Key PHPM Concepts to Review Flashcards
What is a cluster?
An unusually high incidence of disease in a certain place and time. A cluster of cases could be due to chance or could be beginning of an outbreak
What is an epidemic and how is it different from an outbreak and a pandemic?
Occurrence of more cases of disease than expected in a given area or among a specific group. An outbreak is an occurrence of a disease in excess of what would normally be expected in a defined community, geographical area, and time interval; sometimes used synonymously with epidemic, but usually used to refer to a localized epidemic . A pandemic is an epidemic occurring over a wide area, crossing international borders, and affecting a large number of people, examples are the 1918 Spanish influenza, 2009 H1N1 influenza, COVID-19
What is an emerging infectious disease?
An infectious disease with a novel range, host, or mode of transmission. This can be driven by microbial resistance, climate change, international travel, poverty, war, changes in land use (interspecies contact), human susceptibility (immunocompromise), human/vector/reservoir migration (e.g., migration to cities), population growth
Newly emerging: newly recognized in human hosts vs re-emerging: have historically infected humans, but are now appearing in new locations, appearing in drug-resistant forms, or reappearing after control or elimination
What is surveillance and what are its objectives?
Ongoing systematic collection, analysis, interpretation and evaluation of health data closely integrated with timely dissemination of this data to those who need it to improve health. Objectives of a surveillance program are to guide health interventions, estimate trends, identify groups at high risk, monitor changes in patterns of transmission, evaluate prevention strategies and suggest hypotheses for further research
Characteristics of health events conducive to surveillance:
o Important public health problem (e.g., as measured by incidence, mortality, severity, socioeconomic impact)
o Prevention, treatment, or control measures are available
o Health system has the capacity to respond
Describe the epidemiologic triad of disease and six characteristics of each sector of the triad.
Host - Person in whom a communicable disease proliferates. Characteristics:
* Health status: nutritional status, co-morbidities, medications
* Health behaviours: safer sex, smoking, drug use, eating habits
* Non-modifiable factors: age, sex/gender, ethnicity, genetic factors
* Susceptibility: insufficient resistance to prevent contracting the infection
* Innate immunity: body’s initial defense mechanism (skin, temperature, pH)
* Adaptive immunity: body’s second level of defense (e.g. cell-mediate immunity, antibody mediated immunity)
Agent - Infectious microorganism or pathogen (e.g. bacteria, fungi, viruses). Characteristics:
* Attack rate: number of people who become ill
* Infectiousness: relative ease of transmission
* Infectivity: ability of agent to enter, survive, and multiply in the host
* Minimum infectious dose: minimum number of organisms required to cause illness
* Pathogenicity: ability to cause disease
* Virulence: degree of pathogenicity (e.g. proportion of persons with clinical disease who become severely ill or die)
* Case-fatality rate: proportion of those who die from disease
* Basic reproductive number: average number of secondary infections
Environment - May affect exposure and susceptibility to disease and include
* Vectors: living creatures needed for the transmission of an infectious agent
* Fomites: inanimate objects that can harbour infectious organisms
* Reservoir: living or inert source in which an infectious agent lives and multiplies in such a way that it can eventually infect humans
* Physical factors: climate, geology, urbanization
* Socioeconomic factors: overcrowding/housing, sanitation, availability of healthcare services, immigration
* Other factors: global travel, public health infrastructure, food production and preparation, antibiotics and microbial adaptation, human behaviours
Define and discuss the impact of a high infective dose. Give an example.
Minimal infective dose - Minimum number of organisms required to cause illness
-Low infective dose: rotavirus, measles, pertussis, shigella, hepatitis A
-High infective dose: salmonella
The higher the infectious dose consumed, potentially:
-Shorter the incubation period
-May influence how sick the person becomes
What is the basic reproductive number (R)?
Average number of secondary infections generated by the first infectious individual in a population of completely susceptible individuals
o R = S x L x B (number of susceptible hosts x length of time an individual is infectious x transmissibility)
o R < 1, infection will disappear
o R = 1, Infection is endemic
o R > 1, infection can become an epidemic
Examples:
Measles 12-18, Polio 5-7, Pertussis 5.5, Diphtheria 6-7, Rubella 5-7, SARS 2-5,
Smallpox 5-7, Mumps 4-7, Influenza 2-3
Define NAATs, Serology tests, and give two examples of serology tests
Amplification: Tiny amounts of DNA/RNA are replicated many times, able to detect minute traces of an organism in a specimen, avoiding need to culture. Particularly useful for organisms that are difficult to culture or identify using other methods (e.g., viruses, obligate intracellular pathogens, fungi, mycobacteria) or that are present in low numbers. As amplification methods are so sensitive, false-positive results from trace contamination of the specimen or equipment can easily occur
Serological tests: Serological diagnosis is based on either the demonstration of the presence of IgM or IgG antibodies. Immunoassays are the most commonly used serological assays. Point-of-care tests (POC tests), both for antigens and antibodies, are also becoming more and more common in diagnostic use
Ex 1. ELISA
Enzyme immunoassays use antibodies linked to enzymes to detect antigens and to detect and quantify antibodies. Because sensitivities are high, they are usually used for screening. Titers can be determined by serially diluting the specimen as for agglutination tests. Examples are Enzyme immunoassay (EIA) and Enzyme-linked immunosorbent assay (ELISA)
Ex 2. Western blot
Detects antimicrobial antibodies in the patient’s sample by their reaction with target antigens (e.g., viral components) that have been immobilized onto a membrane by blotting. Typically has good sensitivity, although often less than that of screening tests such as ELISA, but generally is highly specific
Discuss the different routes of transmission and give 5 examples of airborne-transmitted diseases
Contact: direct through touching, biting, kissing, sneezing on hands, or sexual intercourse, or indirect through other vehicles (e.g. surgical instruments, foodborne, blood products) or vectors (e.g. mosquitoes, flies)
Droplet: transmission occurs via suspended droplets (>5um) that travel up to 1m through coughing, sneezing, or suctioning.
Airborne: transmission occurs via airborne particles <5um. The three airborne disease are measles, varicella, and tuberculosis.
5 airborne diseases: measles, varicella, tuberculosis, smallpox, Covid-19.
There is a theoretical risk of airborne transmission with monkeypox.
Define and give examples of disease control, disease elimination and disease eradication.
Control: Reduction of disease incidence, prevalence, morbidity, or mortality to a locally acceptable level. Continued intervention measures are required to maintain the reduction. Ex. diarrheal illnesses in North America.
Elimination: Reduction to zero of the incidence of disease or infection in a geographical area. Continued intervention measures are required to prevent re-establishment of transmission. E.g. measles, polio.
Eradication: Permanent reduction to zero of the worldwide incidence of infection. Continued intervention measures no longer required. E.g. Smallpox, rinderpest
List eight factors to consider in deciding whether to target a disease for eradication.
Three indicators of primary importance to achieve eradicability
-An effective intervention
-Sensitive and specific diagnostic tool is available to detect transmission
-Humans are essential for the life cycle of the agent (i.e., no other vertebrate reservoir, no environmental amplification)
Other considerations for pursuing eradication
-Diagnosis is easy and unambiguous
-Disease of public health significance
-Control interventions are simple, cost effective, and easy to implement
-Disease has limited geographical distribution
-No known animal reservoir
-Political commitment from governments is available
Define a PHEIC and describe the criteria
Public Health Emergency of International Concern (PHEIC) is any event that:
-Poses a public health risk to other states through international spread of disease AND
-Potentially requires a coordinated international response
Four diseases always require WHO notification within 24 hours: smallpox, poliomyelitis due to wild-type poliovirus, New subtype of human influenza, SARS
The following diseases must always have a PHEIC assessment: Cholera, Pneumonic plague, Yellow fever, Viral haemorrhagic fevers, (Ebola, Lassa, Marburg), West Nile fever, Other diseases that are of special national or regional concern (e.g. dengue fever, Rift Valley fever, and meningococcal disease).
PHEIC criteria, any two criteria requires WHO notification within 24 hours:
1. The public health impact is serious
2. The event is unusual or unexpected (if it is, must report to WHO no matter what)
3. There is significant risk of international spread
4. There is significant risk of international travel or trade restrictions
Name and describe 4 different types of epidemic curves
- Point source - All cases occur within the max incubation period (e.g., church supper)
- Continuing source Abrupt onset indicating a single continuous source (e.g., contaminated water supply)
- Propagated spread - Single index case results in multiple secondary cases that result in multiple tertiary cases (e.g. Covid-19). Through person to person spread. Generations initially separated by an incubation period, but they merge into a single tall peak.
- Intermittent source - Abrupt onset. Peaks do not increase in size with time. Peaks do not merge (e.g., water supply contaminated based on season)
Describe the steps of investigating an outbreak (there are 12)
Overall approach: MICC (Manage, Investigate, Control, Communicate)
- Confirm diagnosis and outbreak
- Assemble team
- Immediate control (IPAC) measures
- Establish communication
- Establish case definition
- Gather data
- Organize data, make epi curve
- Define population at risk
- Develop and test hypotheses
- Implement longer term control (IPAC) measures (case and contact management)
- Monitor response (initiate or maintain surveillance)
- Debrief, evaluation, summary report
“Cool Agents Investigate Every Eccentric Germ Outbreak, Determined Detectives Implement Measured Decisions”
What are 4 reasons you may have a false outbreak signal
- New laboratory tests (increased sensitivity)
- Change in reporting/case definition
- Seasonal variation
- Diagnostic error/bias
- Improved diagnosis of disease
- Change to disease classification
- Increased awareness of disease
- Increased access to testing
- Change in denominator of population
- Change in demographics of population
Discuss the types of evidence in a food outbreak investigation
Epidemiological
-Geographic/temporal distribution and demographics of cases
-Exposure information (e.g., food items, common event)
-Loyalty card purchase histories
-Quasi case control, cohort analysis, etc.
Laboratory
-Food and environmental sample testing
-Subtyping: Pulsed-field gel electrophoresis (PFGE), whole genome sequencing (WGS)
Food Safety
-Inspection of implicated plant
-Traceback – where did product come from
-Traceforward – where did product go
Discuss how you would manage a case, and also how you would manage contacts
Confirm the case through testing
Obtain TOCIS history (travel, occupation, contacts, immunization, symptoms)
Provide education/counselling
Treat (usually by HCP)
IPAC to prevent transmission (isolation/exclusion)
Contact tracing and notification, identify souce
COPTIC
COPTIC can also be used for contact management with the following considerations:
C - confirm contacts, how many are there?
O - obtain TOCIS history
P - provide education/counselling
T - treat (chemoprophylaxis vs immunoprophylaxis vs presumptive treatment
I - IPAC, quarantine not isolation!
C - continue to monitor contacts
List 8 control measures for managing an outbreak in LTC homes
o Hand washing and proper respiratory etiquette
o Environmental cleaning
o Isolation/cohorting of symptomatic people
o Restricting social activities and group gatherings
o No new admissions, transfers, or outside medical appointments
o Healthy work place strategies including: policies that support staff staying home when ill; and staff education about relevant policies.
o Droplet and contact precautions along with routine practices for cases in healthcare facilities
o Prophylaxis and treatment with antivirals
List and describe the stages in the chain of transmission
Infectious Agent: The pathogen
Reservoir: Where the pathogen lives/grows/multiplies
Portal of Exit: How the pathogen exits the reservoir
Mode of Transmission: How the pathogen gets from one host to another
Portal of Entry: How the pathogen enters the host
Susceptible host: Person at risk of infection
List and describe the steps of the hierarchy of controls
- Elimination: Remove the hazard
- Substitution: Replace the hazard with something less harmful
- Engineering Controls: Controlling the amount of the hazard in the environment such as through physical barriers, environmental cleaning
- Administrative Controls: Change the way people work to minimize the hazard such as through workplace policies
- Personal Protective Equipment: Create a barrier between the worker and the hazard
Define infection prevention and control
Infection prevention and control is a series of practices and measures applied in healthcare settings to reduce the transmission of pathogens amongst, patients, visitors, and staff
Discuss steps to effective IPAC
PIDAICE
P - Planning
I - Later
D - Data Collection
A - Analysis
I - Interpretation
C - Communication
E - Evaluation
Planning
- Assess the population via a health needs assessment (e.g., types of patients service, common diagnoses/treatments, frequently performed procedures, patients at highest risk)
- Select the outcome or process for surveillance (e.g., length of stay, treatment, litigation, potential for successful prevention, quality indicators)
- Use comprehensive and standardized surveillance definitions (e.g., Canadian Nosocomial Infection Surveillance Programme definitions)
Data collection
- Surveillance tools: line listings, infection reports, sentinel sheets, computer data forms
- Data sources: microbiology data, admission/medical records, patient care plans, interviews, diagnostic imaging, pharmacy orders
- Managed by trained and experienced professionals
-Methods developed to fit specific surveillance objectives
-Approach to surveillance determined by objectives and resources
-Key information to collect: demographics (age, sex, diagnosis, underlying disease), clinical infection information, laboratory data, risk factors (surgical procedures, IVs, diabetes), interventions (antibiotics, treatments, devices), response to treatment, length of Stay
Analysis
-Calculate and analyze surveillance rates
-Determine appropriate and feasible measures prior to data collection (e.g. ratios, proportions, rates, crude rates, incidence, prevalence)
-Present data so as to be understandable to user
Interpretation
-Interpret data with people who are trained in epi/data methodology
-Beware of potential problems with external comparisons
-Reports should stimulate improvement in process being measured
Communication
Evaluation
Discuss how to address antimicrobial resistance.
Framework: SIRS
Surveillance systems - detect emerging and re-emerging organisms.
IPAC - Strategies to prevent infections
Research and Innovation - to ensure evidence-based responses to AMR
Stewardship - promote appropriate use of antimicrobials, awareness campaigns etc.
List 10 organisms that are priority for surveillance in Canada as it relates to AMR
o Carbapenemase-producing Enterobacteriaceae
o Clostridioides difficile
o Methicillin-resistant Staphylococcus aureus (MRSA)
o Vancomycin resistant Enterococcus (VRE)
o Group A streptococcus (S. pyogenes)
o Streptococcus pneumoniae
o Neisseria gonorrhoeae
o Mycobacterium tuberculosis
o Typhoidal and non-typhoidal Salmonella enterica
o Candida auris
What is the Pan Canadian STBBI Framework for Action?
