• Disease-specific mortality rate: Numerator restricted to death due to a specific disease
• Case fatality rate = Deaths from a given disease in a specific period of time / Number of diagnosed cases of disease during that period; i.e., what percentage of people diagnosed with disease x die from disease x?; proportion

Question 346

What are definitions of overweight and obesity in children <5, 5-19 and adults?

What are different ways of measuring obesity and their pros and cons.

Answer 346

Obesity and overweight

Measurement techniques: Field methods
BMI
BMI = weight (kg) / height (m2)
- Classifications for adults:
- Underweight = BMI < 18.5
- Normal weight = BMI 18.5-24.9
- Overweight = BMI 25-29.9
- Obese = BMI > 30

For children under 5 years of age (WHO):

overweight is weight-for-height greater than 2 standard deviations above WHO Child Growth Standards median; and

obesity is weight-for-height greater than 3 standard deviations above the WHO Child Growth Standards median.

Children aged between 5–19 years (WHO)

overweight is BMI-for-age greater than 1 standard deviation above the WHO Growth Reference median; and

obesity is greater than 2 standard deviations above the WHO Growth Reference median.

• Prevalence of diabetes, HTN, and CAD correlated with increasing BMI
• CTFPHC recommends measuring BMI at appropriate primary care visits (strong
  recommendation; very low quality evidence)
  _- Pros: Easy, inexpensive, correlated with body fat, predictive of disease and death
• Cons: Does not distinguish between muscle and fat; less accurate in the elderly_

Waist-to-hip ratio
- Ratio of the waist (at the level of the iliac crest) and the hip (at the widest diameter of the
buttocks)
- Pros: Inexpensive, predictive of disease and death
- Cons: More prone to error, harder to measure hips than waist, increased ratio can be
caused by increased abdominal fat or decreased muscle around hips; less accurate if
BMI > 35

Waist circumference
- Measured at the level of the iliac crest; measure of central obesity; cut-offs for waist
circumference are ethnicity-specific
- Waist circumferences of ≥102 cm in men, or ≥88 cm or more in women, is associated
with type 2 diabetes, CAD, and HTN
- Pros: Easy, inexpensive, correlated with body fat, predictive of disease and death
- Cons: Measurement procedure not standardized, not standardized for children, less
accurate if BMI > 35

Skinfold thickness
- Special calipers used to “pinch” skin at multiple locations to predict body fat percentage
- Pros: Easy, inexpensive
- Cons: Less accurate than other methods, less reproducible than other methods, less
accurate if BMI > 35

Bioelectric impedance
- Calculates body fat percentage by sending a low electric current through the body (body
fat provides more resistance than water or muscle)
- Pros: Easy, relatively inexpensive
- Cons: Hard to calibrate, affected by conditions that change ratio of body water to fat
(e.g., illness, dehydration), less accurate than the other methods

Question 347

When is HIV post-exposure prophylaxis indicated?

Answer 347

PEP is indicated when:

1) The source patient is HIV+ or status is unknown with significant
risk factors

2) there has been a percutaneous or mucosal exposure
3) to a potentially infectious body fluid;

PEP should be initiated within 72 hours of exposure

Question 348

Describe elements of the safe system approach to road safety.

What are evidence-based interventions to reduce MVC-related injury recommended by the Community Guide?

Answer 348

Road safety and motor vehicle collisions

In summary:

- Users:

1) DUI/distracted (BAC laws, minimum drinking age, lower BAC for less experienced, checkpoints, school programs)
2) Motorcycle helmets
3) Graduated driving license programs

- Vehicles:

1) seatbelts, child safety seat
2) etoh locks
3) car design and maintenance (car crumple zone, daytime lights, winter tires, ABS breaks, back-up alarm/video)

- Road system:

1) safe speeds, traffic calming, photo radar
2) cycling/pedestrian infracstructure
3) public transit

• *Safe system approach to road safety**:
  1. Safe road users
  a. Helmets: Reduce risk of fatality, head injury, and facial injuries in motorcyclists and cyclists, but may reduce the frequency of active transport
  b. Graduated licensing programs: Reduce fatal MVCs in the driver’s first year
  c. Impaired driving: In 2010, 38.4% of fatally-injured drivers in Canada had some level of alcohol in their blood; road-side and blood testing for cannabis challenging because tolerance varies greatly and it is lipid-soluble and detectable for weeks
  d. Distracted/inattentive driving: Texting (23x increased risk of collision/near collision) > reaching for moving object > talking on the phone (4-5x increased risk of collision/near collision) > talking on headset > putting on make-up > talking to passenger; not a lot of evidence-based interventions

2. Safe vehicles
   a. Crash avoidance: Daytime running lights (to increase visibility), winter tires, ignition interlocks for etoh
   b. Crash protection: Seat belts, child safety seats, car crumple zones
   c. Vehicle maintenance
   d. Autonomous vehicles
3. Safe speeds
   a. Top police-reported contributing factor to MVC fatalities and serious injuries
   b. 71% of Canadians report speeding “on occasion” or “frequently”
   c. Reducing speed reduces the number and severity of MVCs
   d. “But what about the Autobahn?”: Designed for high speeds, no speed limit only in areas where there are no on or off-ramps, no passing on right, stricter licensing laws, speed limit variable based on weather conditions
   e. Photo radar works: reduces speed, probably reduces MVC injuries and fatalities (methodological concerns about the study designs)
4. Safe roads
   a. Traffic calming: Planters, narrowed streets, streets not for thoroughfare; pedestrian streets closed to motor vehicle traffic
   b. Roundabouts decrease car collisions, but increase injury for cyclists
   c. Public transit: Reduces need to drive
   d. Cycling infrastructure: Reduces cyclist fatality
   e. Intersection design for pedestrians: Decreased speed through intersections, pedestrian scrambles, leading pedestrian intervals, signal-controlled crossings

Evidence-based interventions to reduce MVC-related injury recommended by the Community
Guide
- Reduce alcohol-impaired driving through:
- 0.08% BAC laws (*maximum BAC for fully-licensed drivers anywhere in Canada is 0.08%)
- Lower BACs for less experienced drivers
- Do not lower minimum drinking age
- Publicized sobriety checkpoints
- Mass media campaigns
- Ignition interlocks for those convicted of DUI
- School-based instructional programs

• Increase use of child safety seats through:
• Laws mandating use
• Information, education, and enforcement campaigns
• Distribution and education
• Incentives and education
• Increase use of motorcycle helmets through:
• Laws mandating use
• Information, education, and enforcement campaigns
• Distribution and education
• Incentives and education
• Increase use of seatbelts through:
• Laws mandating use
• Primary _enforcement law_s (i.e., not wearing seatbelt is sufficient to be stopped by police)

Question 349

In nature, what type of disease is Anthrax?

In humans, what types of diseases (4) can be caused by Anthrax?

What is the PEP after exposure to anthrax?

Answer 349

Anthrax
- In nature, anthrax is a disease of herbivores that ingest spores present in the soil that
then germinate in their guts (anthrax vaccination is recommended for livestock in
Canada in areas where anthrax has historically occurred)
- Could be deliberately released, resulting in inhalational anthrax
- Anthrax does not spread from person to person (i.e., no PEP required after exposure to
infected humans); natural infection occurs due to exposure to spores in the ground or
from consumption of infected animals
- PEP is required after intentional exposures (e.g., bioterrorism attack): Vaccination x 3 +
doxy OR cipro x 60 days (i.e., PEP for maximum incubation period)
- B. anthracis grows rapidly in culture (i.e., systemic disease easily identifiable via culture)

Question 350

Define the process of risk assessment

Answer 350

Risk assessment process
0. Plan and scope: Who/what/where is at risk? What is the environmental hazard of
concern? What are the potential sources of exposure? What are the potential pathways
and routes of exposure? What are the health effects? How long does it take a health
effect to occur?
a. Pathways: Air, surface water, groundwater, soil, solid waste, food, non-food
consumer products
b. Routes of exposure: Ingestion (food, water), dermal contact, inhalation, non-dietary ingestion (e.g.,
hand-to-mouth behaviour)

1. Hazard identification: Can the exposure result in adverse health outcomes? → Identify
   the toxic substances of concern and identify endpoints of concern; review the literature
   to determine if the substance is linked with the outcome of concern (qualitative)
   a. EPA analysis uses “mode of action”: Detail the sequence of events and
   processes (cell → operational changes → anatomical changes → cancer)

2. **Dose-response assessment**: How probable is it that the severity of the adverse health
effect is related to the dose received? → Based on literature review and extrapolated to
current situation (quantitative)

3. Exposure assessment: What is the magnitude, frequency, and duration of human
   exposure? → Usually estimated indirectly (specific to the population of concern)
4. Risk characterization: Is there a risk? If so, what is the magnitude of the risk and what
   uncertainties still exist? → Combine steps 1-3 to develop an understanding of the risk
   the hazard poses to the population with respect to the identified endpoint;

principles:

a. Transparency
b. Clarity
c. Consistency
d. Reasonableness

Question 351

What is the name of the joint policy that sets the benchmark for ethical conduct for research involving humans in Canada?

What were the 3 federal agencies involved in formulating it?

What are its 3 core principles?

Answer 351

Research ethics

• Tri-C*ouncil Policy Statement on Ethical Conduct for Research Involving Humans (TCPS 2)
• Joint policy of the three federal research agencies

CIHR - Canadian Institutes of Health Research,

NSERC - Natural Sciences and Engineering Research Council,

SSHRC - Social Sciences and Humanities Research Council

• Policy is the benchmark for ethical conduct of research involving humans
• Researchers and agencies receiving Tri-Council funding must adhere to the TCPS 2
• TCPS first adopted in 1998; TCPS 2 published in 2014
• Three core principles:
• Respect for persons: Includes “the dual moral obligations to respect autonomy and to protect those with developing, impaired, or diminished autonomy”
• Concern for welfare: “The welfare of a person is the quality of that person’s experience of life in all its aspects”; determinants of welfare include housing, community membership, privacy, and treatment of human biological materials. (In Belmont report, this is referred to as beneficience)
• Justice: “Justice refers to the obligation to treat people fairly and
  equitably. Fairness entails treating all people with equal respect and concern.
  Equity requires distributing the benefits and burdens of research participation in such a way that no segment of the population is unduly burdened by the harms of research or denied the benefits of the knowledge generated from it.”
• Recommends a proportionate approach to research ethics board (REB) review, to balance the potential benefits of research and the potential research-related harms (i.e., less scrutiny can be applied to research of less risk, full board vs delegated review)

Question 352

How would the inhalation of intentionally-released yersinia pestis present

and what could be done about it?

Answer 352

Plague
- Infection caused by the fleaborne bacterium Yersinia pestis; reservoir = wild rodents
- Could be deliberately released, resulting in pneumonic plague
- Endemic in Africa, South America, Western US, Asia, and SE Europe, and S
Saskatchewan, Alberta, and BC

Question 353

What type of mosquitoes transmits:

• Malaria?
• Zika?
• WNV?

Answer 353

Mosquitoes:

Anopheles (night biter): malaria, lymphatic filariasis

Aedes (day biters): Ae. aegypti (yellow fever mosquito) and Ae. albopictus (Asian tiger mosquito), Chikungunya, dengue, Zika

Culex (night biters): Lymphatic filariasis, JE, SLE, WEE, and WNV

Flies:

Tsetse flies (Glossina) (Day biters; occur only in tropical Africa): African sleeping sickness
Blackflies (Simulium) (Day biters) River blindness
Sandflies (Phlebotomus, Lutzomyia) (usually day biters, may bite in cloudy weather, cannot bite through clothing) Leishmaniasis
Horseflies (Tabanidae): (day biters (esp in sun) painful, deep bite: Loiasis, tularemia

Question 354

Regarding points on a dose-response, define LD-50, RD-50, NOAEL, LOAEL.

How do BMD, RfD, RfC relate to those points?

Answer 354

• LD-50: Dose at which half of exposed animals die
• RD-50: Dose at which half of exposed individuals respond
• NOAEL (no observed adverse effect level): Highest exposure level at which no
  statistically or biologically significant increases in the frequency/severity of adverse
  outcomes is observed; experimentally derived
• LOAEL (lowest observed adverse effect level): Used in cases in which the NOAEL has
  not been demonstrated experimentally; the lowest dose tested; experimentally derived
• BMD (benchmark dose; aka BMDL or benchmark dose lower confidence limit): An
  alternative to the NOAEL; estimated using mathematical modelling; it is a dose of a
  substance associated with a specified low incidence of risk, generally in the range of 1%
  to 10%, of a health effect
• RfD (reference dose): An estimate of daily oral exposure to a human population that is
  unlikely to result in deleterious effects during a lifetime; dose derived from the LOAEL,
  NOAEL, or BMD by applying order-of-magnitude uncertainty factors; expressed in
  mg/kg/day

- RfC (reference concentration): The same as RfD, except used for substances that are
inhaled; expressed in mg/m3

Question 355

What are the risks and benefits of fish consumption and official recommendations?

What are the intake limits for consumption of fifish high in mercury?

Answer 355

Benefits of fish consumption
- Inverse association between fish consumption and risk of: depression, acute coronary
syndrome, death due to ischemic heart disease
- Benefits attributed to the omega-3 fatty acids (EicosaPentaenoic Acid (EPA),
DocosaHexaenoic Acid (DHA)); have anti-inflammatory, antithrombotic, and
antiarrhythmic effects but omega-3 fatty acid supplementation alone is not
associated with decreased CVD risk
- Association exists for tuna and other broiled or baked fish, but not fried fish or
fish sandwiches
- Positive association between fish consumption during pregnancy and
neuropsychological outcomes in children
- Benefits attributed to long-chain polyunsaturated fatty acids (e.g., DHA); DHA is
uncommon in Western diets and fatty fish is the major source of DHA; DHA is
essential to prenatal neurodevelopment
- Other nutrients in fish = Vit A, D, B3, B6, B12, calcium, phosphorus, selenium, iron,
magnesium, potassium, iodine

Harms of fish consumption
- Mercury: Relatively low levels of prenatal exposure to methylmercury are associated
with impairments in cognition, memory, and verbal skills of children; fish consumption is
the primary mechanism of methylmercury exposure in humans
- Persistent organic pollutants: PolyChlorinatedBiphenyl result in reduced IQ, growth impairment, and motor deficits, and may result in cancers
- Botulism: In Canada, outbreaks of botulism have been caused by contaminated raw or
partially cooked seal meat, fermented whale blubber, smoked salmon, and fermented
salmon eggs
- Seafood poisoning

Fish consumption guidelines
- US FDA: Pregnant women should eat < 340 g of fish/week, avoid consuming large
predatory fish (e.g., shark, swordfish, king mackerel, tilefish), and limit consumption of
large fatty fish
- European Food Safety Authority: Pregnant women should eat 150-600 g of fish/week
- Canada’s Food Guide: East at least 2 servings (at least 150 g) of fish/week
- Health Canada: Eat fish high in fatty acids and low in mercury (e.g., anchovy, salmon,
rainbow trout) and eat fish high in mercury (e.g., shark, swordfish, marlin, orange
roughy, escolar) less often according to the list below
- Gen pop: 150 g/week
- Women who are/may become pregnant or breastfeeding: 150 g/month
- Children ages 5-11 years: 125 g/month
- Children ages 1-4 years: 75 g/month

Question 356

What are public health interventions that promote dental health?

