EG notes Flashcards

Question

Describe basic facts about the reportable disease chancroid ## Footnote Organism, Reservoir, Mode of transmission Incubation period, infectious period Epidemiology Presentation, Testing Case management, Contact management +/- Immunization

Answer 1

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

Answer 2

- **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_

Answer 3

**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._

Answer 4

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 ```

Answer 5

**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

Answer 6

**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)_

Answer 7

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**)

Answer 8

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_

Answer 9

**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

Answer 10

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_

Answer 11

- _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: - H**alogenic 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)

Answer 12

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

Answer 13

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.

Answer 14

**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\*\*

Answer 15

- _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

Answer 16

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,

Answer 17

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._

Answer 18

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)

Answer 19

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_

Answer 20

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_)

Answer 21

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 **t**ravellers’ 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)**

Answer 22

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)

Answer 23

- **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

Answer 24

**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

Answer 25

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

Answer 26

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

Answer 27

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

Answer 28

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)

Answer 29

**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](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)

Answer 30

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

Answer 31

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)

Answer 32

**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_

Answer 33

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

Answer 34

**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_)

Answer 35

- 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_

Answer 36

**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)

Answer 37

**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.

Answer 38

**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

Answer 39

* *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)

Answer 40

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_

Answer 41

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?)

Answer 42

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)

Answer 43

**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.

Answer 44

Strep pneumo, neisseria meningitidis, h. flu

Answer 45

**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.

Answer 46

MMRV, OPV, BCG, +/-YF

Answer 47

**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_

Answer 48

**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

Answer 49

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

Answer 50

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)

Answer 51

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

Answer 52

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

Answer 53

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 3. Histogram 4. Scatter Plot 5. Check Sheet 7. Control Chart

Answer 54

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) ***Tri*chloroethylene** (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 ***Tetra*chloroethylene** (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)

Answer 55

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

Answer 56

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)

Answer 57

**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_

Answer 58

- 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

Answer 59

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_]

Answer 60

Labour relations and collective agreements In summary collective bargaining: (mnemonic N C MAL) **N**egotiation **- C**onciliation (MoLabour) - (+/- strike/lockout) - **M**ediation (non-binding) - **A**rbitration (binding) - Back-to-work **l**egislation - **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

Answer 61

**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

Answer 62

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

Answer 63

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

Answer 64

- 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

Answer 65

**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_

Answer 66

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].”

Answer 67

- 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

Answer 68

**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)

Answer 69

**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).

Answer 70

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

Answer 71

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)

Answer 72

**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_.

Answer 73

**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

Answer 74

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

Answer 75

**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

Answer 76

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?)

Answer 77

**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.

Answer 78

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

Answer 79

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)

Answer 80

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

Answer 81

**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)_

Answer 82

- 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

Answer 83

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

Answer 84

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

Answer 85

* *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.

Answer 86

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)

Answer 87

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

Answer 88

**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_

Answer 89

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)

Answer 90

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

Answer 91

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)

Answer 92

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%_

Answer 93

**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

Answer 94

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.

Answer 95

**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_

Answer 96

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)

Answer 97

**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

Answer 98

**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 **C**apability **O**pportunity **M**otivation

Answer 99

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_

Answer 100

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

Answer 101

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

Answer 102

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

Answer 103

**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)

Answer 104

**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

Answer 105

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

Answer 106

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

Answer 107

**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

Answer 108

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_

Answer 109

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

Answer 110

**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

Answer 111

**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

Answer 112

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_

Answer 113

**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

Answer 114

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

Answer 115

**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

Answer 116

**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

Answer 117

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_

Answer 118

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

Answer 119

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.

Answer 120

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)

Answer 121

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

Answer 122

**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**

Answer 123

Measles YF

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

Answer 125

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

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- 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