Goals
-Reduce the incidence of STBBI in Canada
-Improve access to testing, treatment, and ongoing care and support
-Reduce stigma and discrimination that create vulnerabilities to STBBI
Core pillars support an enabling environment
-Prevention
-Testing
-Initiation of care and treatment
-Ongoing care and support
-ALL UNDERSCORED BY AN ENABLING ENVIRONMENT
Guiding Principles
-Meaningful engagement of people living with HIV and viral hepatitis and key populations
-Moving towards truth and reconciliation
-Integrated approach
-Cultural relevance
-Human rights
-Health equity
-Multi-sectoral approach
-Evidence-based policy and programs
Discuss drivers for the emergence of zoonotic and vector-borne diseases.
Globalization
- Travel and tourism: more movement of people
-Global trade: more movement of goods
-Migration: immigrants, asylum seekers can be more vulnerable to disease in new country setting
Environment
-Climate change: changing distribution of vectors, waterborne/foodborne diseases
-Urbanization/built environment: Changes to physical landscape change distribution of vectors
Sociodemographic
-Vulnerable groups: Children, premature infants, pregnant women, elderly persons, men who have sex with men, immunocompromised persons. Can be more susceptible to disease, or have more difficulty accessing care
-Demographic: Population composition with regards to age, income, education can be associated with greater health vulnerabilities
-Social inequality: Uneven distribution of resources in society, including income, wealth, rights, privileges, social power, education. Disadvantaged groups can suffer disproportionately from infectious diseases.
-Lifestyle: High-risk behavior, such as intravenous drug use or unprotected sex with multiple partners can increase exposure and infection rates
-Occupational: Lapses in infection control practices can put healthcare workers, veterinarians, butchers, etc. at risk
-Prevention: Childhood vaccination programs, appropriate prescription practices
-Terrorism: Intentional release or dissemination of biologic agents
Public Health System Failures
Food and water quality: Contamination of drinking and irrigation water sources, water distribution systems, foodstuff can result in both localized and community outbreaks
Animal Health: High animal densities can promote infectious disease transmission. Infected animals close to human settlements can increase the risk for zoonotic epidemics
Surveillance and reporting failure: Lapses in surveillance can impede a rapid response to infectious disease outbreaks
Healthcare system: Healthcare systems contribute to nosocomial infections
What are the characteristics of a good vaccine?
Vaccines prevent CASES
C - Cost
A - Administration (ease) (oral/intranasal preferred to injection, minimum doses)
S - Safety (common side effects mild, severe side effects rare)
E - Effective (immunogenicity (produces immune response), efficacy (reduces disease in clinical trials), effectiveness (reduces disease in real world), duration of protection
S - Stability (minimal/no need for cold chain, long shelf-life)
List and describe 8 determinants of vaccine response
o Vaccine type: live attenuated induces greater response than inactivated vaccines
o Presence of adjuvants: added to inactivated vaccines to enhance the immune response and extend duration of B and T cell activations
o Conjugating proteins: conjugating (linking) a polysaccharide with a carrier protein (protein that is easily recognized by the immune system) leads to a significantly higher immune response
o Antigen dose: higher the dose of inactivated antigen (to a threshold) elicits higher antibody responses
o Timing between doses: adhering to recommended interval between doses allows development of successive waves of antigen-specific immune system responses and maturation of memory cells
o Recipient age: vaccines given early in life when the immune system is immature may result in limited immune response. Vaccines given in older age can result in a reduction in the strength and persistence of antibody responses
o Immune system status: immunocompromised individuals will have restricted vaccine response
o Host factors: age, sex, pre-existing conditions
o Other factors: route
Explain the Erikson DeWals framework.
Considerations for vaccine programs
- Disease characteristics: burden
- Vaccine characteristics: CASES
- Program characteristics: immunization strategy, acceptability, feasibility, ability to evaluate, research questions, cost-effectiveness, conformity (SAFER-CC)
- Contextual factors: PESTLE, Equity, Ethical
List and describe the phases of research involved in drug development (specifically vaccines)
Preclinical: Animal and lab studies looking at feasibility and toxicity
Phase 1: Immunogenicity and toxicity
Phase 2: Safety
Phase 3: Vaccine efficacy, rare adverse events
Phase 4: Real world effectiveness, post-licensing surveillance
Equation and interpretation for Vaccine efficacy/effectiveness
1-Incidence Rate Ratio (IRR) = 1-(incidence in vaccinated/incidence in unvaccinated)
OR
(incidence in unvaccinated - incidence in vaccinated)/incidence in unvaccinated
Individuals who are vaccinated have a (x%) lower risk that those who are not.
Discuss the AEFI reporting system
HCP -> Local PHU -> Provincial PHA -> PHAC CAEFISS (Canada Adverse Events Following Immunization Surveillance System)
Manufacturer -> Health Canada CVP (Canada Vigilance Program) -> CAEFISS
IMPACT (Immunization Monitoring Program ACTive, pediatric hospital-based) -> CAEFISS
Concerns re: causality: CAEFISS -> ACCA (Advisory Committee on Causality Assessment)
Provide 4 examples of vaccines with different levels of effectiveness, and list their approximate effectiveness.
95-100%: Rubella, measles, rabies, Hib, hepatitis B, tetanus, diphtheria, HPV, hepatitis A
90-95%: Rotavirus
75-90%: Pertussis, typhoid
<75: Tb
What is herd immunity and how do you calculate it?
Level of immunity in the population that protects the whole population because the disease can no longer spread
Calculation = 1 - 1/R0
Define vaccine hesitancy and provide a framework for understanding vaccine hesitancy.
Definition: delay in acceptance or refusal of vaccines despite availability of vaccine services
Factors contributing to vaccine hesitancy (4Cs)
-Complacency: Lack of perceived need or value for vaccine, lack of experience with vaccine-preventable diseases
-Convenience: Lack of access (e.g. geographic barriers, cost barriers), cost barriers
-Confidence: Lack of trust in vaccine, provider, or the process, past adverse experiences, perceived risk/benefit, actual risk/benefit (technical concerns over probability of side effects)
-Culture: Religious beliefs, social context, distrust of the medical system or pharmaceutical industry
Explain the 6 E’s Framework and when it can be used.
Can be used to discuss interventions to a public health issue (e.g. vaccine hesitancy) or hazard (e.g. lead in drinking water)
Economic: Create financial incentives
Engineering: New electronic systems
Education: Increase health care provider awareness
Environment: Increase access through school based programs
Enforcement/ legislation: Mandatory vaccine legislation
Empowerment/ encouragement: Engaging religious or other influential leaders
What is epidemiology?
Study of distribution and determinants of health-related states or events in specified populations, and application of this study to the control of health problems.
List and describe 6 ways to control for confounding.
Study design
* Randomization: selection method decides who is exposed and who is unexposed (e.g. random number generator)
* Restriction: limit enrollment based on known cofounders (e.g., do not include alcohol drinkers)
* Matching: based on potential confounders (e.g., match cohort based on age)
Analysis
* Stratification: by a particular variable (e.g. age, sex)
* Standardization: such as standardizing for age
* Multivariate analysis: control for multiple confounders using regression models
Define and provided two examples of effect modification.
Real relationship between the exposure and the outcome and a third variable modifies the direction or magnitude of that effect
Example 1: Individuals exposed to radon who smoke cigarettes have a much higher risk of lung cancer than individuals exposed to radon who do not smoke cigarettes
Other examples:
Smoking, alcohol drinking, and head and neck cancer
-Smoking, asbestos, and mesothelioma
-Smoking, uranium mining (or radon exposure), and lung cancer
-Smoking, slow acetylator (due to variation in genes encoding detoxification enzymes), and bladder cancer
-Aflatoxin, hepatitis infection, and liver cancer
-Obesity, menopause status, and breast cancer
-Smoking, oral contraceptives, and blood clots
Explain stratification
o Method used to determine whether or not the relationship between an exposure and an outcome is due to a confounder or impacted by an effect modifier
o Stratify the exposure and outcome by the potential confounder/effect modifier
o 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
o If the relationship is impacted by an effect modifier, then the strength of the association will be different in every stratum
o If the relationship is impacted by an confounder, then the pooled RR, or adjusted RR, will be different form the crude RR
Discuss the different types of causes.
Necessary cause mean that without the cause, the effect cannot occur, however, sometimes the causes can occur without the effect. For example, a pathogen, causing a disease.
Sufficient cause means the effect must always occur when the cause is present. For example, decapitation causing death.
Causation can be described as necessary and sufficient (X -> Y); necessary, but not sufficient (X+Z->Y); sufficient, but not necessary (X->Y, Z->Y), or neither sufficient nor necessary (X+Z->Y, Z+K->Y).
List Koch’s postulates (Low-yield)
- Is the microorganism found in all diseased organisms, and not found in all healthy organisms?
- Can the microorganism be isolated and grown in culture from the diseased organism?
- Can the cultured microorganism lead to disease when introduced into a healthy organism?
- Can the same microorganism be isolated and cultured from the inoculated diseased organism?
List the Bradford-Hill Causality criteria.
SSPACCE-TB
Strength: Large effect size
Specificity: Single risk factor leads to single effect
Plausibility: Biologically plausible
Analogy: Similarities with other observed associations
Coherence: New data agrees with existing evidence
Consistency: Association is reproducible in different populations and settings
Experimental: Association is demonstrated in experimental evidence
Temporality: Exposure must always precede the outcome
Biological gradient: Dose-response relationship,
A cohort study found the absolute risk among smokers of getting bowel cancer is 20%, and the absolute risk among non-smokers of getting bowel cancer is 8%. 15% of Canadians are smokers.
Put together a 2x2 table and calculate and interpret absolute risks, relative risk, risk difference/absolute risk reduction, attributable risk percent, population attributable risk, and population attributable fraction.
Also calculate and explain the NNT in this situation.
2 x 2 table
Outcome?
Yes No
Exposed 300 1200 1500
Unexposed 680 7820 8500
Total 980 9020 10000
Absolute risk in exposed: a/a+b = 300/1500 = 0.2
Smokers have a 20% risk of bowel cancer
Absolute risk in unexposed: c/c+d = 680/8500 = 0.08
Non-smokers have a 8% risk of bowel cancer
Relative risk: (a/a+b)/(c/c+d) = 0.2/0.08 = 2.5
Smokers are 2.5 times more likely to get bowel cancer compared to nonsmokers
Risk difference: Incidence(exposed)-Incidence(unexposed) = 0.2-0.08 = 0.12 = 120 per 1000 cases
Among smokers, 120 per 1000 cases of bowel cancer in the study are attributable to smoking.
Among smokers 120 per 1000 cases of bowel cancer in the study could be prevented if smoking was eliminated.
Among smokers, there was an additional 120 cases of bowel cancers per 1000 people compared to non-smokers.
Attributable risk percent: [I(exposed)-I(unexposed)]/I(exposed) = 0.12/0.2 = 0.6
Among smokers, 60% of bowel cancer cases in the study were attributable to smoking.
Among smokers 60% of bowel cancer cases could be prevented if smoking was eliminated.
Population attributable risk: I(total)-I(unexposed) = (980/10000)-(680/8500) = 0.098-0.08 = 0.018
18 per 1000 cases of bowel cancer in the population are attributable to smoking.
18 per 1000 cases of bowel cancer in the population could be prevented if smoking was eliminated.
Population attributable fraction: [I(total)-I(unexposed)]/I(total) = 0.018/0.098 = 0.18
Alternate population attributable fraction: [Pexposed*(RRexposed -1)] / [Pexposed *(RRexposed -1) + 1)]
= [0.15 * (2.5-1)] / [0.15 * (2.5-1) + 1]
= 0.225/1.225 = 0.18
18% of bowel cancer cases in the population were attributable to smoking
18% of bowel cancer cases in the population could be prevented if smoking was eliminated.
NNT: 1/ARR (attributable risk) = 1/0.12 = 8.33 = 9 (always need to round up to the nearest whole number for NNT)
9 people would need to eliminate smoking in order to prevent 1 case of bowel cancer.
Explain when you would use an odds ratio versus a relative risk.
Odds ratio (OR): Probability of an event occurring relative to it not occurring. In case-control studies, the incidence of the disease in the exposed or unexposed is unknown (because the study starts by identifying cases).
Calculation: Odds of disease in exposed (among cases)/Odds of disease in unexposed (among controls) = (a/b) / (c/d) = ad/bc
Rare disease assumption: the OR approximates the RR when the outcome is rare.
Summary:
Relative Risk (RR): Use in cohort studies, RCTs, or when risks can be directly calculated. Preferred for intuitive interpretation, especially when the outcome is common.
Odds Ratio (OR): Use in case-control studies, logistic regression, or when the outcome is rare. Also used when risks cannot be directly calculated.
Provide a 2x2 table of a diagnostic test and define and explain all the possible metrics that can come from it.
2 x 2 table
Disease?
Yes No
Test + a b
Test - c d
Sensitivity: Ability of a test to identify correctly those who have the disease when disease is present. Good to rule snOUT disease. Low false negatives. Will rarely miss people with the disease.
a/a+c
Specificity: Ability of a test to correctly identify those without a disease when disease is absent. Good to rule spIN disease. Low false positives. Will rarely misclassify people as having the disease.
d/b+d
False Negative Rate:
c/c+d
False Positive Rate:
b/a+b
Positive Predictive Value: Probability that an individual with a positive test actually has the disease. PPV increases as prevalence increases.
a/a+b
Negative Predictive Value: Probability that an individual with a negative test does not have a disease. NPV decreases as prevalence increases.
d/c+d
Likelihood Ratio: Combines sensitivity and specificity into a single figure that indicates by how much having a test result will reduce the uncertainty of making a given diagnosis.