Answer 356

Dental indicators
- DMFT = Prevalence of decayed, missing, or filled teeth in adults
- DMFS = Prevalence of decayed, missing, or filled surfaces in adults
- deft = Prevalence of decayed, extracted, or filled teeth in children
- defs = Prevalence of decayed, extracted, or filled surfaces in children
- %DMFT = Prevalence of dental caries (a tooth with both a carie and filling is counted
only once, as decayed)
- %D = Prevalence of untreated, decayed teeth
- %Ed = Prevalence of edentulism (no teeth)
- Prevalence calculations for adults use either 28 teeth (wisdom teeth excluded) or 32
teeth (wisdom teeth included) in the denominator
- Prevalence calculations for children use a maximum of 20 teeth in the denominator
- Molars and premolars have 5 surfaces and front teeth have 4 surfaces, so adults have
128 tooth surfaces (wisdom teeth excluded)

Dental epidemiology
- Oral health care is primarily delivered privately
- 62% Canadians pay for oral health care through insurance from their place of
employment
- Lower-income Canadians are less likely to have dental insurance than higher income
Canadians
- Having dental insurance is the primary determinant of whether or not a Canadian
receives dental care
- 96% of Canadian adults report having had a cavity
- 6% of Canadians are edentulous

Dental health interventions
- Toothbrushing with fluoride toothpaste
- Fluoride mouthrinse, tablets, and gels (fluoride interventions most effective when
combined; e.g., fluoridated water + mouthrinse)
- Sealants (recommended in the permanent first and second molars to prevent pit and
fissure caries) (very effective)
- Chewing gum with xylitol or sorbitol (mixed evidence of effectiveness)
- No conclusive evidence regarding the best setting in which to deliver these interventions,
with the exception of fluoride, which is most effective when delivered through water

Question 357

Describe basic facts about hantavirus

Organism, Reservoir, Mode of transmission

Incubation period, infectious period

Epidemiology

Presentation, Testing

Case management, Contact management

+/- Immunization

Answer 357

Hantavirus (reportable)
- Organism: More than 25 different Hantaviruses
- Hemorrhagic fever with renal syndrome (HFRS): Hantaan, Seoul, Dobrava,
Puumala, Saaremaa viruses
- Hantavirus Pulmonary Syndrome (HPS): Andes, Laguna Negra, Juquitiba, Sin
Nombre (+a bunch of other ones)
- Reservoir: Rodents (usually specific hantaviruses infect specific rodent spp); in North
America, the reservoir for the Sin Nombre virus is probably the deer mouse
- Mode of transmission: Aerosolized virus from rodent excreta; with the exception of the
Andes virus, person-to-person transmission not thought to be possible
- Epidemiology:
- HFRS CFR = 5-15% (<1% for Puumala and Saaremaa viruses)
- HPS CFR = 35-50%
- Sin Nombre virus infection occurs rarely in Western Canada (only one case ever
documented in Eastern Canada); Seoul virus has been detected in rats (but not
people) in Ontario
- Incidence in Canada = 0-13 cases/year
- Most Canadian cases occur in the spring and early summer
- Risk factors: Closed, poorly ventilated dwellings, visible rodent infestations,
recreational/occupational exposure
- Presentation:
- Hemorrhagic fever with renal syndrome (HFRS): Five clinical phases:
- Febrile: Fever + flu-like symptoms + hemorrhagic manifestations
- Hypotensive: Defervescence + hypotension +/- shock
- Oliguric: BP normalizes + oliguria +/- severe hemorrhage
- Diuretic: Polyuria of 3-6 L/day
- Convalescent: Weeks to months
- Hantavirus Pulmonary Syndrome (HPS): Four clinical phases:
- Febrile: Fever, myalgias,
- Cardiopulmonary:ARDS, hypotension +/- shock
- Diuretic: Polyuria + rapid improvement of pulmonary edema
- Convalescent:
- Incubation period: 2-4 weeks (range, few days to two months)
- Testing: Serology
- Case management: Supportive; careful fluid management
- Contact management: None
- Other:
- Rodent control: Exclude from buildings, use rodent-proof containers, disinfect
rodent contaminated areas prior to cleaning
- Hantaan and Seoul virus vaccines available in South Korea and China

Question 358

Under the Ontario Employment Standards Act, 2000 (ESA),

what is required when terminating an employee?

Answer 358

Employment law
- In Ontario, the Employment Standards Act, 2000 (ESA) covers most employment related
legal issues
- In Ontario, the Occupational Health and Safety Act, 1990 (OHSA) requires employers to
investigate complaints of workplace harassment and have a workplace harassment
policy in place
- The ESA defines the minimum wage; allows for personal emergency leave, family
caregiver leave, family medical leave, critically ill child care leave, crime-related child
death or disappearance leave; and requires employers to provide a 30-minute meal
break for every 5 hours worked

• Under the ESA, termination includes:
• Firing an employee
• Constructively dismissing an employee: A constructive dismissal occurs when
  an employer makes a change to the terms or conditions of employment that
  would reasonably result in the employee leaving the position (e.g., a large
  decrease in pay, an ultimatum to “quit or be fired”)
• Permanently laying off an employee: A permanent lay-off is any lay-off period
  longer than a temporary lay-off (usually about 13 weeks)
• The ESA requires that terminated employees receive either termination notice or pay
  in lieu of notice
• Termination notice: The amount of notice required prior to termination if an
  employee has been continuously employed for at least 3 months; usually x
  weeks, where x=number of years of services (e.g., employees employed for less
  than 1 year get 1 week’s notice; employees employed for more than 8 years get
  8 week’s notice)
• T_ermination pay_: In lieu of termination notice, the employer may provide the
  employee with a lump-sum payment equal to the regular wages for a regular
  work week that the employee would have otherwise been entitled to during the
  termination notice period
• The ESA also requires that some terminated employees receive severance pay in
  addition to termination pay
• Severance pay: Compensation to a long-term employee for losses associated
  with a job loss (e.g., loss of seniority); employees qualify for severance pay if
  s/he has been working for a large employer for 5+ years

Question 359

Contrast categorical and numerical variables.

Contrast frequentist and bayesian probability.

Answer 359

Biostatistics
Definitions
- Statistics (the discipline): “Art of learning from data. It is concerned with the collection
of data, their subsequent description, and their analysis which often leads to drawing of
conclusions”
- Biostatistics: “Application of statistics to a wide range of topics in biology, including
biology, medicine, and public health”
- Statistics (the numbers): “Numerical summaries or measures of some attribute in a
sample”

• Descriptive statistics: Summarizing data; describe the basic features of a sample
• Statistical inference: Generalizing from a sample to the population
• Population: The entire group you want information about, mean 𝜇 and standard deviation σ
• Sample: The part of the population that you have information about, mean 𝑥 and sample standard deviation s
• Informatics: Information science; includes information processing, information storage,
  and information retrieval (how you make good databases!)
• Data engineering: As far as I can tell, informatics for really big datasets (“big data”)
• Variable: A term that can take on one of a the possible outcomes of a random experiment
• Categorical variables: Non-numeric data; describe using frequency tables, pie charts, bar graphs
• Nominal: Non-ordered attributes (e.g., gender, blood type), “names”
• Ordinal: Ordered categories; no meaningful distance between categories (e.g., Likert scale)
• Numerical variables: Numerical data; describe using distribution, central
  tendency, and variability
• Discrete: Countable sets with meaningful distances between numbers (e.g., number of smokers)
• Continuous: Continuously varying quantities; (e.g., blood pressure)
• (Alternatively, numerical variables can be categorized as ordinal (no meaningful zero) or ratio (absolute zero exists))
• Probability (Event) = Number of times event occurs / Total number of all possible outcomes
• Frequentist probability: As the number of trials increases, the probability
  estimate will approach the true probability; hypothesis testing
  described below is frequentist
• Bayesian probability: Well, frequentists, that’s kind of stupid because you can’t
  repeat an experiment an infinite number of times; let’s guess the prior probability
  that the hypothesis is true and use that instead; P(H|D) = P(D|H)P(H) P(D)
• Probability function: The probability that a hypothesis is true given the
  observations/data (you have some specific set of parameters that characterize a
  distribution; what is the probability that X = x?); P(H|D)
• Likelihood function: The probability of seeing an observation/data given a hypothesis
  (you have some data; what is the probability came from a specific set of parameters?);
  P(D|H)
• Bayes’ Rule: P(AB) = P(A|B)P(B) = P(B|A)P(A) (See Bayesian probability above)

Question 360

Describe municipal water treatment steps

Answer 360

Municipal water treatment
- Preliminary treatment_:_ Addition of chlorine to water in intake pipes
- Screening: Water forced through screens to trap debris
- Pre-chlorination: Addition of chlorine to incoming lake water
- Coagulation: During rapid mixing, coagulants (usually a aluminum or iron salts like alum,
or a polymer) neutralize the negative charge of small suspended solids in the water,
allowing them to stick together in microflocs (1-3 min)
- Flocculation: Slow mixing allows the microflocs created in the coagulation stage to stick
together, creating floc (15-60 min)
- Sedimentation/settling: Floc settles out of the water and cleaner water is drawn off the
top of the tank (note: direct-filtration plants skip this step)
- Filtration: Water passes through filters (carbon or anthracite, sand, and gravel) to remove microfloc, algae, silt, microbes, and odour-producing chemicals
- Note: In slow sand filters (e.g., those used in LMICs that do not have water treatment plants), but not in water treatment plants, the biofilm layer (schmutzdecke) is an integral to the water purification process
- Back washing: Forcing water back through the filter bed to wash out the solids
- Post-chlorination: Additional chlorine, as well as ammonia to stabilize the chlorine, is added to the water
- Chlorination by-products: Produced when chlorine interacts with organic matter; IARC has classified some of the chlorination by-products as 2B (possibly carcinogenic to humans), with small increases in bladder cancer risk; benefits of
chlorination much greater than risks, but individuals who want to reduce their risk further can use activated carbon filters
- Chlorine-resistant micro-organisms: Toxoplasma and Cryptosporidium oocysts are highly resistant to chlorination and should be physically removed with filters; Entamoeba histolytica and Giardia intestinalis are chlorine-tolerant
- Fluoridation

Monitoring (Ontario)
- Under the Safe Drinking Water Act, municipal water supplies fall under the jurisdiction of
the MOECC (Ontario) ; must be tested at an accredited and licensed lab; the MOECC accredits
and licenses drinking water testing labs
- Under the HPPA (Health Promotion and Protection Act), small drinking water systems fall under the jurisdiction of the MOHLTC; must be inspected by a PHI from the LPHA and the SDWS owner/operator must regularly submit water samples to an MOECC-accredited and licensed testing lab
- Private water system owners can submit water samples to their LPHA or PHO Lab for E.
coli and total coliform testing (testing 3x/year is recommended); no requirements
- Other water testing collection sites: Public beaches, recreational water facilities, potable
ice, spas, water suspected of Legionella contamination
- E. coli: Indication of fecal contamination of water; generally do not multiply in water in
temperate climates; no level of E. coli is safe
- Total coliforms: Indication of fecal contamination of water, but may also be isolated from
plants, soil, and sediments; includes E. coli; total coliform count < 5 is safe to drink
- Ray Copes (2017-01-06): Alberta: Similar regulatory framework to ON; BC: health
regulates all water supply; Manitoba: environment regulates all water supply; federally regulated
supply (e.g., reserves, CFBs) follow the provincial guideline in which the area
is located

Question 361

In relation to patient safety,

contrast adverse event, medical error, near-miss incident and no-harm incident.

What is the reason model of error?

Answer 361

Case study: Patient safety
Definitions
- Patient safety: The reduction and mitigation of unsafe acts within the health care
system, as well as the use of best practices shown to lead to optimal patient outcomes
- Patient safety incident: An event or circumstance that could have resulted, or did
result, in unnecessary harm to the patient
- Adverse event (aka harmful incident): Unsatisfactory outcome as a result of health care management that caused harm to a patient; may be due to inherent risk and may not be foreseeable or preventable (e.g., GI bleed due to adequately monitored warfarin)
- Medical error: An adverse event that was preventable (e.g., needlestick injury)
- Near miss incident: A patient safety incident that did not reach the patient; no
harm caused
- No-harm incident: A patient safety incident that reached the patient but no
discernible harm resulted
- Adverse outcome: Unsatisfactory outcome that arises as part of the natural disease
course (e.g., GI bleed due to stress ulcer)
- Reason model of error (aka the Swiss cheese model): Proposes that vulnerable people
are protected from hazards by several layers (see image below)

Question 362

Regarding type 2 diabetes, describe:

• Recent epi trends
• Risk factors
• Screening guidelines
• Health impacts
• Population-level interventions
• CTFPHC screening recommendations?

Answer 362

Type 2 diabetes

• *Epidemiology**
• Prevalence of diabetes = 8.1% (3 millions Canadians) = 1/300 youth 1-19yo, 1 in 10 adults.

- Prevalence increases with age and male sex.

- Prevalence of diabetes has been increasing, but incidence is stable/slightly decreasing (data as of 2013-2014)
- Incidence of DMII in children and youth rising

- Gestational pregnancies 1 in 10

• *Modifiable risk factors**
• Obesity
• Physical inactivity
• Hypertension
• Hypercholesterolemia
• *Unmodifiable risk factors**
• Increased age
• Gestational diabetes
• Family history of diabetes
• Ethnicity
• Lower SES
• Rural residence
• PCOS
• *Health impacts**
• CVD
• ESRD
• Non-traumatic lower limb amputation
• Increased mortality rate (at least 2x increase, depending on the age group)

CTFPHC screening guidelines (2012)
- For adults at low to moderate risk of diabetes (determined with a validated risk
calculator), we recommend not routinely screening for type 2 diabetes (Weak
recommendation; low-quality evidence)
- For adults at high risk of diabetes (determined with a validated risk calculator), we
recommend routinely screening every 3–5 years with A1C (Weak recommendation; lowquality
evidence)
- For adults at very high risk of diabetes (determined with a validated risk calculator), we
recommend routine screening annually with A1C (Weak recommendation; low-quality
evidence)

Canadian Diabetes Association Screening Guidelines
- Screen every 3 years in individuals ≥40 years of age or in individuals at high risk using a
risk calculator
- Screen earlier and/or more frequently in people with additional risk factors for diabetes
or for those at very high risk using a calculator

• *Population-level interventions**
  1. Primary prevention
  a. Reduce prevalence of obesity
  b. Improve health literacy

2. Secondary prevention
   a. Identify individuals at increased risk and target with combined diet and physical
   activity promotion programs
3. Tertiary prevention
   a. Self-management education
   b. Case management

Question 363

What are the stages of organizational change (4)?
What are Kotter’s change management steps (8)?