Answer 127

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

Answer 128

``` 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 ```

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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

Answer 130

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)

Answer 131

**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 plo**t: 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

Answer 132

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

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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

Answer 134

**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

Answer 135

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_

Answer 136

**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

Answer 137

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

Answer 138

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

Answer 139

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_

Answer 140

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

Answer 141

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

Answer 142

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 managemen**t: 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

Answer 143

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)

Answer 144

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)

Answer 145

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

Answer 146

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

Answer 147

* *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

Answer 148

**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)

Answer 149

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)

Answer 150

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_

Answer 151

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

Answer 152

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

Answer 153

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.

Answer 154

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_

Answer 155

**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_)

Answer 156

**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

Answer 157

**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

Answer 158

**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_

Answer 159

- 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

Answer 160

**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)

Answer 161

- 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

Answer 162

1. **Carbon monoxide** (CO): Combustion 2. **PM10** (largest “inhalable particle”) Soil, other crustal materials (e.g., dust from unpavedroads, construction) 2. **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 3. **Ozone** (O3) _Secondary pollutant_ produced by the reaction of NOx and VOCs; usually higher in rural areas than urban areas 4. **Sulfur dioxide** (SO2) Fossil fuel combustion, especially power plants 5. **Nitrogen dioxide** (NO2) _Secondary pollutant_; forms from primary pollutants released by fossil fuel combustion, especially vehicles 6. **Lead** (Pb) Metal processing plants, leaded aviation fuel, waste incinerators, battery manufacturers

Answer 163

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.

Answer 164

**- 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

Answer 165

**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

Answer 166

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

Answer 167

**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_

Answer 168

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

Answer 169

- **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

Answer 170

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_

Answer 171

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

Answer 172

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_

Answer 173

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”

Answer 174

* *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”

Answer 175

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 **_externa_**l 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

Answer 176

**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_**

Answer 177

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

Answer 178

**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_

Answer 179

* *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

Answer 180

- _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_

Answer 181

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

Answer 182

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

Answer 183

**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)

Answer 184

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_

Answer 185

**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”

Answer 186

(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.

Answer 187

- **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

Answer 188

**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_

Answer 189

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

Answer 190

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_

Answer 191

* *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)_

Answer 192

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

Answer 193

- **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_

Answer 194

**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

Answer 195

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.)

Answer 196

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

Answer 197

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](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)_

Answer 198

Host, agent, environment

Answer 199

**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

Answer 200

**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

Answer 201

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)

Answer 202

**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)_

Answer 203

* *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

Answer 204

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

Answer 205

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_

Answer 206

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 managemen**t: 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

Answer 207

**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.

Answer 208

**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)**

Answer 209

- **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)_

Answer 210

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

Answer 211

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)

Answer 212

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

Answer 213

Vaccine, doxy/cipro

Answer 214

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 cance**_r: 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_

Answer 215

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)_

Answer 216

**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

Answer 217

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

Answer 218

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)

Answer 219

**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_

Answer 220

**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_

Answer 221

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

Answer 222

Doxy/tetra/cipro x 7 days Bubonic, septicemic, pneumonic types

Answer 223

**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._

Answer 224

**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)

Answer 225

**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.)

Answer 226

**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)

Answer 227

- **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%**

Answer 228

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

Answer 229

- 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)

Answer 230

**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

Answer 231

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

Answer 232

**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)_

Answer 233

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)

Answer 234

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**.”

Answer 235

**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

Answer 236

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

Answer 237

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

Answer 238

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_

Answer 239

- **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

Answer 240

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

Answer 241

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

Answer 242

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_

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**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

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**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)

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**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_

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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.

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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 C*a-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._

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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

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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
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_

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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

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- **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

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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)

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* *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

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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_

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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

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**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) ```

Answer 257

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)

Answer 258

**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

Answer 259

**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

Answer 260

**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

Answer 261

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 material**s 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)

Answer 262

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%

Answer 263

**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 A**ware** of [a specific guideline], then intellectually A**gree** with it, then decide to follow it in their practice (A**dopt** it), then actually succeed in following it at appropriate times (A**dhere** 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.”

Answer 264

- 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

Answer 265

- ***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

Answer 266

**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

Answer 267

**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_.

Answer 268

**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_

Answer 269

* *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

Answer 270

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

Answer 271

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

Answer 272

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_

Answer 273

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

Answer 274

OPV, YF, MMR, BCG

Answer 275

**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

Answer 276

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

Answer 277

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

Answer 278

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

Answer 279

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

Answer 280

**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

Answer 281

**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_

Answer 282

**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)

Answer 283

**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

Answer 284

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

Answer 285

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

Answer 286

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

Answer 287

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)

Answer 288

**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

Answer 289

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

Answer 290

* *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

Answer 291

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

Answer 292

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

Answer 293

**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

Answer 294

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

Answer 295

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

Answer 296

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

Answer 297

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.

Answer 298

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

Answer 299

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

Answer 300

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

Answer 301

**- 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

Answer 302

**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_

Answer 303

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

Answer 304

- **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)

Answer 305

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: 7_7% 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”)

Answer 306

* *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_

Answer 307

- 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

Answer 308

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_

Answer 309

* *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

Answer 310

**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

Answer 311

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_

Answer 312

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

Answer 313

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)

Answer 314

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)

Answer 315

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

Answer 316

Research ethics * **T*ri-*C*ouncil *P*olicy *S*tatement 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_)

Answer 317

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_

Answer 318

**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

Answer 319

- **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_

Answer 320

**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 (E**icosaPentaenoic 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

Answer 321

**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

Answer 322

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_

Answer 323

**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

Answer 324

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)

Answer 325

**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

Answer 326

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)

Answer 327

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_

Answer 328

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.”

Answer 329

**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_

Answer 330

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

Answer 331

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_

Answer 332

Norovirus, rotavirus, disseminated HSV

Answer 333

**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_

Answer 334

Incubation: 7-21 days Communicability: 4 days before rash onset to 4 days after rash onset

Answer 335

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

Answer 336

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)

Answer 337

* *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

Answer 338

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_

Answer 339

▪ 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.

Answer 340

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

Answer 341

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_

Answer 342

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

Answer 343

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**

Answer 344

Cephalexin (preferred) Erythromycin Clarithromycin Clindamycin

Answer 345

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_

Answer 346

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

Answer 347

* *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_

Answer 348

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

Answer 349

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

Answer 350

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

Answer 351

- **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”

Answer 352

**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

Answer 353

“_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

Answer 354

A Jarisch–Herxheimer reaction is a reaction to endotoxin-like products released by the death of harmful microorganisms within the body during antibiotic treatment.

Answer 355

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, f****requent breaks** - **Backflow** (cross connections with systems that do not contain potable water can contaminate water distribution systems during pressure loss)

Answer 356

**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

Answer 357

- 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

Answer 358

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**

Answer 359

**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

Answer 360

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.

Answer 361

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

Answer 362

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**

Answer 363

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

Answer 364

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_

Answer 365

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

Answer 366

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

Answer 367

**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_

Answer 368

**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

Answer 369

**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_

Answer 370

**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

Answer 371

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_)

Answer 372

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_

Answer 373

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