Positive likelihood ratio (LR+): Indicates how much more likely a person with the disease is to have a positive test result than a person without the disease. It expresses how much a positive test result increases the odds that a patient has the disease
Calculation: sensitivity / (1 – specificity)
Negative likelihood ratio (LR-): Indicates how much more likely a person without the disease is to have a negative test result compared to a person with the disease. It expresses how much a negative test decreases the odds of having it.
Calculation: (1 – sensitivity) / specificity
What is biostatistics?
Application of statistics to a wide range of topics including biology, medicine, and public health, where statistics is concerned with the collection, description and analysis of data.
What is descriptive statistics?
Summarizing data, describe basic features of a sample
Define bias and error.
Bias is systematic difference between sample and population of interest due to study design, can be reduced by random sampling.
Error is differences between sample and population of interest due to sampling variability, can be reduced by increasing sample size.
Discuss the different types of variables.
o Categorical
-Non-numeric data
-Describe using frequency tables, pie charts, bar graphs
Nominal: categories without any numerical ranking (e.g. country of residence, gender, blood type)
Ordinal: categories that can be ranked/ordered but are not necessarily evenly spaced (e.g., Likert scale, cancer staging)
o Numerical variables
-Describe using distribution, central tendency, and variability
Discrete: countable sets with meaningful distances between numbers (e.g., number of smokers)
Continuous: continuously varying quantities
* Continuous 1: Interval: measured on a scale of equally spaced units, but without a true zero point (e.g. date of birth)
* Continuous 2: Ratio: measured on a scale of equally spaced units and has a true zero point (e.g. height in centimetres)
Describe situations in which use of the mean, median, or mode may not be helpful.
The mean is not appropriate in cases of skewed data, outliers, ordinal/nominal data, or small sample sizes.
The median is a robust measure of central tendency, especially for skewed data or data with outliers. However, it is not be appropriate for small sample sizes or nominal data.
The mode is useful for identifying the most frequent value in a dataset, especially for categorical or discrete data. However, it is not appropriate for continuous data or small sample sizes.
What are 5 key features of a normally distributed curve
- Mean = median = mode
- Shaped like a bell
- 68% of values within 1 standard deviation, 95% of values within 2 standard deviations, 99.7% of values within 3 standard deviations
- Perfectly symmetrical
- Total area under the curve is 1
Distinguish between Type I and Type II error
Type I error (α) AKA 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
Type II error (β) AKA false negative: Error of not rejecting the null when the null is false. Can prevent against this by sufficiently powering the study. Power = 1-β
Define P-value
Probability that difference between result and null hypothesis is due to chance. If the p-value is less than the set significance level (α), then we reject the null hypothesis.
Define 95% confidence interval.
Range that would contain the true population mean for 95% of the random samples obtained. AKA For every 100 samples drawn randomly from the population, we would expect 5% to produce point estimates outside of the CI by chance alone. If a confidence interval crosses 1.0, then it is not statistically significant.
Describe 4 random sampling methods.
o Simple random sample: each individual in population has an equal chance of being selected
o Stratified sample: population first divided into strata, then simple random sampling is performed within each strata
o Cluster sampling: each group has an equal chance of being selected; examine all units within the chosen cluster (done because it’s easier and simpler)
o Multi-stage sampling: each group has an equal chance of being selected, then each individual within the selected group has an equal chance of being selected
What is the difference between variance and bias?
Variance (random error) is that the impact on difference between observed and true values is unpredictable.
Bias (systematic error) is where there is consistent deviation of results or inferences that impact on the difference between the observed value and true value in predictable manner (i.e. always occurs in the same direction). It is attributable to a specific cause
What is the difference between validity and reliability?
Validity is the degree of systematic error in a study (i.e., how closely do the results of a measurement correspond to the true value?)
- Internal validity: degree to which the results of a study are not due to bias or confounding
- External validity: degree to which the results of the study are relevant for populations other than the target population
Reliability refers to consistency of a measurement or the amount of random error that occurs in making a measurement.
List and describe 5 different types of statistical tests.
T-test: Used to compare 2 means
-Paired T-test: comparing two normal populations using dependent samples (e.g. before/after, twins).
-Independent T-test: comparing two normal populations using independent samples (e.g. placebo vs treatment, non-exposed vs exposed, control vs case)
ANOVA test: Used to compare more than 2 means
Chi Square test: Used to assess correlation for categorical variables, to compare whether the observed counts match the expected counts
Kappa statistic (ϰ): Used to assess interrator reliability.
ϰ > .75 denotes excellent reproducibility
ϰ between 0.4 and 0.75 denotes good reproducibility
ϰ < .4 denotes marginal reproducibility
Pearson correlation: quantify association between two normal variables
Spearman correlation: quantify association between two ordinal variables
Define linear regression and provide the necessary assumptions.
Linear regression models the relationship between a continuous dependent variable (y) and one or more explanatory variables (x). Allows prediction of a dependent/outcome variable (y) from one or more independent variable(s) (x)
- Simple linear regression: one predictor variable (x)
- Multiple linear regression: multiple predictor variables (x1, x2, x3, …)
Calculation: Y = β0+β1(X) + ε β0= intercept β1= slope of the line ε= random error
Assumptions for linear regression:
Normality: for any fixed value of X, Y has a normal distribution around its mean
Constant variance: variance of Y is the same for any value of X
Independence: error values are statistically independent of another
Linearity: Y is a linear function of X (except for ANOVA)
What is logistic regression?
Logistic regression models the relationship between a binary dependent variable and one or more explanatory variables
-Used for discrete outcomes (usually nominal, binary, or dichotomous outcomes)
-Output is odds ratio
-Easy to interpret compared to slopes from linear regression!
-Particularly useful for case-control studies
-OR are always more extreme than RR, but if outcome rare than OR will be very similar to corresponding RR
In biostatistics, what is an interaction?
Interaction is where 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.
What is environmental health?
Addresses all the physical, chemical, and biological factors external to a person, and all the related factors impacting behaviours. It encompasses the assessment and control of those environmental factors that can potentially affect health. It is targeted towards preventing disease and creating health-supportive environments. It is a branch of public health that is concerned with all aspects of the natural and built environment that may affect human health.
What are some of the limitations of environmental epidemiology?
Environmental epidemiology: study of effect on human health of exposure to physical, biologic, and chemical agents in the external environment and the related social, economic, and cultural factors
o Limitations in detecting disease:
-Long and variable latency periods
-Etiologic non-specificity of disease clinical features
-Small population size and low disease frequency
-Observer bias in reporting illness
-Interpretation of significance can be difficult, i.e., just because a specific toxic agent is present in the body does not mean that it contributes to any changes in structure/function
o Limitations in measuring exposure:
-Dependence on indirect measures (e.g., measurements from ambient environment rather than individual)
-Surrogate estimates of exposure and dose
-Uncertainty about pathways of exposure
-Complexity when accounting for synergistic or antagonistic relationships of multiple chemicals
-Probable low dose levels in most settings
What are different routes of exposure?
Exposure: amount of substance encountered in environment over time
Routes: inhalation, ingestion, skin, or by injection
Duration: Acute vs. chronic
What are the core components of toxicokinetics?
ADME
Absorption: ability to pass into the body
Distribution: transport throughout the body
Metabolism: activation vs. detoxication
Excretion: elimination from the body
Describe 5 different effects of chemicals
Susceptibility: Ability of a living thing to be harmed by an agent. Influenced by genotype, age, gender, environmental factors (e.g., nutrition), and underlying state of health (e.g., immune status)
Bioavailability: ability of a substance that enters the body to be liberated from its environmental matrix (air, water, soil, food); refers to properties of the matrix
Bioaccumulation: progressive increase in the amount or concentration of a chemical in an organism or in an organ or tissue when the rate of uptake exceeds the rate of excretion or metabolism
- Biomagnification: sequence of processes in an ecosystem by which higher concentrations are attained in organisms at higher levels in the food chain
Biotransformation (intermediary metabolism): biochemical changes a chemical undergoes when it reaches cells of the body; metabolism may lessen toxicity (detoxification) or enhance it (activation)
Define a dose-response curve and provide different measures that can be derived from it.
Dose-response curve determines the relationship between dose and incidence of effects in humans.
Dose: amount of agent deposited within the body following an exposure. Depends on the concentration of the chemical and the duration of exposure.
Response: biological response to an agent
Dose-response curve: dose along the x-axis, response (either as severity of response or % of individuals responding) along the y-axis
S-shaped: most dose-response curves are S-shaped with a threshold value
U-shaped: risk of adverse health outcomes with both low and high doses of the substance (e.g., iodine or other vitamins and minerals)
Linear: no threshold dose (e.g., lead)
Terminology
- No-observed effect level (NOEL): highest dose at which there was no effect, experimentally derived. NOEL can be used to describe beneficial or harmful effects of a substance
- No-observed adverse effect level (NOAEL): highest dose at which there is no observed toxic or adverse effect, experimentally derived
- Lowest observed effect level (LOEL): lowest dose at which there was an effect. LOEL can be used to describe beneficial or harmful effects of a substance
- Lowest observed adverse effect level (LOAEL): lowest dose at which there is a toxic or adverse effect
- Threshold effect area: area between NOAEL and LOAEL
- Effective Dose 50 (ED50) - Estimated dose at which substance has an effect for 50% of population. The specified “effect” can be harmful (tumour incidence) or beneficial (analgesia)
- Lethal Dose 50 (LD50) - Estimated dose at which mortality would be expected to occur in 50% of population
- Benchmark dose (BMD): Dose of a substance associated with a specified low incidence of risk of a health effect (generally range of 1% to 10%). Alternative to the NOAEL
- Reference dose (RfD): Estimate of daily exposure to a human population that is unlikely to result in adverse health effects during a lifetime. Expressed in mg/kg/day for oral exposure and mg/m3 for inhalation
- Estimated daily intake (EDI): Estimated total daily exposure to a substance from all exposure pathways; if EDI > RfD, individual is at risk of adverse health outcomes
o Estimating Intake = (C x CR x CF x EF) / BW, where:
C = concentration of substance
CR = contact rate for exposure medium
CF = conversion factor (for units of measurement, if applicable)
EF = exposure factor (no units)
EF= (FxED)/AT
F= frequency of exposure (days/year); ED= exposure duration (years); AT= averaging time (ED x 365 days/year)
BW = body weight
- Tolerable daily intake (TDI): 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)
- Hazard quotient (HQ): Ratio of an exposure level (e.g., EDI) to a toxicity value (e.g., LOAEL, NOAEL)
o <1, likely to be no appreciable risk of adverse health effect
o >1, potential risk for adverse health effect
- Toxicological reference value (TRV): Concentrations at which specific non-cancer adverse effects would not be expected for a defined period of exposure. Based on the threshold determined from toxicity experiments and usually incorporates an Uncertainty Factor (UF) or Safety Factor (SF) to account for uncertainties. UF/SF is a margin of safety to allow for inter and intraspecies variability.
What is the Canadian Health Measures Survey?
National survey that collects general health information from Canadians. Most comprehensive, direct health measures survey conducted in Canada. Uses personal interviews and collects physical measurements. Provides baseline data on indicators of environmental exposures, chronic diseases, infectious diseases, fitness, and nutritional status, as well as risk factors and protective characteristics related to these areas
- Physical measurements include such factors as height and weight, blood pressure, physical fitness and lung function measures
- Many measures based on blood and urine samples including chemicals
- Chemicals are selected based on one or more of the following considerations:
Known or suspected health effects
Level of public concern
Evidence of exposure in the Canadian population
New or existing requirements for public health action
Ability to detect and measure chemical in humans
Similarity to chemicals monitored in other national and international programs to allow for meaningful comparisons
Costs of performing the analysis
Discuss the Canadian Environmental Protection Act (1999)
Provides a wide range of tools to manage toxic substances (e.g. limiting research, development, manufacture, use, storage, transport, disposal, and recycling)
o Ensures the most harmful substances are phased out or not released into the environment in any measurable quantity
o Environment Canada regulates toxic substances under CEPA
o Guiding principles:
- Pollution prevention: shift of focus away from managing pollution
- Precautionary principle: “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”
- Virtual elimination: reduction to level below which release cannot be accurately measured
- Sustainable (economic) development: clean, healthy environment and a strong, healthy economy that meets the needs of the present generation without compromising the ability of future generations to meet their own needs
- Ecosystem approach: interrelationships between land, air, water, wildlife and human activities
- Polluter Pays principle: users and producers of pollutants and wastes should bear responsibilities for their actions
- Science-based decision-making
- National standards
- Intergovernmental cooperation
What is a health hazards? How to we evaluate and respond to health hazards?
Health hazard: chemical, physical or biological factors in our environment that can have negative impacts on health
Risk assessment: Systematic evaluation to determine if exposure to a hazardous agent may cause harm to human health. Not to recommend any particular decision, but to inform decision making
Risk management: Evaluation of health, economic, technical, social & political context for management options, prescriptive (this is what you should do)
Risk communication: Risk communication is the real-time exchange of information, advice and opinions between experts or officials and people who face a hazard or threat to their survival, health, or economic or social wellbeing
We use a HIRA to assess health hazards.
What is a HIRA and what are the steps involved
HIRA = Hazard Identification and Risk Assessment
Objectives:
- Balance risks and benefits
- Set target levels of risk
- Set program priorities (e.g. public health, regulatory agencies)
- Estimate residual risk after steps are taken
Approach:
- Collaborative, involving interested and affected parties
- Flexible, incorporating new evidence as it emerges
- Broad, considering all of the relevant perspectives (SDOH, social, political, economic, environment)
Limitations:
- Not helpful for determining individual risk
Four steps: HI DR. EARC
Hazard identification: Identifying whether the agent is responsible for the health problem, its adverse effects, the target population, and the conditions of exposure
- Sources of data: biochemistry, in vitro tests, animal studies, epidemiologic data, environmental surveillance (air pollution monitoring, population-level blood levels, etc.)