Answer 363

Change management
Stage theory of organizational change
1. Awareness: Senior management recognizes challenges, impacts, and possible
solutions within the organization
2. Adoption: Choose an intervention to address the issue, including identifying resources
and modifying the intervention to align it with an organization and its culture
3. Implementation: Training and capacity-building to introduce and then maintain change
4. Institutionalization: Long-term maintenance

Kotter’s change management steps:
1. Establish a sense of urgency
a. Identify a need for change → communicate broadly about the need (“make the
status quo seem more dangerous than launching into the unknown” → ensure at
least 75% of management is convinced of the need for change)
b. “Management’s mandate is to minimize risk and to keep the current system
operating. Change, by definition, requires creating a new system, which in turn
always demands leadership”
c. Change during times of poor performance makes the impetus for change clear,
but leaves less room for maneuvering; change during times of good performance
requires much more convincing, but more resources are available to make
change
d. It is sometimes helpful for an outsider to identify the need for change, because
people have a tendency to “shoot the bearer of bad news” (not helpful if bad
news bearer is then supposed to lead change)

2. Create a powerful guiding coalition
   a. Coalition should consist of most senior executives (including key line managers)
   and members who are not part of senior management (i.e., must operate outside
   the normal hierarchy of the organization)
3. Create a vision (“a picture of the future that is relatively easy to communicate and
   appeals to customers, stockholders, and employees”; must be clear and specific)
   a. After the vision becomes clear, develop a strategy to achieve that vision
   b. “Without a sensible vision, a transformation effort can easily dissolve into a list of
   confusing and incompatible projects that can take the organization in the wrong
   direction or nowhere at all”
4. Communicate the vision
   a. Communication must be credible, visible, and regular (e.g., included in routine
   discussions: “Employee X, your current performance is helping us achieve Vision
   Y because…” in a performance appraisal); re-frame work and clarify roles to
   include tasks that achieve the new vision; walk the talk (i.e., communicate in
   words and deeds)
   b. This phase is challenging if there will be short-term sacrifices like job losses: “For
   this reason, successful visions usually include new growth possibilities and the
   commitment to treat fairly anyone who is laid off”
   c. Middle managers serve as the conduit between the vision and frontline staff
5. Empower others to act on the vision
   a. Remove obstacles to the new vision: “Too often, an employee understands the
   new vision and wants to help make it happen, but an elephant appears to be
   blocking the path.”
6. Plan for and create short-term wins
   a. “Real transformation takes time, and a renewal effort risks losing momentum if
   there are no short-term goals to meet and celebrate”
   b. Short-term = Within 12-24 months
7. Consolidate improvements
   a. Celebrate wins, but don’t declare victory too soon: “In their enthusiasm over a
   clear sign of progress, the initiators go overboard [prematurely celebrating
   victory]. They are then joined by resistors, who are quick to spot any opportunity
   to stop change.”
8. Institutionalize new approaches
   a. “Change sticks when it becomes ‘the way we do things around here’ …. Until
   new behaviors are rooted in social norms and shared values they are subject to
   degradation as soon as the pressure for change is removed.”

Question 364

What are the source and limits of the legal authority of public health officials?

Answer 364

Public Health Law
Definition: The study of the legal power and duties of the state…to assure the conditions for
people to be healthy (i.e., identify, prevent, and ameliorate risks to health in the population) and
the limitations on the power of the state to constrain the autonomy, privacy, liberty or other
legally protected interests of individuals for the common good (Lawrence Gostin, Georgetown
University)

Source and scope of power
With every public health action, public health officials should consider:
- Why can public health officials do what they do?
- What is the source of their legal authority?
- Delegated by legislation (e.g., in Ontario, HPPA)

• What are the limits of their legal authority?
• Limited by statute (e.g., outlined by the HPPA), jurisdiction (e.g., LPHA does not
  have jurisdiction over federal penitentiaries), and Charter
• “Public health legislation grants public health officials significant powers to restrict
  individual freedoms: to choose what to eat, with whom and how to share
  intimacy, if and when to see a health care provider, whether to go to work and to
  socialize, and to decide with whom to share our health information. Powers must
  be exercised appropriately in light of Charter values.”
• How can they best interpret their role?
• Where do they, and the power they are exercising, fit in the legal landscape governing
  public health law?
• How do they best balance individual autonomy and community safety?
• Public health physicians do not owe a duty of care to individual’s economic
  interests; public health physicians’ duty is to the public
• Must balance: Risk of harm to the community, the effectiveness of the
  intervention, and the degree to which the intervention restricts freedom

Question 365

Describe basic facts about mumps

Organism, Reservoir, Mode of transmission

Incubation period, infectious period

Epidemiology

Presentation, Testing

Case management, Contact management

+/- Immunization

Answer 365

Mumps (reportable)
- Organism: Mumps virus (Paramyxoviridae family)
- Reservoir: Humans
- Mode of transmission: Droplets, direct contact with saliva
- Epidemiology:
- Adults born before 1970 are considered naturally immune
- Occurs world wide
- Canadian incidence has decreased > 99% since the introduction of mumps
vaccine in Canada in 1969
- Proportion of mumps cases in young adults is increasing in Canada
- Outbreaks in Canada most commonly occur in unvaccinated children, and young
adults who only received 1 dose of MMR
- Presentation: Non-specific respiratory symptoms (may be subclinical)
- Parotitis occurs in 40-60% of cases (unilateral in 25%)
- Orchitis occurs in 20-30% of post-pubertal males
- Oophoritis occurs in 5% of post-pubertal females
- Complications: Aseptic meningitis, mumps encephalitis (rare), transient
deafness, permanent deafness (0.5-5/100,000 mumps cases)
- Incubation period: 16-18 days
- Infectious period: 7 days before onset of parotitis to 9 days after onset of parotitis
- Testing: Buccal swab, throat swab, and urine for viral culture and PCR; acute and
convalescent serum for IgM and IgG
- Case management: Supportive
- Contact management: Vaccine and Ig do not alter the clinical severity of mumps and are
not recommended for PEP; however, susceptible individuals should receive vaccination
to protect them from future exposures; non-immune healthcare worker contacts must be
excluded from work fro day 10 to 26 post-exposure
- Vaccine:
- 1-dose MMR introduced in Canada in 1983; 2-dose MMR introduced in 1996-97
in Canada (+ MR or M catch-up, depending on province, leading to large cohort
of young adults under-vaccinated for mumps)
- Even with two doses, mounting evidence of waning mumps immunity
- 1 dose at 12-15 months of age + 1 dose at 18 months-school entry age

Question 366

Describe basic facts about meningococcal disease

Organism, Reservoir, Mode of transmission

Incubation period, infectious period

Epidemiology

Presentation, Testing

Case management, Contact management

+/- Immunization

Answer 366

Meningococcal disease
- Organism: Neisseria meningitidis (aerobic, encapsulated diplococcus), predominantly serogroups A, B, C, Y, and W-135
- Reservoir: Humans
- Mode of transmission: Respiratory droplets
- Epidemiology:
- Endemic at low levels in Canada
- Most common in children < 1 year
- Invasive meningococcal disease mortality = 10%; 10-20% of survivors have longterm sequelae
- 5-10% of adults are asymptomatic carriers (decreases with age); carriers tend to have serogroup-specific protective antibodies
- Canada: Serogroups B, C, W-135, and Y present; serogroup B is the most common cause of IMD in Canada
- Meningitis belt: Area hyperendemic for meningococcal disease; highest-risk countries include Senegal, the Gambia, Guinea-Bissau, Guinea, Mali, Burkina Faso, Niger, Nigeria, Chad, Cameroon, Sudan, South Sudan, and Ethiopia
- Hajj or Umrah pilgrimage: Associated with outbreaks of Men-W-135
Image: http://www.meningitis.org/worldmenw
- Presentation: Conjunctivitis, pneumonia, invasive meningococcal disease: (meningitis, septicemia, orbital cellulitis, or septic arthritis + purpura or petechiae)
- Incubation period: 2-10 days (mean, 3-4 days)
- Infectious period: 7 days prior to symptoms and 1 day post-abx
- Testing: NAT can detect meningococcal DNA in the SF up to 96h post-abx; blood or CSF culture
- Case management: Droplet precautions; if treatment did not include an agent that eliminates NP carriage, cases require chemoprophylaxis with rifampin, ciprofloxacin, or ceftriaxone
- Contact management: Risk of IMD in household contacts persists for up to 1 year; abx x 10 days (including contacts of invasive disease, conjunctival disease, and pneumonia) within 10 days of exposure; vaccine for individuals at ongoing risk of exposure (e.g.,
household contacts but not health care worker contacts) if susceptible to the serogroup
- If the case was aboard an aircraft for > 8h during the infectious period, offer abx prophylaxis to passengers immediately on either side of the case or individuals who had direct contact with respiratory secretions

- Close contacts = household, sleeping, child/staff at day care, direction contact with secretions, 8-hr flight should received atb prophylaxis

• Vaccine:
• Men-C-C (Menjugate): Monovalent conjugate meningococcal C vaccine; recommended for all children at 12 months of age + booster dose
• 4CMenB (Bexsero): Multicomponent meningococcal B vaccine; recommended for high-risk individuals; “consider” for children and adolescents 2+ months of age; associated with high rates of fever +/- febrile seizures
• Men-C-ACYW (Menactra, Menveo): Quadrivalent conjugate meningococcal vaccine; either Men-C-C or Men-C-ACYW are recommended for all adolescents and high-risk individuals; travellers should receive Men-C-ACYW

Question 367

What are examples of organisms necessitating contact precautions?

Answer 367

Norovirus, rotavirus,
disseminated HSV

Question 368

What are the steps to approve of pharmaceutical drug in Canada (8)?

In this process, what is the role of:

• Health Canada?
• Canadian Agency for Drugs and Technology in Health (CADTH)?
• Pan-Canadian Pharmaceutical Alliance (pCPA)?

Answer 368

Approval of pharmaceutical drugs in Canada
Pharmaceutical drugs: Prescription and non-prescription drugs, disinfectants, and some other products (e.g., sunscreen, antiperspirants)

Roles and responsibilities:
- Health Canada is responsible for : Safety, efficacy, and quality of drugs is regulated by, and is the responsibility of, Health
Canada through the Food and Drugs Act
- Tools: Scientific review, monitoring, compliance, enforcement
- Specifically, Health Canada → Health Products and Food Branch → Therapeutic Products Division (TPD)

• Canadian Agency for Drugs and Technology in Health (CADTH) is responsible for recommending whether or not provincial drug plans should reimburse the cost of new medications
• Pan-Canadian Pharmaceutical Alliance (pCPA): An alliance within the Council of the Federation (a group made up of all of Canada’s Premiers); negotiate drug prices for provincial and federal drug plans

Steps to approval of pharmaceutical drug:

1. Preclinical studies: Animal models
2. Clinical trials: Testing in humans; each phase requires approval from the TPD
   a. Phase 1: Is it safe?
   b. Phase 2: Is it efficacious?
   c. Phase 3: Is it more efficacious than the current treatment?
3. New drug submission: Pharmaceutical company requests the TPD to approve its drug for use in Canada
4. Submission review: TPD reviews results from preclinical and clinical trials to determine if, for specific indications, the benefits of the drug outweigh the known risks
5. Market authorization decision: Issued by TPD (Health Canada), indicating that the drug may be sold in Canada
   a. Notice of Compliance: Issued when a drug manufacturer received a successful review from TPD; once Notice of Compliance issued, drug or vaccine is available for private purchase
   b. Product Monograph: Submitted by the drug company and edited by TPD
6. Public access
7. Post-market surveillance (phase 4 clinical trial)
8. CADTH Common Drug Review (CDR): Evaluation of the _clinical and economic evidence by CADTH to determine whether or not it is recommended that a provincial drug pla_n cover a new medication (like the CIC of medications)
9. Pan-Canadian Pharmaceutical Alliance negotiations: Once the CDR releases its final recommendations, the pCPA may negotiate a Letter of Intent between interested P/Ts and the manufacturer for drug prices for F/P/T drug plans

Question 369

What are the incubation period and communicability periods for measles?

Answer 369

Incubation: 7-21 days

Communicability: 4 days before rash onset to 4 days after rash onset

Question 370

Describe basic facts about dengue

Organism, Reservoir, Mode of transmission

Incubation period, infectious period

Epidemiology

Presentation, Testing

Case management, Contact management

+/- Immunization

Answer 370

Dengue
- Organism: Dengue viruses (4 types; flaviviruses)
- Reservoir: Urban cycle (humans-Ae. aegypti cycle); sylvatic cycle (monkey-mosquito
cycle in SE Asia and W Africa)
- Mode of transmission: Vector-borne (primarily Ae. aegypti, some Ae. albopictus)

• Epidemiology: Huge increase in incidence in the last decade; now endemic in most
  countries in the tropic and subtropics; transmission usually occurs year-round with a
  peak in the rainy season
• Presentation: Typically presents as flu-like illness, but can cause severe illness called
  dengue hemorrhagic fever (aka severe dengue)
  1. Febrile phase: _Fever x 2-7 day_s +/- injected oropharynx/facial erythema x 24-48
  h, headache, myalgia, arthralgia, retro-orbital pain, hemorrhagic manifestations
  (petechiae, ecchymoses, purpura, hematuria)
  2. Critical phase: Symptoms initially improve, but marked vascular permeability x
  24-48 h → shock, effusions, ascites +/- death, hepatitis, myocarditis, pancreatitis,
  encephalitis, severe hemorrhagic manifestations (hemorrhage, hematemesis,
  hematochezia, melena, menorrhagia)
  3. Convalescent phase: Vascular permeability resolves → diuresis +/- erythematous
  rash that may desquamate
• Incubation period: 3-14 days
• Testing: Serology (anti-DENV IgM); RT-PCR
• Case management: No antiviral available; supportive care (+++fluids); avoid mosquito
  bites while viremic (up to 12 days after symptom onset)
• Contact management: No chemoprophylaxis available; prevent mosquito bites and
  control mosquito populations
• Other:
• Recovery from one type of DENV provides lifelong immunity to that type, but
  there is no long-term cross-protective immunity following infection (e.g., if you
  had DENV-1 infection, you can still get DENV-2 infection); subsequent infections
  with other DENV types increases the risk of severe dengue/dengue hemorrhagic
  fever
• Dengvaxia (CYD-TDV) vaccine released in 2015; recommended only in settings
  with high burden of disease

Question 371

Regarding the Occupational Health and Safety Act (OHSA):

Describe the OHSA internal responsibility system.

What is the role of Joint Health and Safety Committees?

Answer 371

Ontario Occupational Health and Safety Act (OHSA)

• Purpose: To make workplaces safe and healthy by defining the rights and duties of all parties in the workplace
• Under OHSA, employers have the most responsibility for health and safety
• Internal Responsibility System: Emphasizes the OHSA principle that everyone in the workplace has a responsibility to make workplaces safe and healthy
• Workers hat the RIGHT to participate, RIGHT to know and RIGHT to refuse work
• Employers: (4)

Inform workers of hazards,

provide and ensure workers use PPE,

support an IRS,

do everything reasonable to make sure a workplace is safe and healthy

• Supervisors: (2)

Ensure workers use PPE,

remedy hazards

• Workers: (4)

Report hazards,

use PPE,

report injuries and illnesses,

follow procedures

• Organizations with 20+ employees must have a Joint Health and Safety Committee, with representation from management and staff; the JHSC identifies hazards and makes recommendations
• Employers must report occupational illness and injury to the JHSC, the union (if any), and the Ministry of Labour within 4 days (+/- the MOH if the disease is reportable)

Question 372

What are early childhood public health interventions?

Answer 372

• *Early childhood interventions**
• *Evidence-based parenting programs**
• Triple-P parenting: Positive Parenting Program; uses social learning, cognitivebehavioural, and developmental theories to teach parents to manage familyissues
• Incredible Years: 15-week psycho-educational program for parents that coversplay skills, praise, limit setting, ignoring, reward systems, and effectiveconsequences
• Period of PURPLE Crying: Educating parents to understand that PURPLEcrying (Peak of crying/Unexpected/Resists soothing/Pain-like face/Longlasting/Evening) is a normal part of newborn development; reduces risk ofShaken Baby Syndrome and reduces visits to ER for prolonged crying
• *Parental support:**
• Home visiting programs to support pregnant women and new mothers
• Intimate partner violence prevention
• Social supports for parents
• Mental illness and substance abuse treatment
• Parental leave
• Income support

Early childhood education

Program for young children with an explicit curriculum
designed to support learning and development (e.g., Abecedarian, Perry Preschool)
- Very strong evidence that for ECE for children ≥3 years improves outcomes;weaker evidence for ECE for toddlers (outcomes: cost saving, increasedmaternal work productivity, reduced early school leaving, reduced rates of futureincarceration, increased rates of future employment, higher future educationalattainment, higher future literacy test scores, demographic stability)
- 2000 Cochrane review conclusion: “Day care has beneficial effect on children’sdevelopment, school success and adult life patterns. However, to date, allrandomised trials have been conducted among disadvantaged populations in theUSA. The extent to which the results are generaliseable to other cultures andsocioeconomic groups has not yet been established.”

• Screening: T_he CTFPHC recommends against screening for developmental delay_ (noevidence of benefit, evidence of harm); the province of Ontario recommends screening
  all toddlers at age 18 months and the AAP recommends screening at 9, 18, and 30months; the CPS recommends enhanced 18-mo checks that include screening fordevelopmental delay
• Developmental delay: 1.5+ SDs below the mean for age-expected norms in grossor fine motor skills, speech and language, social or personal skills, cognition, orADLs; sustained developmental delay is a risk factor for learning difficulties,behavioural problems, and functional impairments
• Developmental delay can result from poor maternal health during pregnancy,birth complications, infections, genetics, toxins, trauma, maltreatment, low SES
• Examples of screening tools include Denver Developmental Screening Test,Nipissing District Developmental Screen, and the Ages and StagesQuestionnaire
• Contraception and abortion access: Benefits from delaying pregnancy

Question 373

Regarding violence and conflicts,

what are their impacts on health?

Public health approach to violence prevention?

Answer 373

Violence and conflict
Definitions
- Classes of firearms in Canada:
- Prohibited: Assault weapons, fully automatic firearms, sawed-off rifles or
shotguns
- Restricted: Requires a valid license under the Firearms Act and must be
registered; handguns
- Non-restricted: Requires a valid license under the Firearms Act, but does not
need to be registered except in Quebec; rifles and shotguns
- License under the Firearms Act requires 1) a safety course, 2) criminal background
check, 3) personal references, 4) and a mandatory waiting period

Epidemiology
- Violent crime is decreasing in Canada; firearm-related violent crime is decreasing
fastest; homicide rates peaked in the 1970s and have been decreasing since
- Most violent crime in Canada (80%) does not involve a weapon

• Family violence: Victims of family violence represent 25% of all victims of violent crimes
  (279 victims of family violence/100,000 population in 2011); 70% of victims of family
  violence are female; rates of family violence are decreasing in Canada
• Intimate partner violence: 50% of family violence victims are partners of the
  accused
• Child abuse and neglect: 18% of family violence victims are children of the
  accused
• Elder abuse: 9% of family violence victims are parents of the accused

- Firearms and homicide:
- Firearm homicide rates by country:
- Canada = 0.5/100,000
- US = 3.5/100,000
- Japan = 0.01/100,000
- UK = 0.06/100,000
- Most firearm-related deaths are suicides, accidents, or police shootings; only
20% of firearm-related deaths are criminal offences
- Shootings account for 33% of homicides but most violent crime in Canada does
not involve firearms (firearm-related violent crime accounts for 2% of violent
crime)
- Most firearm-related homicides involve handguns and are more likely to be gangrelated
that homicides committed without a handgun

Impact of conflict on health
- “Disconnected, unhealthy, and poor communities have far higher rates of
violence” (Gilmore, 2016)
- Measuring the impact of conflict on health is challenging because conflict often results in
the cessation of civil registration; as well, available information may be represented for
political gain
- Direct mortality (aka “battle deaths”): Individuals killed in direct fighting; for every military
death, there is one direct civilian death
- Indirect mortality: Commonly reported as 9x higher than direct mortality, although
empirical basis for this figure is unclear

• Non-fatal outcomes:
• Disability secondary to injury (ratio of people injured to those killed = 1.9 to 13)
• Food insecurity leading to malnutrition
• Crowding, decreased access to water and sanitation, and breakdown of
  healthcare system → Increased risk of infectious disease
• Psychological trauma

Population-level interventions
CDC’s Public Health Approach to Violence Prevention:
1. Define and monitor the problem: Analyze violence-related behaviours, injuries, and
deaths to determine where the violence occurs, who the victims and perpetrators are,
and trends
2. Identify risk and protective factors
3. Develop and test prevention strategies based on needs assessments, community
surveys, stakeholder interviews, focus groups, and literature review
4. Once a program has proven effective, assure widespread adoption

Interventions recommended by the Community Guide:
- School-based programs to reduce violence: Behavior modification programs to reduce
anti-social behaviour, bullying, and dating violence
- Therapeutic foster care (foster families are specially trained; structured environment;
program-intensive) from chronically delinquent juveniles (adolescents ages 12-18 with a
history of chronic delinquency)
- Recommend against transferring youth to adult criminal system
- Insufficient evidence to recommend for or against specific types of firearm laws
See also: Early childhood interventions

Question 374

What are evidence-based interventions to decrease sthe consumption of sugar-sweetened beverages at the population level?

Answer 374

▪ Labels which are easy to understand, such as traffic‐light labels, and labels which rate the healthfulness of beverages with stars or numbers.

▪ Limits to the availability of SSB in schools (e.g. replacing SSBs with water in school cafeterias).

▪ Price increases on SSBs in restaurants, stores and leisure centres.

▪ Children’s menus in chain restaurants which include healthier beverages as their standard beverage.

▪ Promotion of healthier beverages in supermarkets.

▪ Government food benefits (e.g. food stamps) which cannot be used to buy SSBs.

▪ Community campaigns focused on SSBs.

▪ Measures that improve the availability of low‐calorie beverages at home, e.g. through home deliveries of bottled water and diet beverages.

Labelling interventions (8 studies): We found moderate‐certainty evidence that traffic‐light labelling is associated with decreasing sales of SSBs, and low‐certainty evidence that nutritional rating score labelling is associated with decreasing sales of SSBs. For menu‐board calorie labelling reported effects on SSB sales varied.

Nutrition standards in public institutions (16 studies): We found low‐certainty evidence that reduced availability of SSBs in schools is associated with decreased SSB consumption. We found very low‐certainty evidence that improved availability of drinking water in schools and school fruit programmes are associated with decreased SSB consumption. Reported associations between improved availability of drinking water in schools and student body weight varied.

Economic tools (7 studies): We found moderate‐certainty evidence that price increases on SSBs are associated with decreasing SSB sales. For price discounts on low‐calorie beverages reported effects on SSB sales varied.

Whole food supply interventions (3 studies): Reported associations between voluntary industry initiatives to improve the whole food supply and SSB sales varied.

Retail and food service interventions (7 studies): We found low‐certainty evidence that healthier default beverages in children’s menus in chain restaurants are associated with decreasing SSB sales, and moderate‐certainty evidence that in‐store promotion of healthier beverages in supermarkets is associated with decreasing SSB sales. We found very low‐certainty evidence that urban planning restrictions on new fast‐food restaurants and restrictions on the number of stores selling SSBs in remote communities are associated with decreasing SSB sales. Reported associations between promotion of healthier beverages in vending machines and SSB intake or sales varied.

Intersectoral approaches (8 studies): We found moderate‐certainty evidence that government food benefit programmes with restrictions on purchasing SSBs are associated with decreased SSB intake. For unrestricted food benefit programmes reported effects varied. We found moderate‐certainty evidence that multicomponent community campaigns focused on SSBs are associated with decreasing SSB sales. Reported associations between trade and investment liberalisation and SSB sales varied.

Home‐based interventions (7 studies): We found moderate‐certainty evidence that improved availability of low‐calorie beverages in the home environment is associated with decreased SSB intake, and high‐certainty evidence that it is associated with decreased body weight among adolescents with overweight or obesity and a high baseline consumption of SSBs.

Adverse outcomes reported by studies, which may occur in some circumstances, included negative effects on revenue, compensatory SSB consumption outside school when the availability of SSBs in schools is reduced, reduced milk intake, stakeholder discontent, and increased total energy content of grocery purchases with price discounts on low‐calorie beverages, among others. The certainty of evidence on adverse outcomes was low to very low for most outcomes.

We analysed interventions targeting sugar‐sweetened milk separately, and found low‐ to moderate‐certainty evidence that emoticon labelling and small prizes for the selection of healthier beverages in elementary school cafeterias are associated with decreased consumption of sugar‐sweetened milk. We found low‐certainty evidence that improved placement of plain milk in school cafeterias is not associated with decreasing sugar‐sweetened milk consumption.

Question 375

Describe basic facts about hepatitis A

Organism, Reservoir, Mode of transmission

Incubation period, infectious period

Epidemiology

Presentation, Testing

Case management, Contact management

+/- Immunization

Answer 375

Hepatitis A (reportable, VPD)
- Organism: Hepatitis A virus; RNA virus from the Picornaviridae family
- Reservoir: Humans (+rarely other non-human primates)
- Mode of transmission: Fecal-oral (household contacts, contaminated food or water,
IVDU, oral-anal sex)

• Epidemiology:
• In LMICs, most people contract HAV as children and then develop lifelong immunity
• In HICs, HAV infection is less common and is typically limit to household and sexual contacts of acute cases +/- daycare contacts, PWID, and sexual contacts
• Attack rate in household contacts = 12-27% (higher if index case is a child)
• Presentation:
• Children < 6 years: Usually asymptomatic (but can excrete virus for up to 6 months)
• Older children and adults: Anorexia, nausea, fatigue, fever, and jaundice; risk of fulminant hepatitis increases with age; 25% of adult cases require hospitalization (usually no longer communicable one week after jaundice onset)
• Incubation period: 15-50 days (infectious during the latter half of the incubation period + a few days following onset of symptoms)
• Testing: Serology
• Anti-HAV IgM: Indicates current or recent HAV infection (present 5-10 days before symptom onset to up to 6 months post-infection); also detectable up to 3 weeks post-HAV vaccination
• Anti-HAV IgG: Indicates either natural or vaccine-derived immunity to HAV
• Total Ig not helpful
• Case management/treatment: Supportive care; provide teaching about handwashing,diaper disposal, and food handling
• Contact management:

1) Age<6 months → Ig alone;

2) immunocompromised, age>60 years, or liver disease → vaccine + Ig;

3) all other contacts → vaccine alone;

vaccine must be provided within 14 days of exposure; exclude asymptomatic, susceptible contacts in high-risk occupations and symptomatic contacts

• Contact = Household members, coworkers and clients of infected food handlers, staff and attendees of child care centres and kindergartens
• Other: PrEP recommended for persons at increased risk of infection (e.g., travellers, MSM, PWID, individuals living in endemic communities) or severe outcomes (e.g. individuals with chronic liver disease, age>60 years)

Health Canada list indications for hepatitis A vaccination:

In particular, the following groups are recommended to be vaccinated for hepatitis A prevention:

travellers to or immigrants from hepatitis A-endemic areas

household or close contacts of children adopted from hepatitis A-endemic countries

populations or communities at risk of hepatitis A outbreaks or in which hepatitis A is highly endemic

for example, some Indigenous communities

military personnel and humanitarian relief workers likely to be posted to areas with high rates of hepatitis A

Additional at-risk groups recommended to be vaccinated include:

persons with lifestyle risks for infection, including:

men who have sex with men

those who use illicit drugs (injectable and non-injectable)

zoo keepers, veterinarians and researchers who handle non-human primates

people with hemophilia A or B receiving plasma-derived replacement clotting factors

workers involved in research on the hepatitis A virus or the production of the hepatitis A vaccine

persons who have chronic liver disease from any cause, including persons infected with hepatitis B or C

these persons may be at risk of more severe disease if infection occurs

Question 376

What are endocrine disruptors and describe examples

What are the sources and health impacts of BPA and phtalates?

Answer 376

Endocrine disruptors
Definition: Chemicals that affect the synthesis, secretion, transporting, binding, or metabolism of endogenous human hormones; term first defined at the 1991 Wingspread conference (see
also: Precautionary Principle); may play a role in the development of DMII (endocrine), increase or decrease the activity of sex hormones (reproductive), or increase cell proliferation; unclear whether effects are clinically
meaningful, and, if they are, whether they follow monotonic (linear) or non-monotonic (Ushaped) dose-response curves and whether the effects only result after exposure during critical periods of development
- Includes some POPs (long half-life): PCBs, dioxins (PCDDs), DDT, mirex, chlordane
- Includes some plastic-associated compounds (short half-life): BPA, phthalates, PVCs
- Includes some compounds used in personal care products: E.g., Parabens, triclosan, triclocarban, oxybenzone
- Includes some pharmaceuticals: E.g., diethylstilbestrol
- Includes some naturally-occurring substances: E.g., Phytoestrogens

Case studies:
- Bisphenol A (BPA): Monomeric building block of polycarbonate plastics; also added to some other plastics (e.g., polyvinyl chloride); estrogen mimic; the polymerization of BPA leaves some BPA monomers unbound, so they can leach from food and drink containers over time (leaching is accelerated by acidic or basic contents and elevated temperatures); “The health risks of BPA are fiercely debated and, after more than 70 years of study, are still not fully understood” (Ann Rev PH); epidemiological studies have
found associations between BPA levels and obesity, endometrial hyperplasia, recurrent miscarriages, and PCOS

• Phthalates: Diesters of phthalic acid, used in plastics, paints, and personal care items; highly susceptible to leaching (leaching accelerated by heat, mechanical stress, and longer storage times); phthalates are rapidly metabolized and excreted from the human
  body; epidemiological studies have found associations between some phthalates and waist circumference, insulin resistance, and poor sperm quality

Question 377

What is the UN HIV 90-90-90?