Dose-response relationship: Examine relationship between exposure and health effects to determine the lowest exposure level for a significant adverse effect to occur
- Use thresholds (deterministic, NOAEL, LOAEL, BMD) for non-cancer events, and non-thresholds (stochastic, slope factor or unit risk) for cancer events and lead
Exposure assessment: Estimating human exposure to a hazard along the exposure pathway (source of contamination, environmental media, location, target population, route, magnitude, duration of exposure)
Risk characterization: Summary statement on extra risk of adverse health problems in the exposed, including major assumptions and level of uncertainty.
- Can be quantitative (e.g., excess cancer risk of 3 in 100 million) or qualitative (e.g. high, medium, low)
- Should describe the risk pathway (pathway from hazard to outcome in question)
Describe the approach to risk management.
TAGOPIE:
T - Assemble Team: Establish roles and responsibilities, involve stakeholders, initiate risk communication
A - Assessment: Identify the issue and the context (PESTLE), assess risks and benefits
G + O - Goal and Objectives: Generate and compare options
1. Primary prevention: minimize exposure, prevent outcome (hierarchy of controls)
2. Secondary prevention: early detection of outcome (e.g., screening)
3. Tertiary prevention: mitigate effects of outcome (e.g., appropriate medical management, chelation)
P - Plan: Select a strategy
I - Implement
E - Evaluate
What is the precautionary principle?
Complete evidence of a potential risk is not required before action is taken to mitigate the effects of the potential risks. Actions should be consistent, accountable, proportionate, targeted, and transparent (CAPTT).
Elements
- Reasonable suspicion of harm
- Scientific uncertainty about cause and effect
- Duty to take action to prevent potential harm
Outline an approach to risk communication.
Low hazard, high outrage = crisis communication
High hazard, low outrage = precaution advocacy
High hazard, high outrage = crisis communication
Safe (non-outrage factors) - VICTOR:
-Voluntary
-Individually controlled
-Certainty
-Trustworthy
-Old and familiar
-Responsive
Outrage factors - MUSIC:
-Morally relevant + Memorable
- Unfair
- Scary/dreaded
- Industrial
- Catastrophic (as opposed to chronic)
What is the IARC classification? List the categories and give 3 examples of each.
International Agency for Research in Cancer Classification. Identifies environmental factors that can increase the risk of human cancer.
Group 1 = carcinogenic to humans, adequate evidence in humans, sufficient evidence in animals. Examples: arsenic, cadmium, asbestos, ethanol, tobacco, radon, sun light, ionizing radiation, HPV, HBV, H Pylori, aflatoxin, iodine
Group 2A = probably carcinogenic to humans, limited evidence in humans, sufficient evidence in animals. Examples: bitumens, DDT, inorganic lead, nitrates, night shift work
Group 2B = possibly carcinogenic to humans, limited evidence in humans, limited evidence in animals. Examples: chloroform, gasoline, radiofrequency electromagnetic fields
Group 3 = not classifiable as to its carcinogenicity to humans, inadequate evidence in humans, inadequate or limited evidence in animals. Examples: drinking water fluoride, crude oil, tannins
What is a cancer cluster? Describe your approach to investigating
Cancer cluster: greater than expected number of cancer cases that occurs within a group of people in geographic area over a defined time period
Cancer Cluster Investigation: TAGOP
T - Assemble Team: epidemiologists, toxicologists, communications, provincial/federal environment ministry, engage community and stakeholders. Make initial contact and response:
-Who, what, where, when, how
-Reasons to stop investigation here: cases genetically linked, different cancers that are not related, cases did not live in the same geographic location during time of latency
A - Assessment: Determine whether the suspected cancer cluster is a statistically significant excess. Calculate Standardized Incidence Ratio (SIR) and 95% confidence interval.
- SIR > 1.0 and statistically significant -> continue investigation
G+O - Goals and Objectives: Determine feasibility of conducting an epidemiologic study to look at association between cluster and particular environmental contaminant
- Review scientific literature for plausible environmental exposures, identify appropriate comparison group, determine whether sufficient resources are available
P - Plan: Conduct etiological investigation through epidemiologic study. Causation cannot be proved through study alone, use Bradford-Hill criteria.
List 4 risk communication strategies or approaches
- Be first, be right, be credible, express empathy, promote action, show respect
- Here’s what we know, here’s what we don’t know, here’s what we are doing about it
- Be open, honest, and transparent
- Acknowledge uncertainty
- Listen to the audience
- Speak clearly and with compassion
Discuss heavy metals and give 4 examples.
Heavy metals are chemicals typically found in the environment, coming from Earth’s crust. Their presence in the environment has been increased through manmade activities like mining, fossil fuels. They are typically toxic at low doses.
Arsenic: Odourless and tasteless. Acute health effects = nausea, vomiting, diarrhea, cardiotoxicity, encephalopathy, death. Chronic health effects = neurotoxicity, diabetes, IARC 1 for lung cancer. Comes from groundwater, fossil fuels, agriculture. Exposure through ingesting food mainly, also drinking water, inhaling in industry. Can mitigate risk through food regulation.
Cadmium: Soft silvery metal. Acute health effects = GI irritation, joint pain, kidney failure, death. Chronic health effects = nephrotoxicity, IARC 1 for lung cancer. Comes from forest fires, mining. Exposure through ingesting food and drinking water, inhaling in industry. Can mitigate risk through elimination, recycling instead of mining.
Lead: Organic and inorganic forms. Acute health effects = nausea, vomiting, abdominal pain, encephalopathy, death. Chronic health effects = neurotoxicity (cognitive deficits), microcytic anemia, IARC 2A for inorganic lead. Comes from soil, mining. Exposure through ingesting food mainly, also drinking water with lead pipes, inhaling dust in environment. Can mitigate risk through replacing lead pipes, restricting lead in consumer products. Current blood lead intervention level is 10 ug/dL, but adverse effects can occur as low as 1-2 ug/dL. Drinking water limit is 5 ug/L (0.005 mg/L).
Mercury: Organic and inorganic forms. Acute health effects = neurotoxicity. Chronic health effects = Mad Hatter’s disease (personality changes), developmental issues with fetal exposure. IARC 2B for methylmercury. Comes from volcanic activity, fossil fuels. Exposure through ingesting predatory fish, inhaling in industry. Can mitigate risk through decreasing fossil fuels, limiting consumption of predatory fish to 150 g/week, 150 g/month if pregnant (shark, swordfish, tuna)
What are VOCs? Give 2 examples
Volatile Organic Compounds are chemicals that readily evaporate into the atmosphere. They are precursors to ozone. Found in fires, animals, vehicle exhaust, building materials. They cause eye, nose and throat irritation, as well as headaches and dizziness. Two examples are trichloroethylene and benzene, both of which are IARC Group 1.
Define and provide 4 examples of endocrine disruptors
Endocrine disruptors are substances that interfere with the normal endocrine system in humans and animals. Examples include BPA (used to be in baby bottles), phthalates (in some children’s toys, used to soften PVCs), DDT (also a POP), and PCBs (also a POP).
Define and provide 4 examples of persistent organic pollutants.
Persistent organic pollutants are synthetic substances that were common in industrial booms, that persist in the environment for long periods of time. They biomagnify in ecosystem. Distinct from PFAS. Examples include PCBs, DDT, dioxins (also endocrine disruptors) and furans (also endocrine disruptors).
Discuss different types of radiation and their health impacts. Give 3 examples.
Radiation - energy that travels through space at the speed of light
Non-ionizing radiation = microwaves, radio waves, visible light and UVA (aging)
Ionizing radiation = UVB (burning), X-rays, gamma rays
Radiation can cause health effects through stochastic and deterministic effects. Stochastic effects have a threshold (beyond which cell DNA is damaged beyond repair) and are dose-dependent. Stochastic effects are random, with varying severity that is independent of the dose, but increased probability of damage that is dependent on the dose. Stochastic effects do not have a threshold.
Example 1: UV radiation. IARC Group 1 for SCC, BCC and melanoma. Prevention with sunscreen, avoidance, clothing to cover skin, legislation to prevent youth using tanning beds
Example 2: Radiofrequency EMF. IARC Group 2B. Causes localized heating of tissues. Causes electromagnetic hypersensitivity, characterized by nonspecific symptoms such as headache, memory changes, dizziness, sleep disturbances. Ubiquitous in modern day - radio, cell phones, wifi, MRI, bluetooth. Prevention by limiting children’s exposure to devices, limiting use of devices, use of handsfree devices. Wi-fi is a non-risk.
Example 3: noise (not radiation, but rather sound waves). Health effects above 40 dB include CVD, sleep disturbance, stress, hearing problems. Canadian recommendations <40 dB at night, <55 dB during daytime. Prevention through elimination (legislation), engineering (road barriers, quieter vehicles), PPE (ear plugs)
Outline an approach to Risk Mitigation.
6 E’s
Economic: taxes, subsidies
Enforcement: restrictions, regulations
Education: awareness campaigns
Environment: planning of where x can be implemented
Engineering: technological advances
Discuss traffic-related air pollution, including its components, health effects, and populations vulnerable to health effects.
Traffic-related Air Pollution (TRAP): mixture of vehicle exhausts, secondary pollutants formed in the atmosphere, evaporative emissions from vehicles, and non-combustion emissions (e.g., road dust, tire wear)
Components: carbon monoxide (CO), fine PM, VOCs, nitrogen dioxide (NO2), diesel exhaust, benzene
PM and NO2 impair lung function. CO causes fatigue, dizziness, and neurological damage. VOCs cause irritation along the respiratory tract. PM is associated with lung cancer, benzene is associated with leukemia
Vulnerable populations: young and elderly, pre-existing cardiac and respiratory diseases (e.g. COPD, asthma)
What are the different sizes of particulate matter and how far do they travel?
PM < 100 µm irritate mucus membranes, PM10 reach upper respiratory tract, Fine PM2.5 reach lower respiratory tract, Ultrafine PM0.1 reach alveoli
What is the AQHI and how is it interpreted?
The Air Quality Health Index (AQHI) is a tool to communicate the excess mortality risk from PM, NO2, and O3. Each unit represents a 1% increase in mortality.
1-3 = Low Risk
4-6 = Moderate Risk (risk populations should consider reducing if having symptoms)
7-10 = High Risk (children and elderly should take it easy, risk populations should reduce time outdoors, general population should consider reducing if having symptoms)
11+ = Very High Risk (risk populations should avoid outdoors, children and elderly should avoid outdoor exertion, general population should reduce time outdoors)
Special Air Quality Statement = AQHI 7+ for 1-2 hours
Air Quality Health Advisory = AQHI 7+ for 3 or more hours
Discuss the cause of wildfires, reasons they occur, and their impacts.
50% of wildfires are caused by lightning strikes, the other 50% are caused by manmade activity.
Contributors: dry conditions, lack of precipitation, warm temperature, strong winds, air density (this last one can increase pollution).
Pollution: Mainly from wildfire smoke which contains, PM2.5, NO2, VOCs, O3
Impacts:
-Fires damage infrastructure and housing, and lead to soil erosion
-Smoke contains many pollutants (above), PM2.5 can be inhaled deeply due to small size
-Acute smoke exposure causes irritation of mucous membranes, runny nose, cough. Can also cause dizziness, shortness of breath, asthma attacks
-Smoke exposure is associated with asthma exacerbation, COPD exacerbation, and premature death
-Wildfires also affect mental health through PTSD, anxiety, depression
High-risk populations in wildfires:
-Young children and older adults, pregnant, disabled
-Indigenous
-Smokers
-Rural/remote
-Homeless/poverty/unemployed/low education
-Outdoor workers
-Pre-existing health conditions
-Newcomers
Provide 10 examples of indoor air pollutants and explain how indoor air quality can be improved.
Indoor air pollutants: mould, fungi, asbestos, dust mites, pollen, ozone, environmental tobacco smoke, radon, lead, bacteria
Control through: controlling the source (cleaning, avoiding idling, controlling humidity), ventilation (HVAC, open windows), filtering the air (HEPA filters)
Compare radon, asbestos, and mould/fungi
Radon: Colourless, odourless, radioactive gas produced by the breakdown of uranium in soils and rocks. Undertake remedial measures when average annual concentration > 200 Bq/m³ (Becquerels per cubic metre). IARC group 1 for lung cancer, smokers at higher risk.
Asbestos:
Sources: cement, plaster, heating systems, building insulation, floor and ceiling tiles. Health effects are pulmonary fibrosis (asbestosis and pneumoconiosis), IARC Group 1 for mesothelioma. No risk if undisturbed.
Mould/fungi:
Moisture enables growth. Health effects include eye, nose and throat irritation, coughing, asthma, allergy. Aflatoxin is associated with liver cancer. Control by reducing humidity and ensuring no water damage/leakages/visible mould.
Define climate change and describe its health impacts
Climate change: statistically significant variation in the average state of the climate that persists for an extended period. Greenhouse gases (O3, NO2, CH4 (methane), CO2) are warming the Earth.
Health impacts:
- Increased food insecurity and malnutrition from reduced crop yields due to hotter temperatures and water shortages
- Increased heat-related morbidity and mortality due to extreme temperatures. Also more extreme weather leading to injury and population displacement
-Respiratory impacts of increased air pollution, due to many factors including increases in wildfires
-Increases in waterborne diseases from flooding and sewage runoff, increase in marine algae blooms from warmer water
-Increase in vector-borne diseases from mosquitoes and ticks extending range due to warmer temperatures
-Increase in foodborne illness from more frequent warm days
-Negative impact on mental health from stress of disasters and displacement
-Increase in diseases of sun exposure (sunburn, skin cancer, cataracts) due to depletion of stratospheric ozone layer
Compare and contrast mitigation and adaptation.
Mitigation: Actions that aim to reduce emissions of greenhouse gases. Needed to prevent future anthropogenic interference with the climate system. Ex. carbon pricing to reduce high carbon practices and incentivize the development and use of low carbon technologies (through cap and trade or carbon tax)
Adaptation: Actions that reduce impacts of ongoing and expected climate change on human communities. Needed now and can provide immediate and short term benefits. Ex. development of drought-resistant crops, emergency response planning for disasters.
Define One Health
One health is an approach to health that recognizes the interacting and synergistic relationships between human health, animal health and ecosystem health, and aims to optimize each of them.
Define health, wellness, illness, disease, impairment, disability, and handicap.