Answer 377

90-90-90: UN HIV/AIDS target for 2020; 90% of all people living with HIV will know their
status, 90% of all individuals diagnosed with HIV will receive HAART, and 90% of people
receiving HAART will achieve viral suppression

Question 378

Compare and contrast different levels of IPC precautions and give examples.

Answer 378

Question 379

Define error/bias, validity, reliability.

What are 5 examples of selection biases.

What are 5 examples of information biases.

Answer 379

Bias and error

• *Error**: Difference between the observed value and the true value
• Random error: Impact on the difference between the observed value and true value is unpredictable
• Systematic error (aka bias): Impact on the difference between the observed value and true value is predictable and always occurs in the same direction
• Non-differential misclassification: Direction of systematic error is unrelated to the group (i.e., exposed vs. unexposed, cases vs. controls); biases results towards the null
• Differential misclassification: Direction of systematic error depends on the group (i.e., exposed vs. unexposed, cases vs. controls); may bias results in either direction (towards or away from the null)

Error results from invalid or unreliable measurements or study designs:

• Validity: Ability of a test to measure the phenomenon of interest
• Reliability: Consistency or dependability of a measurement

There are 3 threats to internal validity: selection bias, information bias and confounding.
- INFORMATION BIASES: Systematic error in measurement, producing differential accuracy of information by level of exposure or outcome, the misclassification can be differential or non-differential.

Examples:

misclassification bias (e.g. imprecise measurements, non-differential)

recall bias (solution is triangulation)

observer bias (solution is blinding)

interviewer bias (solution is standardized questionnaire and blinding)

regression dilution bias (creates underestimation of effect, solution is multiple measurements before classification)

detection bias (or surveillance/ascertainment bias) (increased detection because of other condition, solution is selecting controls with similar degree of scrutiny)

• SELECTION BIASES: Subjects are selected such that the distribution of a characteristic among the subjects differs from the distribution of the characteristic in the target population

Examples:

sampling

loss to follow-up bias (attrition)

selective reporting bias (can be based on different factors such as publication bias, duplicate publication bias, delayed publication bias, positive outcome reporting bias, citation bias, language bias, location bias)

non-response bias

incidence-prevalence bias (Neyman, survival)

coufounding by indication bias

volunteer bias

Question 380

What is the post-exposure prophylaxis for severe invasive group A strep?

Answer 380

Cephalexin (preferred)
Erythromycin
Clarithromycin
Clindamycin

Question 381

Describe the federal, provincial and municipal roles in water quality (includes recreactional and drinking water)

Answer 381

Water standards and guidelines
Federal role: Health Canada
- Guidelines for Canadian Drinking Water Quality: Outlines microbiological, chemical and
physical, and radiological parameters for water contaminants that are found in Canada
and could lead to adverse health effects
- Usually expressed as a Maximum Acceptable Concentration (MAC); a MAC is
multiple times lower than the LOAEL
- National Recreational Water Guidelines: Outlines bacteriological, cyanobacterial,
physical, and aesthetic parameters for water contaminants that are found in Canada and
could lead to adverse health effects through direct contact (e.g., swimming, bathing,
water skiing) or secondary contact (e.g., fishing, canoeing) (does not apply to
recreational facilities like pools or spas)
- Ensure water safety in federal jurisdictions (reserves south of 60 degrees; Canadian Force Bases;
penitentiaries; cruise ships, airplanes, and trains)
- Regulate bottled water, prepackaged ice, and water used in food processing (through
Food and Drug Act)
- Source protection (through Canada Water Act, Canadian Environmental Protection Act,
and Fisheries Act)
*Note: Federal guidelines are not enforceable unless they are included in regulations by the
P/Ts, which does not occur uniformly across Canada

P/T role
- Responsible for ensuring the provision of safe drinking water to the public
- Responsible for ensuring recreational water quality
- In Ontario, the Drinking Water Quality Standards (Re. 169/03) of the Safe Drinking
Water Act make the Guidelines for Canadian Drinking Water Quality enforceable in
Ontario
- In Ontario, the Recreational Water Protocol of the HPPA (Health Protection and Promotion Act) identify how often recreational water facilities, beaches, and recreational camps should be inspected

Municipal role
- Responsible for day-to-day operations of water treatment facilities
- Through LPHAs, responsible for recreational water testing and small drinking water
system testing

Question 382

Discuss the risk factors for sudden unexpected infant deaths and available public health interventions

Answer 382

Safe sleep and SIDS
Sudden unexpected infant death (SUID): Sudden death of an infant < 1 year of age that is likely related to sleeping environment at the outset of a death investigation; definition is not universal (usually preferable to use the cause of death that is determined at the end of a death investigation); generally includes:

• Sudden infant death syndrome (SIDS): Sudden death of an infant < 1 year of age that cannot be explained despite investigation and autopsy
• Leading cause of death among healthy infants in Canada
• Peaks between 2-4 months of age
  - Risk factors: Male, premature, low birth weight, poverty, Aboriginal, prone sleeping position, maternal smoking during pregnancy, exposure to secondhand smoke, overheating
• Back to Sleep campaign reduced rate of SIDS by 50% between 1999 and 2004
• In practice, difficult to distinguish from SUID and accidental
  suffocation/strangulation in bed
  - Prevention through safe sleep: Supine, firm mattress, fitted sheet, no other items in crib, room sharing, room temperature, one-piece sleep wear. Breastfeeding, pacifiers
• Accidental suffocation/strangulation in bed: Death due to suffocation, overlay, entangling, entrapment, or strangulation
• Risk factors: Infants sharing a sleeping surface with another person, presence of soft bedding, sleeping on a sofa or arm chair, use of pillows/duvets/comforters/bumper pads, sleeping in the sitting position, adult use of drugs or alcohol

Plagiocephaly: Positional flat head due to lying supine; incidence increasing due to “back to sleep” campaigns; can reduce through supervised tummy time while awake

Question 383

How are the following measures of association calculated?

Absolute risk reduction, NNT

Relative risk, relative risk reduction

Attributable risk, population attributable risk

Population attributable fraction, Exposed attributable fraction

[see Mayo review]

Answer 383

• *Absolute difference measures:**
• Absolute risk: Incidence of a disease in a population
• Absolute risk reduction (ARR; aka risk difference) = Probability of disease in exposed-(minus) probability of disease in unexposed
• Number needed to treat = 1/ ARR

Relative difference measures:
- Relative risk (aka risk ratio; RR): Ratio of the risk of disease in exposed individuals to
the risk of disease in non-exposed individuals; probability of disease in exposed /
Probability of disease in unexposed = (a/a+b)/(c/c+d); can be calculated from a cohort
study
- Relative risk reduction = 1-RR

• Odds ratio (OR): In case-control studies, the incidence of the disease in the exposed or
  unexposed is unknown (because the study starts by identifying cases), so an odds ratio
  is used to estimate the RR
  OR = Odds of disease in exposed / Odds of disease in unexposed
  = (a/b) / (c/d)
  = ad/bc
• OR is always more extreme than the RR; but when the disease is rare, the OR
  approximate the RR, because a/a+b ≃a/b and c/c+d ≃c/d (rare disease assumption)
• If you run a logistic regression, the beta is an OR
• Hazard ratio: Similar to a RR, but RRs are cumulative over an entire study period, while
  HRs represent instantaneous risk of the study time period

Attributable fractions and risks:
Attributable risk: The number of cases of disease among exposed individuals that can be
attributed to that exposure; AR = Incidence in exposed - incidence in unexposed
- Population attributable risk: Number of cases in the population attributable to an
exposure (i.e., the number of cases of disease that would not occur in a population if the
factor were eliminated / no one was exposed)
- PAR = Probability of disease in the population - probability of disease in unexposed

Attributable fraction: Multiple definitions; may refer to the population attributable fraction or
excess fraction
- Population attributable fraction (aka population attributable risk percentage):
Fraction of cases in the population attributable to an exposure
- PAF = (Probability of disease in the population - probability of disease in
unexposed) / probability of disease in the population x 100%
- PAF = Prevalence of exposure*(RR-1) / [1 + Prevalence of exposure*(RR-1)]
(Levin’s formula)
- If you calculate PARs for multiple exposures, Levin’s formula will add to sums
greater than one
- Exposed attributable fraction (aka excess fraction): Fraction of cases in the exposed
attributable to the exposure
- EAF = (Probability of disease in the exposed - Probability of disease in
unexposed) / Probability of disease in exposed
- EAF = (RR-1)/RR

Question 384

Describe Haddon’s matrix and give examples

Answer 384

Question 385

Describe the hierachy of exposure data

Answer 385

hierarchy of exposure data:
1. Quantitative personal dosimeter measurements
2. Quantitative ambient measurements in vicinity of residence or activity
3. Quantitative surrogates of exposure (e.g., estimates of water
consumption)
4. Residence or employment in proximity to source of exposure
5. Residence or employment in general geographic area of source of
exposure

Question 386

Compare and contrast the focus and main principles

of public health ethics versus biomedical ethics.

Answer 386

Public health ethics vs. biomedical ethics

• Principles of public health ethics are less well-defined than biomedical ethics
• Clinical ethics are not an appropriate model for public health ethics

Question 387

Discuss the public health value of nutritional labeling of prepared foods

Answer 387

Case study: Menu labelling (hot topic)
- Frequently eating in restaurants is related to higher intakes of fat and sodium and lower
intakes of nutrient-dense food
- Most consumers underestimate the number of calories contained in foods purchased
outside the home (the higher the caloric content, the greater the degree of
underestimate)
- The greater the discrepancy between actual and estimated caloric content, the greater
the impact on menu labelling on the intention to purchase
- Caveat: Evidence to date suggests that labelling menus with caloric content decreases
consumption in coffee shops, sub shops, and full-service restaurants, but not fast-food
restaurants
- Women are more likely to use nutrition labels to inform food choices than men
- In Ontario, the Healthy Menu Choices Act was passed in 2015 and will come into force
on Jan 1, 2017; requires restaurants and other businesses that prepare meals (e.g.,
grocery stores, movie theatres) with 20+ locations to display caloric content for all
standard food items
- At the federal level, all prepackaged foods sold in Canada must have a nutrition label
that includes caloric content
- In the US, chain restaurants with 20 or more US locations must provides caloric content
for food
- In BC, restaurants may voluntarily provide nutrition information under the Informed
Dining Program

Question 388

Describe the epidemic curves and typical spread of:

• Point source
• Continuing source
• Intermittent source
• Limited spread
• Propagated spread

Answer 388

Question 389

Define vulnerable populations, priority populations, and equity-seeking groups

Answer 389

• Vulnerable populations: “Groups that have increased susceptibility to adverse health
  outcomes as a result of inequitable access to the resources needed to address risks to
  health” Because the term “vulnerable populations” can be disempowering, the terms
  “special populations” or “priority populations” are preferred
• Marginalized populations: “Groups denied opportunities to meaningfully participate in
  society due to their lack of economic resources, knowledge about political rights,
  recognition and other forms of oppression”; also can be considered pejorative or
  disempowering
• Equity-seeking groups: “Groups taking an active role in altering processes and
  structures that influence health”
• High-risk populations: According to Lalonde, populations with high-risk behaviours and
  biological markers; criticized because it does not alter the social forces that influence
  health behaviours
• Priority populations: “Those at risk and form whom public health interventions may be
  reasonably considered to have a substantial impact at the population level”
• Intersectionality: Describes the intersecting nature of social categories like social class
  and race; “Various lines of inequality and identity can intersect and often reinforce each
  other in individuals and communities”
• Culture: The knowledge, beliefs, art, morals, laws, and customs shared amongst a
  group of people (anthropological definition; Edward Taylor)
• Cultural awareness: “Being conscious of similarities and contrasts between cultural
  groups; understand the way in which culture may affect different people’s approach to
  health, illness, and healing”; me-centred
• Cultural sensitivity: “Awareness and understanding of the characteristic values and
  perceptions of your own culture and the way in which this may shape your approach to
  patients from other cultures”; sensitive and open to cultural differences; shifting towards
  other-centred
• Cultural competence: “Attitudes, knowledge, and skills of practitioners necessary to
  become effective health care providers for patients from diverse backgrounds”; othercentred
• Cultural safety: “Understanding that there exist inherent power imbalances and
  possible institutional discrimination that derive from historical relationships with people of
  different origins; implies the ability to keep these differing perspectives in mind whilst
  treating the patient as a person worthy of respect in her own right”; first developed in the
  1980s in New Zealand
• Anti-oppressive practice: Practice that acknowledges the power differentials that arise
  through social differences (e.g., race, gender, class, sexual preference, disability, age,
  etc.), reflexively examines the practitioner’s own social identity and values, and
  challenges these inequalities (in some cases, using the power the practitioner’s social
  position has granted him/her to deconstruct the power differentials)
• Privilege: Benefits not available to everyone
• Power: The ability to influence the behaviour of others or the course of events
• Racialized groups: “non-dominant ethno-racial communities who, through the process
  of racialization, experience race as a key factor in their identity and experience of
  inequality”

Question 390

What are controlled acts?