Health: Not only the absence of disease or infirmity, but also the state of physical, mental and social wellbeing
Wellness: Physical, mental, social and spiritual wellbeing that enables a person to achieve full potential and live enjoyable life.
Illness: A person’s subjective experience of feeling unwell
Disease: Pathological process that may or may not produce symptoms that result in patient’s illness
Impairment: Any loss or abnormality of psychological, physiological, or anatomical structure or function
Disability: Restriction or lack of ability to perform an activity in a manner or range considered normal for a human being, due to impairment
Handicap: Disadvantage that results when a disability or impairment limits/prevents the fulfillment of a role that is normal depending on age, sex, and social/cultural factors for that individual
Example: Stephen Hawking who’s motor neuron disease damaged his vocal cords (impairments) removed his ability to speak (disability), but as he is cognitively intact and his disability has not had a serious handicap for his career is as a theoretical physicist.
List 10 determinants of health.
I EAT HEALTHYR
I - Income and Social Status
E - Employment and Working Conditions
A - Access to Health Services
T - Healthy Behaviours (Think “T” for “Take care of yourself”)
H - Housing + Physical Environments
E - Education and Literacy
A - Adverse Childhood Experiences
L - Social Supports and Coping Skills (Think “L” for “Love and support”)
T - Biologic and Genetic Traits (Think “T” for “Traits”)
H - Gender (Think “H” for “He/She”)
Y - Culture (Think “Y” for “Your background”)
R - Race/Racism
What is poverty, how can it be measured, and how can we reduce it?
Poverty: condition of a person who is deprived of the resources, means, choices and power necessary to acquire and maintain a basic level of living standards and to facilitate integration and participation in society.
Canada’s poverty rate is ~10%
3 measures of poverty:
1. Market Basket Measure - used to determine Canada’s official poverty rate. Based on the cost of buying things that represent basic standard of living, including clothing, transportation, shelter and other expenses
2. Low-income cut off - Income threshold below which families must devote 20% or more of disposable income on necessities (food, shelter, clothing)
3. Low-income measure - household considered low-income if its income is below 50% of median household incomes
National Poverty Reduction Strategy (2018): Three pillars - dignity, opportunity and inclusion, resilience and security
Discuss social determinants of Indigenous health
Tree model
Root determinants: Deeply embedded structural factors, and are considered to have the most profound influence on health. E.g. Colonization, Indian residential schools, Indigenous self-determination, Reserves
Core determinants: Intermediate determinants. E.g. Criminal justice system, health care system, community infrastructure and resources
Stem determinants: Immediate factors directly linked to health outcomes. E.g. Income, employment, food insecurity, access to safe drinking water
Intersections: Social determinants intersect and jointly affect individuals, and there are cumulative effects of disadvantage on health
Indigenous Self-Determination: Five principles - freedom, authority, support, responsibility, confirmation
Cultural Resurgence: Through ceremony, language, traditional healing
Explain the health belief model
Framework to understand individual health behaviours. 6 components:
Perceived susceptibility - whether the person believes they are at risk
Perceived severity - whether the person believes the disease is serious
Perceived benefits - whether a person believes there are significant positive effects
Perceived barriers - whether the person believes there are obstacles to a health action
Cues to action - triggers that push an individual towards a a health action
Self-efficacy - person’s confidence in their ability to perform a health action
Describe the stages of organizational change.
- Awareness - Identify the problem and possible solutions
- Adoption - Decide on a solution, ensure mid-levels are on board
- Implementation - Organization-wide implementation of the solution
- Institutionalization - Long-term maintenance of the solution
Describe the key stages and concepts of Organizational Development Theory.
Stages: Diagnosis, Action-Planning, Implementation, Evaluation
Concepts:
Organizational climate - The personality and mood or the organization e.g. openness, level of conflict
Organizational culture - the values, norms and behaviours of an organization e.g. “we work really hard”
Organizational capacity - ability of an organization to function and meet its goals.
Describe the diffusion of innovation theory.
Process by which an innovation (policy, program, intervention) is shared and taken up within a system.
- Innovators (2.5%): enthusiasts, risk takers. Encouraged by the idea of being “change agents”
- Early adopters (13.5%): visionaries, opinion leaders, and trend setters, respected by peers
- Early majority (34%): pragmatists, want reliable innovations, respond well to peer recommendations
- Late majority (34%): conservatives, influenced by peer pressure, skeptical and cautious
- Laggards (16%): skeptics, little contact with opinion leaders, desire to maintain status quo
Describe an approach to community engagement. Why is it beneficial?
Community engagement is a process of having community members participate in assessing, planning, implementing, and evaluating solutions to problems that affect them.
5 levels of community engagement (ICICE)
I - Inform: Give community information
C - Consult: Obtain community feedback on solutions
I - Involve: Obtain community input on ideas
C - Collaborate: Work together with community to make change
E - Empower: Provide tools and resources to help community solve their own problems
- Diverse voices contribute to better planning and decision-making
- Engage under-served populations by reducing barriers to involvement
- Engagement contributes to better health outcomes while building healthier workplaces and communities
- Engage partners to find collective solutions that will lead to healthy communities
- Engage with transparency and integrity in a way that builds trust with our communities and demonstrates accountability
***List 8 important characteristics of a population health approach
Definition: approach to health that aims to maintain and improve the health of entire population while reducing inequities in health status among population groups.
Key Elements:
- Focus on the health of populations
- Address the determinants of health and their interactions
- Base decisions on evidence
- Increase upstream investments
- Apply multiple strategies
- Collaborate across sectors and levels
- Employ mechanisms for public involvement
- Demonstrate accountability for health outcomes
How can we build healthy public policy? What is health in all policies?
LOFT
o Legislation: mandated rules or directives that encouraged healthy behaviours or discourage high-risk behaviours
o Organizational change: modifying behaviours in an organizational setting such as in a school or workplace
o Fiscal measures: use of financial incentives to promote and maintain good health (e.g. Children’s fitness tax credit)
o Taxation: levying of a tax on income or products (e.g. tobacco). It is one of the most powerful policy levers for influencing health at the population level
Health in All Policies (HiAP): HiAP is a collaborative approach that integrates and articulates health considerations into policymaking and programming across sectors, and at all levels, to improve the health of all communities and people
What is Kotter’s model of change management?
ECCC-ECCI
- Establish a sense of urgency
- Create a powerful guiding coalition
- Create a vision of change
- Communicate the vision
- Empower others to act on the vision
- Create short-term wins
- Consolidate improvements and produce more change
I - Institutionalize the change, and anchor within the organizational culture
Provide 4 examples of assessments used in public health.
Population Health Assessment: Describes the health status of a community, including the SDOH
-Planning
-Data Collection
-Analysis and Interpretation
-Repot
-Action
Situational Assessment (Health Needs Assessment): Reviews the context and health needs of a community, considering SDOH
-Planning
-Data collection
-Analysis and Interpretation
-Report
-Action
Health Impact Assessment: Reviews the health effects associated with a non-health policy, program, or initiative
-Screening
-Scoping
-Assessment/Appraisal/Analysis
-Report
-Monitoring and Evaluation
Health Equity Impact Assessment: Reviews the effect on health inequities and disadvantaged groups associated with a policy, program or initiative.
-Scoping
-Potential Impacts
-Mitigation
-Monitoring
-Dissemination
Outline 2 frameworks for the built environment.
- 5C’s of a healthy community
* Complete: mixed land use, availability of services and goods, healthy food options, schools, employment, public transit, and open green spaces
* Compact: decrease land use by efficient planning
* Connected: efficient and safe networks, direct routes to destinations, safe/complete streets
* Cool: parks, trees, green spaces provide shade and improve air quality, making community cooler
* Convivial: attractive and lively public spaces where people can easily connect with each other - Domains of a healthy built environment:
Healthy Neighborhoods Need Food and Transit
● Housing - affordable, well-designed, and diverse housing options
● Neighborhood Design - land use focused on the 5 c’s
● Natural Environments - preserves and connects the surrounding natural environment
● Food Systems - access and affordability of healthy foods through planning and design
● Transportation Systems - supports active transportation modalities
What are 10 features of a healthy built environment?
Promote physical activity
-High residential density
-Connected streets
-Place to walk and ride a bike
-Close to stores, school and work
-Attractive areas
-Parks, green spaces and recreation facilities
-Good public transit
Provide healthy food options
-Stores that sell healthy food nearby
-Farmers’ markets
-Community gardens
Create a supportive environment
-Places to gather
-Front porches, front yards
-Good sidewalks
-Access to attractive and green spaces
-Cultural spaces, architecture, public art
What is a healthy built environment? What are design features to consider for specific vulnerable populations? What are the positive health impacts of a healthy built environment?
Healthy built environment: Designing the manmade or modified physical environment where people live, work, study and play so that healthy choices are easier choices.
Design features for specific populations
* Children: traffic calming, limit access to unhealthy food near schools
* Older adults: walkability for those with mobility issues, social isolation, benches to rest
* Disability: good accessibility, safe streets, open spaces, low traffic density
* Indigenous: challenges include lack of housing, safe drinking water, food availability, security, safety, access to health care
Health impacts:
decrased premature death
decreased obesity, diabetes, CVD
decreased cancer
decreased mental health illness
Provide the objectives and recommendations of Canada’s Food Guide.
Objective: promote healthy eating, overall nutritional well-being, and support improvements to the Canadian food environment
Health rationale:
- Fibre reduces CVD, colon cancer, diabetes
- Vegetables and fruits reduce CVD
- Plant based protein and nuts LDL cholesterol
Recommendations
- Have plenty of vegetables and fruits
- Make water your drink of choice
- Eat plant-based proteins
- Choose whole grain foods
- Be mindful of eating habits
- Use food labels
- Cook more often
- Enjoy your food and eat meals with others
- Be aware of food marketing
- Limit foods high in sodium (<2300mg/day), free sugars (<10% total energy intake), and saturated fat (<10% total energy intake)
Fruits, Vegetables, Water, Whole Grains, and Plant-based Proteins Make (Mindful eating) Cooking Really (Read food labels) Enjoyable (Enjoy meals and eat with others) and Build Amazing (Be aware of food marketing) Lives (Limit sodium, free sugar and saturated fat)
What is food security and how can it be monitored?
Food security: exists when people have physical and economic access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life
Monitor through National Nutritious Food Basket - monitors the cost and affordability of healthy eating in Canada through determining the cost of a group of foods that represent a healthy diet for a certain demographic
What are the risk factors for SIDS and ways to prevent it?
- Definition: sudden death of an infant < 1 year, cannot be explained despite investigation/autopsy
- Risk factors
- Non-modifiable: male, premature birth, low birth weight, poverty, Indigenous population
- Modifiable: prone sleeping position, maternal smoking during pregnancy, exposure to second-hand smoke, overheating
Prevention
* Back to sleep campaign reduced SIDS by 50%
* Safe sleep: supine, firm mattress, fitted sheet, no items in crib, room sharing, one-piece sleep wear
What are the benefits and contraindications of breastfeeding?
Benefits:
Mother - Postpartum weight loss, decrease in breast and ovarian cancer, decreased metabolic disease, cost-saving, delayed ovulation
Child - Improved bonding, transfer of immunoglobulins, decrease in infections, reduced atopy, prevention of diabetes/obesity/IBD, optimal nutrition, decreased SIDS, NEC
Society - Cost savings from mother/child health benefits, less environmental impact
Contraindications:
-HIV with detectable viral load
-HSV with active lesion on breast
-Certain medications e.g. cytotoxic, radioactive
-Ebola
-Varicella
-Active pulmonary tuberculosis while contagious
What is the Baby-Friendly Initiative?
BFHI is an international program established by the WHO to help families make informed decisions about infant feeding and breaks down barriers to breastfeeding
MAW BIRTHED
- 6 Months exclusive breastfeeding
- Avoid substitutes
- Written policy
- Baby-led feeding
- In-to-out of hospital (seamless transition)
- Rooming: keep mothers and infants together in room for 24 h
- Training of staff
- Help technique: assist with lactation
- Education on importance of breastfeeding
- Direct skin-to-skin contact in first hour of life
List the points of the WHO International Code of Marketing Breastmilk Substitutes
o No advertising of products (i.e., formula, bottles, nipples, pacifiers) to the public
o No free samples to mothers
o No promotion of artificial feeding products in health care facilities, including the distribution of free or low cost supplies
o No company representatives to advise mothers
o No gifts or personal samples to health workers
o No words or pictures idealizing artificial feeding, including pictures of infants on the labels of products
o Information to health workers should be scientific and factual
o All information on artificial infant feeding, including the labels, should explain the benefits of breastfeeding, and cost and hazards associated with artificial feeding
o Unsuitable products, such as sweetened condensed milk, should not be promoted for babies
List 10 different ACES, describe their prevalence, and provide 10 outcomes
Adverse Childhood Experiences (ACEs) Definition: negative, stressful, traumatizing events that occur before the age of 18 and confer health risk across the lifespan. The ten most studied ACEs are divided into three umbrella areas:
- Abuse: emotional, physical, sexual
- Neglect: physical and emotional
- Household dysfunction: witnessing intimate partner violence, household substance abuse, mental illness, parental separation or divorce, having an incarcerated relative, death of a parent
Epidemiology: 33% of Canadians aged 15 and older experienced some form of maltreatment during childhood
Outcomes: graded, dose-response relationship between ACE and poor health
- Mental health: depression, anxiety, suicide, PTSD
- Maternal health: unintended pregnancy, pregnancy complications, fetal death
- Infectious disease: HIV, STIs
- Chronic disease: cancer, diabetes
- Risky behaviour: alcohol abuse, drug abuse, unsafe sex
- Missed opportunities: education, occupation, income
- Other: early death
Describe the Comprehensive School Health Framework
Comprehensive school health is an internationally recognized framework for supporting improvements in students’ educational outcomes while addressing school health in a planned, integrated and holistic way.
- Social and Physical Environment - relationships, emotional wellbeing, building, play space, equipment, sanitation, air quality
- Teaching and Learning - resources, activities, curriculum
- Partnerships and Services - support student and staff health/well-being
- Healthy School Policy - rules, procedures and management practices
What is mental health and mental illness? How common is mental illness?
Mental health: state of well-being in which the individual realizes their own potential, can cope with the normal stresses of life, can work productively, and is able to make a contribution to their community
Mental illness: full range of patterns of behaviour, thinking or emotions that bring some level of distress, suffering or impairment in areas such as school, work, social and family interactions or the ability to live independently
- At any time, 1 in 5 Canadians have a mental illness or addiction
- By age 40, 1 in 2 Canadians have experienced mental illness
List 10 Recommendations of the Canadian Task Force on Preventive Health Care
-Recommends screening for breast cancer with mammography if the patient would like it every 2-3 years from age 40-74 (used to be 50-74)
-Recommends screening for lung cancer with annual low-dose CT x 3 in health care settings with expertise and diagnosis and treatment of lung cancer for people aged 55-74 with 30 pack year smoking history who currently smoke or quit smoking less than 15 years ago. Recommend against lung cancer screening with low dose CT for all other adults, and recommend against chest X-ray for lung cancer screening.
-Recommends cervical cancer screening every 3 years for women aged 25-69. Recommends ceasing at age 70 or when 3 successive negative tests.
-Recommends screening for colorectal cancer with FOBT every 2 years or flexible sigmoidoscopy every ten years for adults ages 50-74. Recommends not screening adults 75 and over, and not screening using colonoscopy.
-Recommends against screening adults with chronic GERD for esophageal adenocarcinoma or its precursors
-Recommends against screening all men for prostate cancer with PSA
-Recommend against routine screening for depression in adults and subgroups of adults at increased risk of depression
-Recommend against screening for depression in pregnancy and postpartum period for all individuals using a tool with cut-off scores
-Recommends against instrument-based screening of asymptomatic older adults (≥ 65 years) for cognitive impairment
-Recommends asking children and youth aged 5-18 or their parents about tobacco use opportunistically, and offering support accordingly
-Recommends against screening nonpregnant asymptomatic adults for thyroid dysfunction
-Recommends one time screening with ultrasound for abdominal aortic aneurysm for men aged 65 to 80.
-Recommends blood pressure measurement to check for hypertension and interpretation according to CHEP recommendations at all appropriate primary care visits.
-Recommends screening pregnant women with urine culture once in the first trimester for asymptomatic bacteriuria
-Recommends opportunistic screening in primary care visits for chlamydia and gonorrhea for sexually active individuals under the age of 30 not belonging to high-risk groups using self-collected or physician collected sample.
-Recommends against screening for developmental delay in children aged 1-4 with no signs or concerns of development issues
-Recommends screening for diabetes type 2 for adults at high (q 3-5 y) and very high (q 1 y) risk. Recommends against routine screening for adults at low to moderate risk
-Recommends screening to prevent fragility fractures with FRAX +/- BMD in women aged 65 and over. Recommends against screening for men, and for women aged 40-64.
-Recommends against screening for HCV for adults who are not at increased risk
- Recommends against primary care screening for impaired vision for community-dwelling adults aged 65 and over
-Recommends against screening pelvic examination in asymptomatic women
Discuss the risk factors and interventions to address oral health.
Risk factors:
- Tobacco use
- Alcohol use
- Unhealthy diets high in sugar
- Low income
Dental health interventions
o Tooth brushing with fluoride toothpaste
o Fluoride to prevent tooth decay. Sources include toothpaste, water, varnishes, mouth rinses, gels and foams, supplements
o Promoting a well-balanced diet low in free sugars and high in fruit and vegetables, and favouring water as the main drink
o Stopping use of all forms of tobacco, including chewing of areca nuts
o Reducing alcohol consumption
Discuss the benefits and harms of community water fluoridation (CWF)
Community Water Fluoridation (CWF)
* Background: monitoring fluoride level in drinking water to optimal level for caries prevention, reduces the frequency of dental caries by 50%
* Health benefits: inhibits tooth demineralization, enhances re-mineralization, inhibits enzyme activity of plaque bacteria
* Potential harms: dental fluorosis, skeletal fluorosis, IARC Group 3
* Fluoride drinking water guidelines: MAC of 1.5 mg/L, based on prevention of moderate dental fluorosis (based on cosmetic effect, not health). Optimal concentration for dental health: 0.7 mg/L
What is the difference between leadership and management?
Leadership is developing a vision and inspiring others by giving them a why and directing them towards the vision.
Management is organizing, planning, controlling and directing an organization’s resources to achieve defined objectives. Involves day to day administration.
Name and describe 5 different leadership styles
- Servant leadership - Instead of people working to serve the leader, the leader exists to serve the people and invest in them
- Authoritative (visionary) leadership - Inspiring, move people toward a common goal. Tells their teams where they’re all going, but leaves it up to team members to find their way to the common goal
- Coaching leadership - Connects people’s personal goals with the organization’s goals. Focused on developing others for future success
- Coercive leadership - Autocratic approach depends on orders and often unspoken threat of punishment, and tight control. Use in crisis situations or with problem employees
- Democratic (collaborative) leadership - Leaders focus on collaboration by actively seeking input from their teams, and they rely more on listening than directing
What is the LEADS in a Caring Environment Framework?
Represents the skills, behaviours, abilities, and knowledge required to lead all levels of the health system
Lead self - self-aware, emotional intelligence, self-reflection, self-regulation, empathy, motivation
Engage others - foster development, social skills, build teams
Achieve results - set direction, take action
Develop coalitions - build partnerships, navigate socio-political environments
Systems transformation - demonstrate critical thinking, support innovation, champion change
What is the Delphi method?
- Consensus-reaching 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
Strengths:
- Rapid consensus can be achieved
- Individuals are able to express their own opinions as opposed to “Group think”
- Offers a method which can be used where data are lacking
Weaknesses:
- Does not cope well with widely differing opinions or large changes in opinions (paradigm shifts)
- Differing opinions may not be sufficiently investigated
What are the benefits of a strategic plan and what are its core elements?
Benefits:
- Improved organizational effectiveness
- Aids decision-making
- Promotes strategic thinking
- Gives organization legitimacy
Components:
-Mission: Core purpose of the organization, the “why”
-Vision: Statement of where the organization should go, “what we want to be”
-Values: Beliefs and underlying assumptions that guide the organization
-Strategic Directions: Broad objectives to achieve the mission and vision
-Goals and Measures: Medium-term (3-5 yr) objectives that fit within the directions, should be SMART
What are the steps of developing a strategic plan?
TAGOPIE
T - assemble Team: including staff, external partners (A MANIC HUG), community members, do stakeholder and PESTLE analysis
A - Analysis: Stakeholder and PESTLE, then SWOT analysis (Internal strengths, internal weaknesses, external opportunities, external threats)
G - Goals: Set strategic goals/directions
O - Objectives: Set objectives under each strategic direction and also determine metrics for measuring success, aka performance oversight (could be a dashboard, scorecard, etc)
P - Planning: Draft the strategic plan document and ensure agreement with key stakeholders
I - Implement: finalize strategic plan and communicate internally and externally (e.g. annual reports
E - Evaluate: Monitor progress using performance oversight framework
List and describe 5 different approaches to conflict management/negotiation
Thomas Killman Framework of Conflict Resolution
Accommodating (Mexicoing): Lose-win. Unassertive and cooperative. Letting the other side get what they want, good when preserving the relationship is important.
Avoiding (Britain and France in 1930-ing): Delay. Unassertive and uncooperative. Postponing discussion, good when more time is needed.
Compromising (Canada-ing): Middle ground. Intermediate assertiveness and cooperativeness. Exchanging concessions, good when parties have mutually exclusive goals.
Collaborating (EUing): Win-win. Assertive and cooperative. Work through differences, good for complex or important issues, and when one party cannot solve the problem alone.
Competing (TRUMPing): Win-lose. Assertive and uncooperative. Imposes decisions, good when quick decision is required.
What is your approach to conflict resolution?
RIP NANIE
R - Rules of engagement - honesty and clear communication are important I - Information gathering - let individuals express themselves P - Problem identification - meet with employees separately first N - Needs of all groups involved - find out what each side is hoping for A - Assess potential solutions - look for areas of agreement N - Negotiate one or more solutions with groups - make sure there is buy-in from all involved I - Implement solutions E - Evaluate and debrief - follow up to see how the parties are doing, ensure the conflict is resolved
If conflict is not resolved, may need to consider coaching, performance evaluations, disciplinary action
What is the difference between quality control, quality assurance and quality improvement?
Quality control: activities to test or inspect a product or service to identify problems before the product or service reaches the customer; “find it, fix it” (retrospective)
Quality assurance: activities to identify problems in a process that might lead to problems with a product or service; “looking further up the line” (prospective)
Quality improvement: continuous and ongoing effort to achieve measurable improvements in the efficiency, effectiveness, performance, accountability, outcomes, and other indicators of quality in services or processes which achieve equity and improve the health of the community
What is Lean Six Sigma?
Six Sigma Goal: to eliminate defects in products and variation in process through continuous process improvement
Lean: Goal: eliminate waste and increase efficiency in process through a systematic approach in identifying and eliminating waste (non-value-added activities) through continuous improvement
Describe an operational plan.
- A specific plan for the use of the organization’s resources to pursue the strategic plan
- Details specific activities to be undertaken to implement strategies
- Annual plan for day-to-day management of the organization
- Produced by CEO and staff
Describe 3 different approaches to budgeting.
Budgeting: Estimation of revenue and expenditure over a set period of time, often defined as a fiscal year
NB: Salary/Wages/Benefits is ~80% of budget
o Zero-based budgeting: new budget is based on the justification of the expense, regardless of the amount budgeted in previous years
o Incremental budgeting: new budget is the product of incremental, small changes to the previous budget
o Program-based budgeting and marginal analysis (PBMA): Review budgets at the program level, identifies where funding could significantly improve program, and where loss of funding would have minimal impact on program, and allocates funds accordingly
What is an approach to budget cuts?
Increase revenue or decrease expenditures.
To increase revenue, can increase fees, sell capital assets, draw from reserves, or cash out investments
To decrease expenditures, can decrease or modify number of staff, find efficiencies, freeze spending, or cut benefits.
Can also consider global reductions (more fair but may make some programs unsustainable) vs targeted reductions (harder choices to be made, but strategic)
How would you go about presenting a business case?
- Show strategic alignment between me and funder
- Describe expected business outcomes
- Give a problem statement
- Describe the scope of the investment
- Analysis - give different possible options including status quo, and explain why the option chosen is best
- Show cost-benefit
- Provide a schedule and implementation plan
- Include a budget
- Identify risks and show how you intend to mitigate it
What is a project charter? List 8 essential components.
Project charter: comprehensive overview of the project that is vital to ensuring that everyone are aware of the project’s purpose and objectives
Components:
- Scope and background
- Goals and objectives (SMART)
- Project governance (use RASCI matrix)
- Key partnerships (Internal and external)
- Key performance measures
- Milestones, deliverables (with timelines)
- Resources and costs
- Risk analysis/mitigation, dependencies/ contingencies, assumptions, HEIA should be done
Add on: Can use a Gantt chart as a visual depiction of project schedule
Describe the components of a logic model.
Logic model: Visual illustration of a program’s resources, activities and outcomes
Target Audience: Main population to be impacted by the program
Inputs: Resources put in to program
Activities/Processes: Planned activities/interventions to achieve program objectives
Outputs: Immediate results at the program level through the execution of activities (LSEE absolute number)
Outcomes: Short- or intermediate- results at the population level (LSEE percentage)
Impact: Overall goal or long-term outcome the program hopes to achieve (LSEE rate or percentage)
Outline an approach to recruitment and hiring and key considerations for the process.
Recruitment: Process of searching for and hiring candidates to fill a vacant position in an organization.
Should include job evaluation - systematic process of assessing the value of jobs in an organization in order to determine the worth of individual jobs and the compensation to be paid to employees who hold those jobs. Ensures workers are paid fairly
Hiring Steps:
Write Job Description: Essential functions and qualifications needed to successfully perform a job. Helps employee to know what is expected of them.
Job posting: Official advertisement for a job opening, used as a marketing tool to support recruitment.
Review applications: With assistance of HR
Interviews: Group, panel, or one-on-one
Background check: Verify employment history
Reference check: Job performance, workplace conduct
Selection and decision: Ensure all relevant staff involved
Job offer: Should contain salary, benefits, vacation, start date, etc.
Onboarding
Other considerations:
-Document all decisions, rankings
-Do not discriminate (race, ethnicity, gender, sexual orientation, age, marital status, family status, etc.
What is performance management and when can it be used?
Employee performance management: Process for establishing a shared understanding about what is to be achieved and how it is to be achieved (align individual with organizational goals)
- Engage high-performers - provide constructive criticism, recognize hard work. keep happy
- Address poor performance. Can be due to:
-Knowledge/skill deficiency
-Workplace constraints
-Interpersonal/behaviour issues
-Personal challenges
-Serious issues (violence, theft, fraud)
What are 6 different approaches to performance management?
Process:
1. Performance planning - Set SMART goals
2. Coaching - help employee find their own way
3. Check-in - provide feedback, document progress
4. Performance assessment: Formal documentation, recognition
Performance evaluations:
1. Objective: based on previously-agreed objectives
2. Narrative: written description
3. Competency: employee assess based on list of competencies
4. Multi-rater: 360 evaluation by multiple individuals
Describe 10 different types of interpersonal bias
- Halo effect: employee’s strong performance in one domain falsely increases impression of overall performance; or the reverse, with weak performance
- Recency effect: most recent performance influences entire assessment
- High performer bias: highly rating a person who shows great potential, but has not yet met many of their goals
- Past performance bias: outcomes of previous assessment influence current assessment
- Status effect: rating a person based on their status within an organization, rather than their performance
- Groupthink: Set aside own perspective and accept perspective of the group
-Confirmation bias: rating a person in such a way to confirm own beliefs, such as incorrectly poorly rating employee after feeling disdain towards choice of attire
Describe the approach to progressive discipline.