Answer 390

Controlled acts
Controlled act: Acts that may only be performed by healthcare professionals, unless
specifically delegated to others under appropriate circumstances
In Ontario, controlled acts are defined by the Regulated Health Professions Act, 1991 and
include (verbatim):
1. Communicating to the individual or his or her personal representative a diagnosis
identifying a disease or disorder as the cause of symptoms of the individual in
circumstances in which it is reasonably foreseeable that the individual or his or her
personal representative will rely on the diagnosis.
2. Performing a procedure on tissue below the dermis, below the surface of a mucous
membrane, in or below the surface of the cornea, or in or below the surfaces of the
teeth, including the scaling of teeth.
3. Setting or casting a fracture of a bone or a dislocation of a joint.
4. Moving the joints of the spine beyond the individual’s usual physiological range of motion
using a fast, low amplitude thrust.
5. Administering a substance by injection or inhalation.
6. Putting an instrument, hand or finger,
a. beyond the external ear canal,
b. beyond the point in the nasal passages where they normally narrow,
c. beyond the larynx,
d. beyond the opening of the urethra,
e. beyond the labia majora,
f. beyond the anal verge, or
g. into an artificial opening in the body
7. Applying or ordering the application of a form of energy prescribed by the regulations
under the RHPA.
8. Prescribing, dispensing, selling or compounding a drug as defined in the Drug and
Pharmacies Regulation Act, or supervising the part of a pharmacy where such drugs are
kept.
9. Prescribing or dispensing, for vision or eye problems, subnormal vision devices, contact
lenses or eye glasses other than simple magnifiers.
10. Prescribing a hearing aid for a hearing impaired person.
11. Fitting or dispensing a dental prosthesis, orthodontic or periodontal appliance or device
used inside the mouth to prevent the teeth from abnormal functioning. *Only controlled
act that physicians are not authorized to perform
12. Managing labour or conducting the delivery of a baby.
13. Allergy challenge testing of a kind in which a positive result of the test is a significant
allergic response.
14. Treating, by means of psychotherapy technique, delivered through a therapeutic
relationship, an individual’s serious disorder of thought, cognition, mood, emotional
regulation, perception or memory that may seriously impair the individual’s judgement,
insight, behaviour, communication or social functioning. *This act may not be delegated

The authority for performing controlled acts comes from one of:
- Orders: Direction to perform a controlled act that is within the scope of practice of the
professional who receives the order (e.g., nurses are authorized to dispense medication;
a physician can order a nurse to dispense a medication)
- Direct order: Specific direction for a specific patient
- Medical directive: Direction for a group of patients meeting specific criteria
- Delegation: Direction to perform a controlled act that is not within the scope of practice
of the professional who receives the order; delegated acts can also be either direct
orders or medical directives; when an act is delegated, the responsibility for the act still
remains with the delegating physician; when can a controlled act be delegated?
- When it is in the best interests of the patient
- Physician has current knowledge of the patient’s clinical status
- If the act can be performed as safely and effectively by another person as it
would have been by a physician
- Initiation: Both initiating and performing the controlled act is within your scope of
practice

Steps for developing medical directives
1. Assess performance readiness: Is it appropriate to establish a directive? Do authorizers
and implementers have the necessary competencies to authorize/perform the procedure
and manage its outcomes?
2. Performance readiness plan: How can we achieve performance readiness?
3. Assure authority: Identify who has ordering authority and implementing authority
4. Develop supportive documents: Approval forms, performance readiness checklist
5. Assure clinical appropriateness: Assess the clinical appropriateness of applying the
medical directive during every situation where the directive may be applied

Question 391

Compare and contrast different modes of physician compensation.

Answer 391

“Physician expenditure is second only to hospital expenditure as a share of total public sector
spending on healthcare” (CFHI - Canadian Foundation for Healthcare Improvement)
- Expenditure on physicians and healthcare costs are rising
- “Although increased healthcare spending (even in percentage terms) may be a good
thing if it reflects a country’s increased wealth and ability to pay for valued care, there is
a widely held belief that the growth rate in Canada is not sustainable nor is it necessarily
improving our health outcomes” (CFHI)

Payment types:

• Fee for service
• Capitation
• Pay for performance
• Salary: Lowest actual-to-expected ED visit ratio in Ontario (e.g., CHCs)
• Fee-for-time (e.g., per diem)
• Retainer

Question 392

What is a Jarisch–Herxheimer reaction?

Answer 392

A Jarisch–Herxheimer reaction is a reaction to endotoxin-like products released by the death of harmful microorganisms within the body during antibiotic treatment.

Question 393

What are reasons for distribution failures of municipal water?

Answer 393

Municipal water distribution:

Distributed via high lift pumps, reservoirs, and pumping stations;
distribution failure occurs when the system is unable to reliably deliver an adequate quantity of water at a minimum pressure with quality that meets the Guidelines for Canadian Drinking
Water Quality; failure may be due to:
- Corrosion of unlined metallic pipes or poor maintenance practices
- Reduced hydraulic capacity
- High leakage rate, frequent breaks
- Backflow (cross connections with systems that do not contain potable water can contaminate water distribution systems during pressure loss)

Question 394

What are core principles of crisis communication?

What are process steps for strategic risk communications?

What is the crisis communication life cycle?

Answer 394

PHAC/HC strategic risk communications framework

Step 1: Define the Opportunity
Step 2: Characterize the Situation

Step 3: Assess Stakeholder Perceptions of the Risks, Benefits, and Tradeoffs
Step 4: Assess How Stakeholders Perceive the Options

Step 5: Develop and Pre-test Strategies, Risk Communications Plans, and Messages
Step 6: Implement Risk Communications Plans
Step 7: Evaluate Risk Communications Effectiveness

Guiding principles:

• Integral to integrated risk management
• stakeholders are the focal point
• evidence based decisions (social and natural sciences)
• transparent process
• contnuous improvement through evaluation

Crisis communication
Core principles of crisis and emergency risk communications (CDC)
*Principles apply primarily to mass communication techniques during a crisis situation
1. Be first: Crises are time-sensitive (note: this is enhanced by social media)
2. Be right: Accuracy establishes credibility; describe what is known, what is not known,
and what is being done to address gaps; counter myths and rumours in real time; avoid
mixed messages from multiple experts; consider how risk is perceived (i.e., be careful
with risk comparisons; people will reject these comparisons if the current event is
perceived to be riskier)
a. E.g., “We know how difficult it is to hear how tentative we have to be because
there is still so much we don’t know…”
3. Be credible: Be honest and open; avoid public power struggles or confusion; repeat
your message; “sugar coating” or hiding information can engender panic; don’t overreassure
(you may want people to be vigilant); use plain language
a. E.g.,“it’s less serious than we thought” is better than “it’s more serious than we
thought)
4. Express sympathy: Acknowledge harms and suffering in words; express sympathy
early
a. E.g., “I share your concern”; don’t respond to fear with criticism, mockery, or
statistics
5. Promote action: Give people constructive and meaningful actions; when possible, offer
a range of responses matched to their level of concern; engage the community
a. Give positive actions (“stay on streets x, y, z”) rather than negative actions
(“avoid downed power lines”)
6. Show respect: Do not attempt humour; do not be paternalistic

• *EPA’s 7 cardinal rules of risk communication**
  1. Accept and involve the public as a legitimate partner
  2. Listen to the audience
  3. Be frank, honest, and open
  4. Coordinate and collaborate with other credible sources
  5. Meet the needs of the media
  6. Speak clearly and with compassion
  7. Plan carefully and evaluate performance

PHAC communication strategies

Don’t over-reassure
Acknowledge uncertainty
Express wishes (“I wish I had answers.”)
Explain the process in place to find answers
Acknowledge people’s fear
Give people things to do
Ask more of people (share risk)
Express empathy and caring
Express competence and expertise
Express honesty and openness
Express commitment and dedication
Stay on message
Be first, be right, be credible

• *Strategic Risk Communications process Steps:**
  1. Define the Opportunity
  2. Characterize the Situation
  3. Assess Stakeholder Perceptions of the Risks, Benefits and Tradeoffs
  4. Assess How Stakeholders Perceive the Options
  5. Develop and Pre-test Strategies, Risk Communications Plans and Messages
  6. Implement Risk Communications Plans
  7. Evaluate Risk Communications Effectiveness

Crisis communication life cycle
1. Pre-crisis: Consider the types of disasters your organization may need to address; draft
a communication plan, including anticipated questions and responses; brief community
partners; integrate the crisis communication plan with the overall emergency plan;
identify the mechanisms you will use to obtain and analyze feedback from your
audiences
2. Initial crisis: Simplicity, credibility, verifiability, consistency, and speed are most
important due to initial confusion and intense media interest; ongoing credibility depends
on succeeding in this phase
3. Crisis maintenance: Provide background and encompassing information (e.g., how
could this happen? How do we prevent this from happening again?); correct
misinformation; anticipate sustained media and scrutiny and expect to be criticized; give
people things to do
4. Crisis resolution: Examine what did and did not work; expect scrutiny regarding how
the event was handled; reinforce messages while issues are current
5. Evaluation: Evaluate communication plan performance; document lessons learned;
determine specific actions to improve; be regretful, not defensive

Question 395

Describe vaccine recommendations for immigrants arriving to Canada

Answer 395

• Many recently arrived immigrants to Canada are susceptible to VPDs:
• 30-50% are susceptible to tetanus
• 32-54% are susceptible to one of measles, mumps, or rubella
• 20-80% arriving from HBV-prevalent countries are susceptible to HBV
• Foreign-born individuals account for 65% of all active TB cases in Canada

Question 396

What are outbreak investigation steps?

Answer 396

1. Confirm outbreak and diagnosis
   a. Are there more cases than expected in a given area in a given time interval among a specific group of people?
   b. Are there control measures that should be implemented immediately?
   c. Is further investigation needed?
2. Assemble an outbreak response team
3. Establish and maintain communications
4. Establish case definition (standard set of criteria for determining if a person should be classified as part of an outbreak, such as lab diagnosis, symptoms, person, place, and time; may be divided into confirmed, probable, and suspect)
5. Identify cases and contacts, and obtain information
   a. Line list
   b. Active surveillance
6. Organize data in terms of person, place, and time
7. Define the population at risk
8. Develop and test hypotheses
   a. Case-control, cohort, or environmental sampling
9. Implement control measures: The chosen control strategies should take into account epidemiology, study findings, environmental sampling, and theory; practically, control strategies will also be influenced by jurisdictional authority, legal roles, political sensitivity, timeliness of outbreak detection, interpersonal issues, and available resources
   a. Control source (e.g., insecticidal spraying, food recall)
   b. Interrupt transmission (e.g., education or policy to change behaviour, isolation; see case and contact management below)
   c. Modify host response (e.g., vaccination)
10. Monitor the response
11. Summarize in a report

Question 397

Define the 5 stages of emergency management cycles

Answer 397

Emergency management cycle

Prevention: Activities and programs that prevent a potential emergency from occurring
- This phase is usually the focus of public health activities
- The HIRA (see below) underlies emergency planning, bridging between prevention and
mitigation

Mitigation: Activities and programs that reduce the impact of an emergency on a community;
can occur before, during, or after an event

Preparedness: Activities and programs that prepare individuals, organizations, or communities
for an efficient emergency response; occurs before an event; best practices in preparedness
include:
- System checks
- Emergency plans: The ERP (see below) bridges between the preparedness and
response phases
- Training and exercises

Response: _Activities and programs that address the immediate effects of an emergenc_y
- Public health is not typically a first responders; first responders usually include fire,
police, and paramedics; hospitals are first receivers
- The COOP (see below) bridges between the response and recovery phases by
promoting the return to normal operations

Recovery: Activities and programs that restore a community to an acceptable condition;
typically the longest phase of the emergency management cycle

Question 398

Name and describe 7 types of seafood poisonings

Answer 398

Seafood poisonings
Most seafood poisonings arise from the consumption of seafood that has consumed toxinproducing
algae. For example, in Ontario, algae composed of cyanobacteria is a concern (aka “blue-green algae”); on the west coast of Canada, algae composed of dinoflagellates is a concern (aka “red tide”); on the east coast of Canada, algae composed of diatoms is a concern.

Paralytic Shellfish Poisoning
- Marine microorganisms produce biotoxins → Consumed by shellfish, gastropods, or
crustaceans → Human consumption → Illness
- PSP occurs world-wide secondary to consumption of PSP biotoxins
- Biotoxins not destroyed by cooking
- S/S = Tingling and numbness, headache, N/V, diarrhea, hypersalivation, fever,
diaphoresis, arm and leg weakness, ataxia; may progress to progress to respiratory
failure, paralysis, and death
- S/S occur within 15 min-10 h of eating biotoxin (mean = 1h)
- Treatment = Supportive only
- Public health response = Public education, closure of harvest site (associated with red
tides; clears in a few weeks), CFIA food recall (in BC, water temperature monitored by
satellite and all bivalves tagged; restaurants must save tags for tracing)

Other seafood poisonings:

• Scombroid: Similar symptoms to PSP; caused by microbial production of biogenic amines in fish or cheese; resolves within 12 h (*not due to algae)
• Ciguatera: GI symptoms w/in 1 h of fish consumption, followed by neuro symptoms lasting for weeks to months; caused by toxins produced by a dinoflagellate growing on reefs (i.e., not in Canada); most common seafood poisoning worldwide
• Neurotoxic shellfish poisoning: Red tides in Florida → brevetoxin → shellfish → similar symptoms to PSP in humans; symptoms resolve quickly
• Diarrhetic shellfish poisoning: Dinoflagellates → okadaic acid → mussels, scallops, clams → diarrhea, N/V, abdo pain in humans
• Amnesic shellfish poisoning: Diatom → domoic acid → shellfish → symptoms of DSP + short-term memory loss; first reported in Atlantic Canada in 1987; mussels and clams now monitored for domoic acid and beds closed to harvesting when levels are high
• Anisakiasis

Anisakiasis is a parasitic disease caused by anisakid nematodes (worms) that can invade the stomach wall or intestine of humans. The transmission of this disease occurs when infective larvae are ingested from fish or squid that humans eat raw or undercooked. Cooking or freezing kills the worm. The treatment for anisakiasis may require removal of the worm from the body by endoscopy or surgery.

Question 399

Describe basic facts about rabies

Organism, Reservoir, Mode of transmission

Incubation period, infectious period

Epidemiology

Presentation, Testing

Case management, Contact management

+/- Immunization

What should an assessment of a rabies incident include?

How should the biting animal be managed?