Before disciplining:
-Gather information
-Identify expectations
-Identify issues, e.g. written warning that employee is not meeting job expectations
-Identify solutions, e.g. training, supervision, instruction
Plan: Set SMART objectives
Monitor: After reasonable amount of time has been given, assess for improvement
Evaluate: Formal documentation needed
Above is good approach for incompetence, and if performance doesn’t improve SHOULD dismiss quickly (if you don’t dismiss you are condoning poor work performance and then can’t use it as a reason for dismissal)
When dealing with progressive discipline for misconduct take the following approach (with the exception that if severe - violence, fraud, theft - should immediately dismiss):
- Verbal warning
- Written warning
- Suspension
- Termination
Describe 3 employment legislation acts.
- Employment Equity Act - Encourages the establishment of working conditions that are free of barriers, corrects the conditions of disadvantage in employment and promotes the principle that employment equity requires special measures and the accommodation of differences for the four designated groups in Canada (women, Aboriginal peoples, persons with disabilities, members of visible minorities)
- Employment Insurance Act - Outlines EI benefits and contributions. Designed to provide income protection for employees who are unemployed for various reasons.
- Pay Equity Act - Federal employers should ensure employees are paid equally for work with is of “equal value” to the employer and not just for work which is substantially similar (considers the skill, effort, and responsibility of the employee)
What are key considerations for an employer engaging with a union? What contingency plans should the employer have in place?
Collective agreement - Contract negotiated between union and employer
Collective bargaining - Process of negotiating collective agreement
Conciliation - Process where officer meets with union and employer to try to finalize a collective agreement
Mediation - Voluntary process where neutral third part assists union and employer to reach collective agreement, mediator makes non-binding recommendations
Work stoppage - Through strike or lockout
Arbitration - process where arbitrator makes binding and final decision to achieve collective agreement
Ratification - Union members vote on collective agreement to bring it into effect
Grievance - Written complaint alleging a contravention of the collective agreement
Contingency planning for labour dispute:
-Prioritize critical organization functions
-Identify minimum staffing levels
-Develop strategies to minimize labour disruptions
List 4 different types of public communication and 4 considerations for public health communication.
Types of public health communication
o Health education: individual level
o Social marketing: community level
o Mass media campaigns: population level
o Media advocacy and agenda-setting: policy level
Considerations: speaker, audience, medium, message (SAMM)
What are the Four P’s of Social Marketinh?
Product - Core benefit of behaviour, goods or services being promoted for behaviour adoption
Price - Monetary and non-monetary costs of the behaviour, aka perceived risks and barriers such as money, time, effort
Place - Where and when the target will perform the desired behaviour
Promotion - Persuasive communication to inspire the target audience to do the behaviour using various communication channels e.g. social media, signage and displays
What is a conflict of interest and how should it be approached?
Conflict of interest: personal, financial, professional, or political interests that may impact professional judgment or actions
Approach:
-Awareness
-Identification and Disclosure
-Evaluation
-Manage
Describe Indigenous principles of data sovereignty.
First Nations - OCAP Principles
-Ownership
-Control
-Access
-Possession
Metis - OCAS
-Ownership
-Control
-Access
-Stewardship
Inuit - Qanuippitaa (National Inuit Health Survey)
-Inuit-determined
-Inuit-owned
-Strengths-based
-Collaborative
-Rigorous in methods
-Innovative
-Focused on Inuit health and social equity
What is health equity?
Health equity is the absence of unfair systems and policies that cause health inequalities. Health equity seeks to reduce inequalities and to increase access to opportunities and conditions so that everyone has a fair opportunity to live a healthy life. Aka have health for all.
Health inequity refers to health inequalities that are unfair or unjust and modifiable. For example, Canadians who live in remote or northern regions do not have the same access to nutritious foods such as fruits and vegetables as other Canadians.
Distinguish stereotyping, prejudice, and discrimination. Also define harassment.
Stereotyping (how we think): Happens when we view or judge an individual based on generalizations we make about their group
Prejudice (how we feel): Holding a judgmental attitude and negative feelings toward a person, based solely on membership in a group
Discrimination (how we behave): Treating someone differently because of their membership in that group
Harassment (workplace): harassment and violence means “any action, conduct or comment, including of a sexual nature, that can reasonably be expected to cause offence, humiliation or other physical or psychological injury or illness to an employee, including any prescribed action, conduct or comment.” This includes all types of harassment and violence, including sexual harassment, sexual violence and domestic violence.
Describe the continuum of cultural understanding.
Cultural awareness: Knowing that there are differences in other cultural groups and that those differences can affect health and wellbeing
Cultural sensitivity: Recognizing the need to respect and consider cultural differences in interactions with others
Cultural competence: Requires self-awareness, it is knowing the importance of different cultures’ impact on a patient’s perspectives, and adjusting approach accordingly to provide quality care
Cultural safety: Safety goes beyond competence to advocate actively for the patient’s perspective and considers the broader socio-political and historical context. The patient/community decides whether the care provided is culturally safe.
Other factors:
Cultural humility: Process of self-reflection to understand personal biases and privilege
Anti-racism: An approach to reduce power differences by uplifting oppressed racialized groups
Trauma-informed care: Understanding root causes of a persons trauma and committing to provide services in a way that recognizes the special needs of those affected by trauma
What are four public health roles for action to reduce health inequities?
APIP
Assessment: Identify impact of health inequities and strategies to reduce them
Partnerships: Work with government and community organizations to reduce inequities and improve health outcomes
Intervention: Reduce inequities, with an understanding of the unique needs of populations who are marginalized
Policy: Lead, support, participate, and advocate with other organizations in policy analysis and development
Define the main types of racism, as well as race and ethnicity
Internalized racism - Stigmatized race believes what society has assumed about them, and they act according to the stigma around them
Interpersonal racism - Treating a person a certain race differently because of their race in person-to-person interactions
Systemic racism - Societal discrimination leading to a certain race facing disadvantage through inequitable treatment under the law, unfair policies, rules, and regulations
Race - A social construct used to judge and categorize people based on perceived differences in physical appearance in ways that create and maintain power differentials within social hierarchies. There is no scientifically supported biological basis for discrete racial groups. However, interpersonal and structural racism and discrimination create inequities in health care access, quality, experiences and outcomes.
Ethnicity - A multi-dimensional concept referring to community belonging and a shared cultural group membership. It is related to socio-demographic characteristics, including language, religion, geographic origin, nationality, cultural traditions, ancestry and migration history, among others.11
How does stigma affect health?
Stigma is negative attitudes, beliefs or behaviours about or towards a group of people because of their situation in life.
(Implicit bias refers to attitudes and stereotypes that occur unconsciously and inform our thinking, beliefs, and behaviours about social groups.)
Impacts:
- reduced access to care and social services
- increase in chronic stress/poor coping
- puts stigmatized people at higher risk of assault
Outcomes:
-anxiety, depression, suicide
-CVD, hypertension, injury
-Decreased birth weight, prematurity
What are the components of an Immigration Medical Examination (IME)? What other preventive interventions should be considered for migrants?
IME: Foreign nationals (except refugees) can be inadmissible if likely to be a danger to public health, public safety, cause excessive demand on health or social services
- Active tuberculosis screening with Chest X-Ray, to be treated before arrival
- Urinalysis for CKD screening, may be reason to be deemed inadmissible
- Syphilis, to be treated before arrival
- HIV, may be a reason to be deemed inadmissible
Other preventions to consider:
Vaccination: MMR, Varicella, Tdap, Hep B if susceptible/incomplete records
Screening: Hep B, Hep C, HIV, syphilis, intestinal parasites, diabetes, iron-deficiency anemia, depression, dental disease
What is an age-friendly community? List 8 key characteristics
A community set up to help seniors live safely, enjoy good health and stay involved.
Key characteristics:
- outdoor areas and public buildings are pleasant, safe and accessible
- housing is affordable, safe and well designed for seniors
- roads and walkways are accessible and kept in good shape
- public transportation is affordable and accessible
- neighbourhoods are safe
- relationships are respectful
- health and community support services are available
- opportunities for seniors to be socially active exist
- seniors can take part in volunteer, political and employment positions
What are the health-related calls to action of the Truth and Reconciliation Commission?
ACAFVIE (sounds like “a café vibe”)
- Acknowledge that current Indigenous health is the result of government policies
- Close health gaps and publish reports in consultation with Indigenous people
- Address off reserve FNIM distinct health needs
- Fund Indigenous healing centres
- Value Indigenous healing practices and use them when requested, with healers
- Increase number of Indigenous health providers, retain in Indigenous communities, and require cultural competency training for all HCPs
-Educate students on Indigenous issues
What is the Stages Heuristic Framework?
APDIE
(Problem Identification)
Agenda-setting
Policy formulation
Decision-making
Policy implementation
Policy evaluation
What are the key dimensions to consider when analyzing a policy?
U EFACED
Unintended effects: What are the unintended effects of this policy?
Effectiveness: What effects does the policy have on the targeted health problem?
Feasibility: Is this policy technically feasibly?
Acceptability: Do the relevant stakeholders view the policy as acceptable?
Cost: What is the financial cost of this policy?
Equity: What are the effects of this policy on different groups?
Durability/sustainability: capacity of policy to be sustained over time and continue producing effects
Describe 4 different types of advocacy.
o Community activism: enable communities to address the causes of poor health at a policy level
o Social policy reform: champion legislative reform that redresses health inequities
o Community development: enable individuals to identify and address their own needs
o Representational/client advocacy: representing the rights and interests of those unable to represent themselves
Describe the process of planning programs.
PC DS DR (Piece ‘dis (together), doctor!)
- Pre-planning and project management - assemble team, create work plan, timeline, roles and responsibilities
- Conduct a situational assessment - planning, data collection, data interpretation and analysis, reporting, action
- Develop overall program objective - SMART goal, include audience and desired outcomes
- Select strategies and activities - create your logic model, determine activities, outputs
- Develop indicators - process and outcome indicators, they should be specific, observable and measurable
- Review and adjust the program plan
Describe three different types of economic analyses.
Cost-benefit analysis: Determine if monetary valuation of an intervention benefits exceeds its cost, and its magnitude. Measured in dollar, and expressed as a ratio or difference. Can use to compare different health and non-health interventions. Not as commonly used in healthcare.
Cost-effectiveness analysis: Compare health interventions with the same health objectives. Usually compares new intervention to accepted intervention. Outcome is ICER. Downside is can only look at the same health outcome.
Cost-utility analysis: Sub-type of CEA used when focus is on quality of life or if treatments have many outcomes. Measured in $/QALY. Creates a common unit that can be used to compare different health outcomes.
NB. <$20,000/QALY considered excellent value, >$50-80,000/QALY considered poor value.
What is knowledge translation?
Knowledge translation (KT) is the process of taking findings and ensuring they are effectively shared, understood, and applied in real-world settings to improve policies, practices, and outcomes.
Describe the steps required to pass a bill.
o Policy proposal: submitted to and considered by Cabinet; if Cabinet approves, a bill is drafted
o First reading: presentation of the bill to the House of Commons
o Second reading: debate of the principle of the bill; if the principle is adopted, it moves to committee
o Committee: hears witnesses, examines the bill clause by clause, and suggests amendments
o Report stage: committee reports its amendments to the House of Commons; House votes for or against amendments
o Third reading: amended bill is reviewed in the House of Commons for the final time (debate, then vote)
o Senate: bill goes through first, second, committee, and third readings again within the Senate
o Royal Assent: given by the Governor-General and bill becomes a law
What are the 3 branches of government?
Executive branch - Enforces and applies the law
Judiciary branch - Interprets and upholds the law
Legislative branch - Makes the law
Describe two international treaties of public health significance.
International Health Regulations (IHR): A series of regulations agreed to by WHO member states that enables to prevention, control, and response to international public health emergencies. Requires capacity for surveillance and response, and immediate reporting to WHO of potential emergencies of international significance. Smallpox, new subtype of human influenza, SARS, and wild-type polio must be reported. Otherwise report when 2 of the following 4 criteria are met:
-Event is unusual or unexpected
-Event has serious public health impact
-Event has significant risk of international spread
-Event has significant risk of international travel or trade restrictions
Potentially notifiable diseases: Plague, cholera, VHF (e.g. ebola, Marburg, yellow fever, dengue)
Framework Convention on Tobacco Control (FCTC): Created to have international coordination for tobacco control. Specific steps outlined in MPOWER:
M: Monitor tobacco use and prevention policies
P: Protect people from tobacco smoke
O: Offer to help quit tobacco use
W: Warn about the dangers of tobacco
E: Enforce bans on tobacco advertising, promotion, and sponsorship
R: Raise taxes
What are the 5 pillars of the Canada Health Act?
Universality: all eligible residents are entitled to uniform health insurance coverage
Public administration: health insurance plan must be administered by a non-profit, 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
Provide a brief description of the following acts:
-Emergency Act
-Personal Information Protection and Electronic Documents Act (PIPEDA)
-Public Safety Act
-Quarantine Act
Emergency Act: Authorizes the taking of special temporary measures to ensure safety and security during national emergencies. Gives the federal government powers to regulate travel, evacuation, and establish emergency hospitals. Power to compel action to prevent the spread of disease
-PIPEDA: Applies to federally regulated organizations across Canada that collect, use or disclose personal information. People have the right to access their personal information held by an organization.
Public Safety Act: 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: Protects public health by taking comprehensive measures to prevent the introduction and spread of communicable diseases. Authorizes the Minister of Health to establish quarantine stations and quarantine facilities anywhere in Canada
For which populations does the federal government hold responsibility for healthcare delivery?
o First Nations on-reserve, inclusive of First Nations who have assumed responsibility for health services under a transfer agreement
o Active members of Canadian Forces
o Federal offenders or inmates of federal penitentiaries
o Refugee claimants, protected persons, detainees under the Immigration and Refugee Protection Act, and rejected refugee claimants
o Canada-based staff at missions abroad
Explain 5 different funding options for health systems
o 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
o Co-payments: healthcare payment is partly financed by the public sector and partly financed through either out-of-pocket payments or private insurance
o Group-based publicly funded coverage: certain population sub-groups are eligible for publicly-covered health care; the rest of the population must pay out-of-pocket or through private insurance
o Sectoral coverage: certain health care sectors are publicly covered, while the rest are not
o Parallel public and private systems
Define privacy, confidentiality, and personal health information.