Answer 399

Rabies (reportable, VPD)
- Organism: Classical rabies virus + some other lyssaviruses (Mokola, Duvenhage,
European bat lyssavirus, Australian bat lyssavirus)
- Reservoir: All mammals
The animals in Canada most often proven rabid are wild terrestrial carnivores (e.g., raccoons, skunks and foxes), bats, cattle and stray dogs and cats. Squirrels, hamsters, guinea-pigs, gerbils, chipmunks, rats, mice or other small rodents, as well as lagomorphs (such as rabbits and hares) are only rarely found to be infected with rabies because it is believed that they are likely to be killed by the larger animal that could have potentially transmitted rabies to them. Larger rodents, such as groundhogs, woodchucks and beavers, can potentially carry rabies.
- Mode of transmission: Direct mucous membrane or skin break contact with infectious saliva; airborne transmission in caves heavily infested with bats has been reported

• Epidemiology:
• Globally, almost 55,000 deaths/year, mostly in LICs, mostly due to dog bites
• Risk factors: Veterinarians, wildlife researchers, spelunkers, animal control
  workers, laboratory personnel, long-term travellers
• Since 1924, there have been 24 cases of human rabies in Canada; the most recent case occurred in Alberta in 2007
• Prevalence of animal rabies in Canada is declining through oral vaccination (baiting programs) and trap-vaccinate-release programs
• Presentation: Progressive viral encephalitis causing headache, fever, malaise, paresthesias at the bite site, hydrophobia, and excitable delirium
• Incubation period: Usually 3-8 weeks, but highly variable (few days to years)
• Infectious period: Not well-defined for most spp.; dogs, cats, and ferrets are infectious up to 10 days prior to symptom onset
• Testing:Post-mortem brain tissue staining; CSF PCR; serology
• Case management: Intensive, supportive care
• Contact management:
• Immunization:
  Two commercially available products in Canada: Human diploid cell vaccine (HDCV) and purified chick embryo cell vaccine (PCECV). HDCV and PCECV are equivalent in immunogenicity.
  Dose for PrEP: 1. 1.0 mL or 0.1 mL ID on days 0, 7, and 21-28

Treatment

Wound cleaning+flushing, no sutures if possible, RabIG + vaccine
Dose for PEP (best to administer as soon after exposure as possible, but can be given at any time):
1. 1.0 mL on days 0, 3, 7, 14, and 28 for immuno-compromised patients and patients taking antimalarials;
2. 1.0 mL on days 0, 3, 7, and 14 for immuno-competent, previously unimmunized patients;
3. 1.0 mL on days 0 and 3 for patients who have received a prior rabies vaccine
Administration: IM; do not administer in the gluteal muscle, as this may lead to decreased immune response; deliver the vaccine and RabIg using separate needles and syringes at separate sites

Rabies immunoglobulin
Dose for PEP: 20 IU/kg (can be diluted two- or three-fold using sterile normal saline if there are multiple wounds) on day 0; rabies IG should not be given to those who have previously been vaccinated
Administration: Infiltrate around the wound; give remaining dose IM; deliver the vaccine and RabIg using separate needles and syringes at separate sites

Indications for PrEP:

• Occupational exposure to animals
• Laboratory workers handling rabies virus
• Certain travellers
• Hunters and trappers in areas with rabies
• Spelunkers

What should an assessment of a rabies incident include?

This should include an assessment of the risk of rabies in the animal species involved (including vaccination status, history of potential exposure to other animals of unknown rabies vaccination status, and travel history) and the behaviour of the particular domestic animal implicated.

Severity of bites, location (hands+face), provoked or not

How should the biting animal be managed?

Dogs, cats and ferrets that are apparently healthy should be confined and observed for 10 days after an exposure incident, regardless of the animal’s rabies vaccination status. Animals that are alive and healthy at the end of the 10-day period would not have transmitted rabies in their saliva at the time of the bite. If illness

Question 400

Describe some best practices when facilitating meetings.

Answer 400

Facilitating meetings

• *Content**
• Purpose: Desired outcomes
• Agenda (well-thought out)
• Item: Content topic to be discussed
• Desired outcome: E.g., decision, discussion, FYI
• Time: Amount of time provided for discussion
• Who: Person responsible for topic
• How: Method for considering each topic (e.g., brainstorming, feedback)
• Participants
• Address potential conflicts of interest

Process
- Facilitation: Explain the agenda, remind participants of time, redirect conversation if it
moves off-topic
- Record keeping/minutes (with appropriate level of detail)
- Main ideas discussed in the speaker’s own words
- Action items: List of tasks to be accomplished and individuals assigned to
complete them
- Decisions: List agreements reached at the meeting and documentation of
decision-making process
- Parking lot: List of future agenda items
- In-camera: Confidential, not recording in minutes

Logistics

Question 401

Why is the frequency and severity of natural hydro-meteological events increasing?

Regarding each natural emergency event (e.g. flooding, heat, cold, wildfire, earthquake),

what are the risk factors?

health impacts?

interventions?

Answer 401

Emergency events
Natural hydro-meteorological disasters
- The frequency of natural hydro-meteorological disasters is increasing
- The severity of natural hydro-meteorological disasters is also increasing, attributed to changes in climate variables (increased temperature, increased precipitation extremes, increased wind speed) and changes in land use (urbanization, deforestation, environmental degradation)

• *FLOODING**
• Flooding is caused by heavy or prolonged rainfall, rapid snowmelt, ice jams, or sea level rise, in conjunction with environmental factors like drainage, soil type, and flood control systems
• Short-term health risks:
• Drowning (most commonly while trapped in a vehicle or building, or when trying to swim in flood water)
• Injuries
• Hypothermia
• Electrocution (secondary to damaged electrical wiring)
• Long-term health risks:
• Waterborne disease (secondary to flood waters overwhelming water treatment
  and sewage systems)
• Chemical contamination of drinking water
• Foodborne disease (secondary to loss of refrigeration)
• Vector-borne disease (secondary to increase in mosquito breeding sites)
• Mold exposure (secondary to damp building materials)
• Carbon monoxide poisoning (secondary to use of gas-powered appliances during power outages)
• Mental health effects (secondary to loss of life, loss of possessions, and PTSD)
• Public health roles:
• Food safety education: Throw away perishable foods and foods that have come in contact with flood water
• Issue boil water advisory, as needed
• Education regarding removing stagnant water, preventing mold growth, and preventing CO poisoning
• *EXTREME HEAT**
• In the US, extreme heat events have resulted in more deaths than all other extreme weather events combined
• Risk of heat-related illness and death are greatest when individuals have not yet acclimatized to the heat (i.e., heat waves during spring and early summer pose the greatest risk)
• Heat island: High densities of brick and stone, paving, and tar that accumulate and radiate, rather than dissipate, heat; because of the heat island effect, most heat-related deaths occur in urban areas
• Heat wave: Created by a combination of:
• High daytime temperatures
• High humidity
• Warm nighttime temperatures (prevent dissipation of stored daytime heat)
• Sunshine

Risk factors for heat-related health impacts:
- Extremes of age (children have greater heat transfer from the environment; CVS of the
elderly less able to compensate for the increased CO required for peripheral heat
dissipation)
- Chronic disease: CV, resp, neuro, renal, DM, and mental illness
- Certain medications: Anticholinergics, antidopaminergics, TCAs, antipsychotics,
sympathomimetics, diuretics
- Athletes and outdoor workers, especially if required to wear equipment that prevents
heat dissipation
- Poverty (lack of air conditioning, unable to open windows at night in high-crime areas)
- Social isolation

Adverse health effects of heat:
- Heat stroke: Core temp > 40 C; altered mental status; skin is warm and dry; will progress
to multiorgan failure without emergency resuscitation
- Heat exhaustion: Core temp < 40 C; alert and oriented; hot flushed skin and sweating
- Heat fainting
- Heat cramping
- Heat rash
- Heat edema

Interventions *No evidence of effectiveness for any heat-related interventions
- Heat alerts: In Canada, cut-offs vary depending on location (however, note that most
heat-related deaths occur during moderately hot days, not on heat-alert days)
- Education: Restrict physical activity to the coolest period of the day, seek out air conditioning, drink fluids, wear light-coloured clothing and a well-ventilated, widebrimmed hat
- Suspension of utility service shutoffs for unpaid bills
- Outreach: Street outreach to homeless, check-in system for vulnerable populations (e.g.,telephone, buddy system)
- Cooling centres
- Urban and facilities planning (e.g., increase green space to reduce heat island effect)

• *COLD WEATHER EVENTS**
• Most temperature-related mortality burden in Canada is attributed to cold temperatures (as compared to hot temperatures) (contrast with US)
• Mortality vs. cold temperature follows a close-to-linear curve
• Physiological responses to cold that result in poor health outcomes persist longer than responses to heat
• *Risk factors for cold-related health impacts**:
• Extremes of age (infants and the elderly)
• Homelessness/marginal housing
• Athletes and outdoor workers
• Poverty (lack of heating, poorly insulated housing)
• Loss of electricity
• *Adverse health effects of cold:**
• Hypothermia: Shivering, exhaustion, confusion, slurred speech, drowsiness
• Frostnip
• Frostbite: White, numb skin that feels waxy and numb
• Windburn
• Increased risk of MI (secondary to increase blood pressure via vasoconstriction and increased blood viscosity, as well as increased plasma fibrinogen and inflammatory response)
• Increased risk of bronchospasm and respiratory infections (secondary to bronchoconstriction and suppressed mucociliary action)
• *Interventions**
• Cold alerts (however, note that most cold-related deaths occur during moderately cold days, not cold-alert days)
• Warm-up locations
• Education: Drink warm fluids; avoid alcohol; cover exposed skin; avoid strenuous exercise in the cold

Other examples of natural hydrometeorological disasters:

• Storms
• Ice storm
• Snow storm (heavy snow accumulation)
• Hail storm
• Blizzard (heavy snow + strong winds)
• Thunderstorm
• Hurricane, cyclone, typhoon
• Tornado
• Drought

Natural geophysical disasters

• *WILDFIRES** (hot topic - literally and figuratively)
• Wildfires in Canada are expected to increase in size, severity, and duration
• Causes of forest fires: Lightning, smoking, campfires
• *Risk factors for wildfire-related health impacts:**
• Fetus
• Children (due to higher RR)
• Elderly
• Pre-existing conditions (resp and CVS disease, DM, obesity)
• Lower SES
• *Adverse health effects of wildfires:**
• Burns
• Home and community damage
• Smoke inhalation: Smoke contains CO, NOx, PAHs, benzene, and VOCs
• Particulate matter (can travel far from fire site): PM in wildfire smoke is much finer than PM in urban air pollution; exposure increases emergency room visits and hospitalization for asthma, COPDE, bronchitis, and pneumonia, MI, eye irritation, sore throat
• *Interventions**
• Education: Stay indoors, reduce outdoor physical activity, activate asthma/COPD action plans
• Cancel outdoor events
• Community clean air shelters
• Augment air filtration in institutions
• Evacuation; recommended when:
• Severe smoke hazard lasting > 1 week
• Smoke contaminated with particularly hazardous substances
• Particularly susceptible subgroup
• *Case study: 2016 Fort McMurray Wildfire**
• Wildfire burned from May 1 to July 1, 2016 in northern Alberta and Saskatchewan, destroying 2,400 homes in Fort McMurray, requiring the evacuation of multiple communities, and the shutdown of petroleum production in some of the oil sands
• Fire occurred during an unusually hot, dry summer and was spread via gusting winds
• Boil-water advisory issued because untreated water was pumped through the municipal water system to supply firefighters with sufficient water
• Most expensive disaster in Canadian history
• *Earthquake**
• *Risk factors for earthquake-related health impacts:**
• Large, dense population located in a seismically-active area
• Inadequate building practices and regulations
• Absence of warning systems
• Absence of public awareness of earthquake risks
• *Adverse health effects of earthquakes:**
• Physical trauma (building collapse, tsunami, landslides)
• Psychological trauma
• Interrupted health care delivery (poorer maternal-child and chronic disease health outcomes)
• Environmental exposures secondary to destruction of infrastructure
• *Interventions**
• Community preparedness: Health emergency risk management systems, health system resiliency, mobile medical response teams
• Land-use control
• Building regulations

Other geophysical disasters:

• Volcano
• Landslide/rockfall/avalanche

Question 402

Describe basic facts about measles

Organism, Reservoir, Mode of transmission

Incubation period, infectious period

Epidemiology

Presentation, Testing

Case management, Contact management

+/- Immunization

Answer 402

Measles (reportable)

• Organism: Measles virus (Paramyxoviridae family)
• Reservoir: Humans
• Mode of transmission: Airborne, droplet, and direct contact with respiratory secretions
• Epidemiology:
• 1997: Endemic measles eliminated in Canada
• 2002: Endemic transmission measles interrupted in Americas
• 2016: Measles eliminated in region of the Americas
• Measles requires ~95% immunity to eradicate
• >90% secondary attack rate in susceptible individuals
• Vitamin A deficiency increases the risk of respiratory complications
• Presentation: Prodrome (fever, cough, coryza, conjunctivitis, Koplik spots), followed by
  rash (begins on face, then tunk, then arms and legs)
• **Complications: Occur in 10% of cases
• Pneumonia: 1-6/100 cases (commonest cause of death)
• Encephalitis +/- blindness, death: 1/1000 cases
  -**Subacute sclerosing panencephalitis: 1/25,000 cases (more common if
  measles is acquired prior to 2 years); develops 7-10 years post-infection
• Incubation period: 10 days (range: 7-18 days)
• Infectious period: 4 days before symptoms to 4 days after rash onset
• Testing: Urine, NP or aspirate, serology (PCR for dx, serology for immunity [PPV of
  serology is poor])
• Difficult to dx clinically (usually presents with nonspecific symptoms, despite what
  clinicians say)
• Case management: Isolate x 4 days post-rash onset; supportive care + vitamin A for
  children with poor nutritional status (reduces pneumonia-specific mortality)
• Contact management: No exclusion for contacts who have received IgG or MMR
  vaccine unless they are healthcare workers; contacts who are unvaccinated and have
  not received PEP must be quarantined x 21 days;

PEP:
- Susceptible individuals 12+ months old (including those who have only received a
single dose of MMR): MMR vaccine within 72 hours of exposure
- Susceptible infants, 6-12 mos: MMR vaccine within 72 h of exposure OR human
Ig if > 3 but < 6 days of exposure
- Susceptible individuals who are pregnant, immunocompromised, or infants < 6
mos: Human Ig within 6 days of exposure

• Vaccine:
• 1-dose MMR introduced in Canada in 1983; 2-dose MMR introduced in 1996-97
  in Canada (+ MR or M catch-up, depending on province, leading to large cohort
  of young adults under-vaccinated for mumps)
• Efficacy of 1 dose = 85-95%; efficacy of 2 doses = Almost 100%
• Adults born before 1970 can be presumed to be immune but healthcare workers,
  travellers, and military personnel born before 1970 should still be vaccinated

Question 403

What are examples of:

• Live attenuated vaccines?
• Inactivated/killed vaccines?
• Subunit/Purified antigen?
• Toxoid vaccine?

Answer 403

Question 404

What is urushiol?

Answer 404

Poison ivy, poison oak, and poison sumac: All produce urushiol, which causes dermatitis
within 12-48 hours of exposure; urushiol can be inhaled and cause lung irritation if plants and
burned

Question 405

Describe basic facts about non-polio enteroviruses

Organism, Reservoir, Mode of transmission

Incubation period, infectious period

Epidemiology

Presentation, Testing

Case management, Contact management

+/- Immunization

Answer 405

Non-polio enteroviruses
- Organism: RNV viruses; >100 enteroviruses cause infection in humans; includes the
polioviruses (see polio), coxsackie A viruses, coxsackie B viruses, echoviruses, and a
few other viruses (e.g., enterovirus D68, enterovirus 71)
- Reservoir: Humans
- Mode of transmission: Droplet (for respiratory viruses); fecal-oral (for GI viruses)
- Epidemiology: Most common in children
- Presentation:
- Coxsackie A viruses: Cause hand, foot, and mouth disease
- Coxsackie B viruses: Typically cause coryzal symptoms, but can cause
myocarditis, pericarditis, meningitis, and pancreatitis
- Echoviruses: URTIs
- Enterovirus D68: Mild to severe URTI; in rare cases, can cause death or
neurological symptoms
- Enterovirus A71: Major causative agent of hand, foot, and mouth disease; in rare
cases, can cause aseptic meningitis, encephalitis, and acute flaccid paralysis
- Incubation period: 3-5 days
- Testing: Cross-reactivity common
- Case management: Enteric or respiratory precautions
- Contact management:Describe S/S and when to seek medical care (no PEP)
- Treatment:Supportive
- Other:
- EV-D68 is an emerging respiratory virus; large outbreak in North America in fall
2014, with multiple hospitalizations and deaths (rare in Canada prior to 2014)
- EV-A71 is also an emerging virus, with increasing large outbreaks and increasing
incidence of neurologic complications being reported in the Asia-Pacific since
1974

Question 406

Describe the following ethical frameworks:

• Kass (6 questions)
• Upshur (4 principles)
• Nuffield ladder (8 ladder steps)
• IDEA
• Accountability for reasonableness A4R (3 elements)

Answer 406

Ethical decision-making frameworks

Kass framework
Question: What are the ethics implications of a particular public health intervention,
policy, research project, or program?

1. What are the public health goals of the proposed program? A public health
   intervention should not be undertaken if it cannot, on its own or part of a larger package
   of programs, reduce morbidity and mortality
2. How effective is the program in achieving its stated goals? Examine existing data
   to challenge assumptions; the greater the burdens imposed by a program, the greater
   the evidence required to underpin the program
3. What are the known or potential burdens of the program? For example, burdens
   might include stigmatization, loss of liberty, loss of privacy, and coercion
4. Can burdens be minimized? Are there alternative approaches? We are required to
   choose the approach that poses the fewest burdens if the outcomes are the same
5. Is the program implemented fairly? Public health benefits should be distributed
   equitably
6. How can the benefits and burdens of a program be fairly balanced? Do the
   expected benefits justify the expected burden?

Upshur framework
Question: Is this individual-level public health intervention ethically justifiable?
- Framework proposes a set of four principles to use in the practice of public health
decision-making (e.g., should I isolate this person?), excluding screening, programs, and
research

1. Harm principle: “The only purpose for which power can be rightfully exercised over any
   member of a civilized community, against his will, is to prevent harm to others. His own
   good, either physical or moral, is not a sufficient warrant.” - JS Mill
2. Least restrictive or coercive means: More coercive methods should be employed only
   when less coercive methods have failed (see Nuffield ladder below)
3. Reciprocity principle: Public health agencies must compensate individuals or
   communities for the burdens they bore in complying with public health requests
4. Transparency principle: Decisions must be made in a transparent and accountable
   manner, giving all legitimate stakeholders equal input into deliberations (see A4R
   framework below)

Nuffield ladder
Question: What level of policy or program intervention is ethically justifiable?
- Attempt to balance the freedoms of the individual and the freedoms of the community
- Proposes a ladder of possible government public health actions
- “In considering which ‘rung’” is appropriate for a particular public health goal, the benefits
to individuals and society should be weighed against the erosion of individuals freedom.
Economic costs and benefits would need to be taken into account alongside health and
societal benefits.”
- Similar to the 6E approach to the hierarchy of controls in occupational health, but the
hierarchy of controls does not consider the impact on liberty

• *IDEA framework**: Specific to decision-making in healthcare settings
• Identify the facts
• Determine the relevant ethical principles
• Explore the options
• Act

Accountability for reasonableness (A4R): How do we establish a fair process for priority
setting?
- Transparent process
- Based on evidence or rationales that everyone involved agrees are relevant
- Procedures for revising decisions

Question 407

What are the 5 stages of the policy cycle?

Describe 2 different policy frameworks:

• Multiple streams
• Advocacy coalition

What factors influence the policy process?

Answer 407

Policy frameworks

• *Policy stages cycle (mnemonic AFDIE)**
• Frequently-used heuristic in public health; generally rejected by political scientists because policymaking is not rational or linear

AFMC primer:

• *Agenda setting:** How an issue comes to the attention of policy makers. The process is not always rational, and it can often be difficult to see why some issues rise to the top of political agendas while other, seemingly more important issues, remain unaddressed
• *Policy formulation**: Decision-makers (governments, health regions, hospitals, care teams etc.) formulate policy options. Government policy-making usually occurs behind the scenes and is carried out by professional policy analysts
• *Decision-making**: How decision-makers decide what to door not do about an issue
• *Policy implementation**: Putting the decisions into effect. Not as simple as it sounds, as it usually entails changing habits and ingrained ways of doing things
• *Policy evaluation** (all too often neglected) Examining implementation and outcomes to check if the policy has been properly implemented and if the desired outcomes were achieved
• *Multiple streams framework (MSF - Kingdon)**
• Multiple streams framework explains how systems-level decisions are made in conditions of ambiguity
• Ambiguity = Situations where additional information will not lead to the identification of a solution
• Framework posits that problems requiring policy solutions, politics, and policy development flow in streams that are independent from one another

How does policy change occur, according to the MSF?
- Policy window: A critical point in time when the *problem, policy, and politics* stream converge; the preferred solution in the policy stream at the time of the convergence will more likely be accepted by policymakers as the method to address the problem
- Routinized window: E.g., budgets, elections
- Discretionary window: E.g., MInister’s Mandate Letter
- Spillover problem window: E.g., SARS led to re-design of public health
- Random problem window: E.g., Ebola, severe weather event
- Policy entrepreneur: An individual who couples the problem, policy, and politics streams in a policy window
- In order to have his/her preferred policy solution accepted by policymakers, a policy
entrepreneur employs:
- Salami tactics: Breaking up a major policy change into smaller, more palatable policy changes that are presented sequentially to policymakers
- Framing: Frame change as avoiding a major loss (individuals are usually more loss averse than gain seeking)
- Symbols: An event or image that conveys a clear, simple message

• *Advocacy coalition framework (ACF)**
• The advocacy coalition framework explains how policy change occurs in high-conflict situations in a policy subsystem
• Policy subsystem: A system defined by a single policy topic, encompassing a geographical region and all actors who influence policy on that topic; allies and opponents of particular policy solutions tend to develop and remain stable over time; within a policy unit of analysis of the ACF
• The ACF posits that policy subsystems are best understood by analysing the advocacy coalitions within them
• Advocacy coalitions: Actors organized based on shared beliefs about and strategies to approach a policy issue; a construct of the policy analyst; actors within an advocacy coalition share the same deep core and policy core beliefs, but may not share secondary beliefs
• Deep core beliefs: Fundamental beliefs about rights, human nature, etc.
• Policy core beliefs: Specific beliefs about the best policy option
• Secondary beliefs: Specific beliefs about the best way to implement the policy
• How does policy change occur, according to the ACF?
• Policy-oriented learning: “enduring alterations in thought or behavioural intentions that result from experience and which are concerned with the attainment or revision of the precepts of the belief system of individuals or of collectives”; generally takes place in public fora
• Policy brokers: Similar to the MSF’s policy entrepreneur
• External shock: “events outside the control of subsystem participants”; might include economic or regime changes, disasters, or changes in other subsystems (often necessary, but not sufficient, for policy change)
• Internal shock: Events directly related to the policy subsystem that “confirm the policy core beliefs of minority coalitions, increase doubts about the core beliefs of the dominant coalition, and bring into question the effectiveness of their policies”
• Negotiated agreement:Agreement between two or more parties that disagreed over a policy choice; requires a hurting stalemate, in which the status quo hurts all parties

What factors influence the policymaking process?

9i framework

• Context: issue, impacts (cost/benefits), impetus
• Stakeholders: involved, impacted, invested
• Policy makers: ideas, interests, institutions

Other consideration:

Experience, expertise, judgment

Resources, cost

Values

Pressure (public, lobby)

Pragmatics, contingencies

Question 408

Describe the hazard identification and risk assessment process (HIRA) in emergency preparedness

Answer 408

Hazard Identification and Risk Assessment (HIRA)
Definition: Risk assessment tool used to identify hazards that pose the greatest risk to a community, both in terms of probability of occurrence and severity of impact
HAZARD = SOURCE OF DANGER
RISK = PROBABILITY OF OCCURENCE X SEVERITY OF IMPACT

HIRA process
1. Hazard identification: Identify hazards that could affect the community, including natural hazards, technological hazards, and anthropogenic hazards

2. Risk assessment: What is the probability that the hazard will occur? What is the severity of impact of the hazard? Consider factors like where people and economic activity are concentrated, where critical infrastructure is located, and special populations.
a. Probability assessment
Rare: <1% chance of occurrence in any year (occurs q >100 years)
Very unlikely: 1-2% chance of occurrence in any year (occurs q 50-100 years)
Unlikely: 2-10% chance of occurrence in any year (occurs q 20-50 years)
Probable: 10-50% chance of occurrence in any year (occurs q 5-20 years)
Likely: 50-100% chance of occurrence in any year (occurs q 5 years or less)
Almost certain: 100% chance of occurrence in any year (occurs annually)
b. Severity assessment: Consider social impacts, property damage, environmental damage, infrastructure or service disruption, business and financial impact, and psychosocial impact; rank consequences for each consideration on a scale from none to catastrophic
None (e.g., hazard unlikely to result in injuries in the community)
Minor (e.g., hazard could result in <100 people being evacuated)
Moderate (e.g., hazard could disrupt 2-3 infrastructure services)
Severe (e.g., hazard could cause irreversible environmental damage)
Catastrophic (e.g., hazard could result in >50 fatalities in the community)

3. Risk analysis: Risk = Probability x Severity; rank the hazards, from greatest to least risk; record in a risk assessment grid
4. Monitoring and review: Monitor and review the HIRA regularly

Question 409

What is a health equity impact assessment and what are its main steps?

Answer 409

Health equity impact assessment
Definition: Tool used to determine how a program or policy will differentially impact populations based on pre-existing inequities; meant to identify unintended impacts before implementation

Steps
1. Scoping: Identify which populations may experience unintended impacts and identify
which SDOH and health inequities need to be considered for this population
2. Potential impacts: Outline the unintended potential impacts of the program (both
positive and negative)
3. Mitigation: Identify ways to reduce the negative impacts and amplify the positive
impacts
4. Monitoring: Identify ways to measure whether or not the mitigation strategies are
working
5. Dissemination: Identify ways to share results to allow others to improve equity

Question 410

What are modifiable and non-modifiable risk factors for cardiovascular diseases?

What are available population level interventions?

Answer 410

Cardiovascular disease

Epidemiology
- Prevalence of heart disease in Canadians = 4.8% (2007)
- Prevalence of prior stroke in Canadians = 1.1% (2007)
- Over the last 60 years, mortality due to CVD has decreased more than 75% due to
medical intervention
- Hypertension is the most common reason Canadians visit their physicians

• *Modifiable risk factors**
  1. Hypertension
  2. Hypercholesterolemia
  3. Overweight and obesity
  4. Poor diet (especially low fruit and vegetable intake)
  5. Smoking (accounts for 15% of all CVD in Canada)
  6. Diabetes
  7. Low levels of physical activity
  8. Stress
• *Unmodifiable risk factors**
  1. Age
  2. Family history
  3. Ethnicity
  4. Education level
  5. Income

Population-level interventions
- Sodium reduction (highly cost-effective; see Nutrition)
- Self-measured blood pressure monitoring (2013 systematic review found mean
decrease in BP of 3.2/1.3)
- Address risk factors (see Obesity and overweight; Diabetes; Physical activity; Nutrition)

Question 411

Contrast Pearson and Spearman coefficient.

How is a linear regression different from a logistic regression?

What are the assumptions when using a linear regression?

When can a logistic regression be used?

What is the output of a logistic regression?

Answer 411

Correlation and regression

• *Correlation**: Quantification of the relationship between two random variables
• Population correlation coefficient = 𝜌 (rho)
• Sample correlation coefficient = r (note: r is unitless)
• Pearson correlation coefficient = sample covariance between x and y / [(sample SD of x)(sample SD of y)] (continuous + normal data)
• Measures the association between two continuous variables
• Correlation varies from -1 to +1
• Spearman correlation (ordinal data or non-normal data))
• Goodness of fit: How much of the variance of Y is explained by the variance in X?
• Correlation does not imply causation!

Regression: Prediction of one variable from another
- Linear regression: 𝑌 = 𝛽: + 𝛽 𝜀= random error
The equation defines the line that best predicts Y from X by minimizing the sum of
squares of the vertical (Y) distances of the points from the line; used for continuous data
- Simple linear regression: One predictor variable (x)
- Multiple linear regression: Multiple predictor variables (x1, x2, x3, …)
- ANOVA: Special case of multiple linear regression

• Linear regression is used to predict the continuous dependent variable using a given set of independent variables. Logistic Regression is used to predict the categorical dependent variable using a given set of independent variables.
• Assumptions for linear regression
• Normality: For any fixed value of X, Y has a normal distribution around its mean
• Homoscedasticity: Variance of Y is the same for any value of X
• Independence: The error values are statistically independent of of another
• Linearity: Y is a linear function of X (the only assumption that is not also an
  assumption of ANOVA)
  *Assumptions only apply within observed values, so you cannot use regression line to
  predict values outside the observed values (i.e., no extrapolation with regression lines!)
• Coefficient of determination (r2): Quantification of the variance in the dependent
  variable that is predictable from the independent variable; variation in y explained by x /
  variation in y not explained by x; (sample correlation coefficient)2 = r2
• Logistic regression: Used for discrete outcomes (usually nominal, binary, or
  dichotomous outcomes); output is odds ratios; particularly useful for case-control studies
• (There are lots of other types of regression, including log binomial, robust Poisson…)

Interaction: The magnitude of the effect of one independent variable (X) on a dependent
variable (Y) varies as a function of a second independent variable; related to effect modification;
interaction may be additive or multiplicative

Question 412

Describe basic facts about C. diff

Organism, Reservoir, Mode of transmission

Incubation period, infectious period

Epidemiology

Presentation, Testing

Case management, Contact management

+/- Immunization

Answer 412

Clostridium difficile (reportable)

• Organism: Clostridium difficile (motile, anaerobic, spore-forming bacterium)
• Reservoir: Humans, pigs, cows
• Mode of transmission: Fecal-oral route
• Epidemiology:
• Occurs worldwide; colonizes 2-5% of healthy people
• Main cause of nosocomial antibiotic-associated diarrhea
• Risk factors: Frailty, peripartum women and infants, antibiotic therapy, underlying
  illness, chemotherapy, proton pump inhibitors
• Presentation: Abx therapy → destruction of normal gut flora → C. diff overgrowth → Illness
  ranges from a few days of loose stool to life-threatening pseudomembranous colitis
• Incubation period: 5-10 days
• Testing: Detection of toxins in stool is the gold standard
• Case management: Fluid management +/- abx, depending on symptom severity +/- fecal
  transplantation; susceptible to metronidazole and vancomycin
• Contact management: Prophylaxis not recommended; spores are resistant to
  disinfection