Privacy: An individual’s right to be free from intrusion or interference by others
Confidentiality: The duty or obligation to protect entrusted information from unauthorized access, use, disclosure, modification, loss, or theft
Personal Health Information (PHI): Any identifiable information about an individual, written or verbal, that relates to the provision of health care
What are the PIPEDA Fair Information Principles?
CALI-SOCIAL
Consent - Knowledge and consent of the individual are required for the collection, use, or disclosure of personal information
Accountability - Organization responsible for personal information and must appoint someone to be accountable
Limiting collection - Collection of personal information must be limited to that which is needed for the purposes identified
Identify purpose - Purposes for which the personal information is being collected must be identified
Safeguards - Personal information must be protected by appropriate security mechanisms
Openness - An organization must make detailed information about its policies and practices relating to the management of personal information publicly and readily available
Challenging compliance - An individual shall be able to challenge an organization’s compliance with the above principles (usually their Chief Privacy Officer)
Individual access - Upon request, an individual must be informed of the existence, use, and disclosure of their personal information and be given access to that information
Accuracy - Personal information must be as accurate, complete, and up-to-date as possible
Limiting use, disclosure, and retention - Personal information can only be used or disclosed for the purposes for which it was collected
Describe your approach to a privacy breach.
RCNRD
Respond: Notify relevant staff
Contain: Secure PHI
Notify: All affected individuals, and notify of extent of breach
Remediate: Review circumstances, update existing policies/procedures/training as appropriate
Discipline: If liable may face fine
What is the Canada Drug and Substances Strategy?
Comprehensive, collaborative, compassionate and evidence-based approach to drug policy
4 Pillars:
-Prevention and Education
-Substance use services and supports (treatment and harm reduction)
-Evidence (research)
-Controls (enforcement)
All supported by a strong evidence base
Discuss youth substance use.
-25% of youth engage in high risk drinking behaviour
-Opioid-related hospitalizations have been increasing among young adults
-Youth use substance for the social aspect (#1) and to cope with stress (#2)
-Youth are more likely to use cannabis than adults
Interventions should:
-Target primordial factors like poverty and housing
-Promote positive social norms
-Help youth develop resilience and skills
-Come early for youth that need support
What is harm reduction and what are the core principles? Give 5 examples.
Harm reduction: policies, programmes, and practices that aim to minimize negative health, social and legal impacts associated with drug use, drug policies and drug laws
Examples:
-Needle exchange programs
-Safe injection sites
-Naloxone kit programs
-Drug checking services
-Managed alcohol programs
Core principles: FUSION
- Focus on harm: decreasing negative impacts rather than eliminating use
- Understand: use occurs for range of reasons
- Support: non-judgmental, respect for autonomy
- Involve: empower people who use drugs
- Options: recognize variety of approaches
- Needs met: meet people where they are
Discuss the short and long term impacts of alcohol use.
Short-term: Alcohol poisoning, violence, injuries/risky behaviour
Long-term: Liver cirrhosis, hypertension, cancer (oral, pharyngeal, laryngeal, esophageal, liver, breast, colon, rectum) low birthweight, prematurity, FASD, hepatitis, pancreatitis, neuropathy
Explain Canada’s low-risk drinking guidelines, and national guidance on alcohol and health.
Low-risk drinking guidelines: max 10 drinks per week for women, max 15 drinks per week for men
Canada’s guidance on alcohol and health:
0 drinks per week - safest
1-2 drinks per week - low risk
3-6 drinks per week - moderate risk, increased risk of cancers
7+ drinks per week - high risk, increased risk of heart disease and stroke
Additionally:
-No safe amount of alcohol in pregnancy
-Not drinking while breastfeeding is best
-Drink lots of water while drinking
-Eat before and while drinking
-More than two drinks per occasion has increased risk of harm including violence and injuries
What are the WHO SAFER strategies?
High-impact strategies that can help governments to reduce the harmful use of alcohol and related health, social and economic consequences
S - Strengthen restrictions to alcohol availability
A - Advance and enforce drunk driving counter measures
F - Facilitate access to screening, brief interventions and treatment
E - Enforce bans or strict restrictions on alcohol advertising, sponsorship and promotion
R - Raise prices on alcohol through excise taxes and pricing policies
Discuss the epidemiology of tobacco use.
- The prevalence of current cigarette smoking among Canadians aged 15 years and older in 2022 was 11%
- In 2022, the prevalence of current cigarette smoking among youth aged 15 to 19 years was 4%
- Higher rates in Indigenous populations, LGBTQ+, young men aged 20-24, and construction workers
- Tobacco is the largest single cause of premature death globally
- Smoking tobacco accounts for 85% of lung cancer in Canada
- Laryngeal, esophageal, oral, nasopharyngeal, stomach, colorectal, liver, pancreatic, ovarian, kidney, bladder cancers as well
- In fetus/infants: Stillbirth, premature birth, low birth weight, sudden infant death syndrome
- In children: Asthma exacerbation, pneumonia, bronchitis, leukemia, lymphomas, brain tumours, otitis media
Discuss nicotine products, its effects, and interventions to address it
- In 2022, youth (15 to 19) and young adults (20 to 24) have the highest rates of ever vaping, 30% and 47.5% respectively
- The most common reasons for vaping among youth aged 15 to 19 years were to reduce stress , for curiosity, and because they enjoy it. Among adults aged 25 years and older, the most common reasons were smoking cessation and to avoid returning to smoking.
- Vaping nicotine was increased amongst those with less than a university degree, those who identified as a visible minority, those who identified as Indigenous, those who were not heterosexual, and those who rated their mental health as fair or poor
- Nicotine is highly addictive and can lead to dependence and nicotine addiction
- Can affect memory and concentration, it can alter teen brain development through reduced impulse control/cognitive and behavioural problems
- E-cigarette use is associated with subsequent smoking initiation among youth and young adults
- Second-hand vapour: health effects are unknown. E-cigarette use increases airborne concentrations of particulate matter, nicotine and other toxicants in indoor environments compared with background levels
-EVALI: Hundreds of cases and several death. No cause found in Canada. Vitamin E acetate was the cause in the US - Novel nicotine products: Includes electronic nicotine delivery systems (ENDS aka vapes), heated tobacco products, and nicotine pouches, amongst others.
- In July 2023 Health Canada approved Zonnic, a nicotine pouch, under the Natural Health Products Regulations as a nicotine replacement therapy
- This approval led the pouches to be sold without adhering the Tobacco and Vaping Products Act, which meant there was no age restriction, no plain and standardized packaging requirements, no restrictions of promotions and product displays, and no flavour restrictions
- Advocacy from various health organizations led to Minister of Health introducing new measures for NRT to decrease recreational use amongst people who do not smoke, particularly youth, in August 2024. The measures include:
- Prohibit advertising or promotion, including labelling and packaging, that could be appealing to youth.
- Require NRTs in new and emerging formats, such as nicotine pouches, to be sold only by a pharmacist or an individual working under the supervision of a pharmacist, and to be kept behind the pharmacy counter.
- Prohibit NRTs in new and emerging formats, such as nicotine pouches, from being sold with flavours other than mint or menthol.
- Require a front of package nicotine addiction warning, as well as a clear indication of the intended use as a smoking cessation aid for adults trying to quit smoking.
Discuss the epidemiology and harms of cannabis use.
- 40% of Canadians report ever using cannabis; 10% report use in the last year
- Age of initiation is 16
- 1 in 6 youth who use will develop a cannabis use disorder
Legalized in 2018 to protect youth, reduce judicial burden, protect public from black market and promote research
Health impacts:
- Reduced cognitive function
- Psychosis
- Addiction/dependence
- Depression/anxiety
- COPD
- Hyperemesis
- Injury
What are the lower risk cannabis use guidelines?
F-IRONCLADS
Frequency - limited
Inhaling deeply - avoid
Risky behaviour - avoid
Operating vehicles or heavy machinery - avoid
Natural - no synthetic
Contraindicated populations - pregnant, personal/family history of psychosis or substance use disorder
Low strength, low THC
Abstinence is best
Delay until after adolescence
Smoking - avoid
Discuss the epidemiology, health effects, and approach to preventing opioid use.
- Opioid related hospitalizations and deaths in Canada are on the rise
- Most deaths occurred among males aged 30-39
- Indigenous and people with mental health conditions are at increased risk for opioid toxicity and death
Health effects: respiratory depression causing death, addiction, constipation, injuries from falls and road accidents
-When starting opioid-naive patients on opioids for chronic non-cancer pain, do not exceed 90 mg morphine equivalents daily, ideally less than 50
What are the key objectives of supervised consumption sites (SCS)?
o Prevent overdose deaths
o Facilitate entry into drug treatment services
o Reduce the risk of disease transmission (such as Hepatitis C and HIV) caused by unhygienic practices, such as needle sharing
o Reduce public disorder
o Prevent public consumption of illegal substances
o Prevent consumption equipment being discarded in community
o Connect people who use drugs with basic health and social services (drug treatment, counselling, withdrawal management, access to detoxification for people that are ready and willing to seek treatment, housing services)
o Reduce impact on Emergency Medical Services attending to drug overdoses
Define and provide examples of each of the stages of disease prevention.
Primordial prevention - prevent risk factors for disease by modifying social determinants of health. E.g. improved sanitation, early childhood development programs, basic income
Primary prevention - prevent the onset of disease. E.g. Vaccination programs, fluoridation, smoking cessation (to prevent lung cancer)
Secondary prevention - prevent disease progression through early diagnosis. E.g. cervical cancer screening, colonoscopy, mammography
Tertiary prevention - minimize impact of disease on patient function and quality of life. E.g. cardiac rehab, weight loss for diabetes
Discuss four different approaches to delivering public health services to populations
Universal approach - Apply the same intervention to an entire population.
Targeted approach - Apply the intervention only to priority groups, e.g. equity-seeking groups
Targeted universalism - Everyone is offered the same intervention, but steps are taken to promote the intervention to high-risk groups
Proportionate universalism - The intervention is modified based upon the risk level of the group involved (e.g. various levels of support for new mothers ranging from a phone call to home visiting services)
What is the difference between demographic transition and epidemiologic transition?
- Demographic transition: evolution from high to low fertility and mortality rates, decrease in the proportion of children and young adults and an increase in the proportion of older persons in the population
- Epidemiologic transition: shift from mortality primarily caused by infectious disease to mortality primarily caused by chronic disease
Discuss the epidemiology of chronic disease
- Greatest burden of disease is mental health, cancer, cardiovascular disease (including)
For cancer, in 2024:
-45% (2 in 5) of Canadians will be diagnosed with cancer in lifetime
-Most common cancers are 1. lung, 2. breast, 3. prostate, 4. colorectal
-22% (1 in 4) of Canadians will die from cancer
-Most common cancer mortality is 1. lung, 2. colorectal, 3. pancreas, 4. breast, 5. prostate
-economic burden of cancer will continue to increase
-Leading causes of cancer: number one is smoking (22% of cancers), others are HPV, HBV, HCV, schistosomiasis, EBV, HIV, alcohol, radiation, H. pylori, arsenic
Amongst Canadians ages 65 and over in 2021:
-Most common chronic diseases are 1. hypertension, 2. periodontal disease, 3. osteoarthritis, 4. ischemic heart disease, 5. diabetes
Amongst Canadians ages 20 and over in 2021:
-Most common chronic diseases are 1. hypertension, 2. osteoarthritis, 3. mood or anxiety disorder, 4. osteoporosis, 5. diabetes
For mental health in 2012:
-1 in 3 will be affected by mental illness in lifetime
Top causes of death (2022):
1. cancer
2. heart disease
3. covid-19
4. injury
5. cerebrovascular disease (CVD)
What is burden of disease? What are challenges to chronic disease surveillance?
Burden of disease: measure of the severity of a health setback for an individual or population, measured by cost, mortality, morbidity, and other key indicators
Challenges:
Temporality - Long disease latency makes it difficult to attribute causality
Disease course - Protracted disease course with exacerbations and remissions
Cause of disease - Often no single cause; complex interaction of triggers and risk factors
Data sources - Databases usually not designed for surveillance
Data collection - Event-oriented (e.g., hospitalizations, primary care visits) rather than person-oriented
Comorbidity - Common and important for service planning; treating one comorbid condition often impacts another
Authority - With the exception of cancer registries, no legislated authority to collect chronic disease data (unlike reportable diseases)
What is screening? What are the Wilson and Jungner criteria for implementing a screening program?
Screening - Systematic process to identify individuals with a disease in asymptomatic phase
Wilson and Jungner criteria: NIL AS AP FOE
Disease (NIL):
Natural history known
Important health problem
Latent/early symptomatic stage
Test (AS):
-Acceptable test
-Suitable test
Treatment (AP)
-Acceptable treatment
-Policy on who to treat
System (FOE)
-Facilities available for treatment
-Ongoing screening occurs
-Effective from cost perspective (cost-effective)
Other things to consider (Andermann 2008):
-Defined target population
-Scientific evidence of effectiveness
-Quality assurance to minimize risk of harm
-Informed choice, confidentiality and autonomy
-Equity
-Plan for programme evaluation
-Benefits outweigh the harms
What are the criteria for evaluating a screening program?
CRAASSS
C - Cost-effectiveness (QALYs/DALYs)
R - Repeatability (consistent results)
A - Accuracy
A - Acceptability
S - Sensitivity
S - Specificity
S - Simplicity (easy to perform and interpret)
What types of bias are relevant in screening??
- Selection bias: healthy people more likely to be screened
- Lead-time bias: overestimate survival because the cancer is diagnosed earlier in the natural history of the disease but the patient still dies of the cancer
- Length-time bias: overestimate survival by only detecting slowly progressing disease
Overdiagnosis bias: Severe case of length-time bias where cases that would not cause death are detected, leading to overestimate of survival
Discuss the epidemiology and 5 risk factors for each of the top 4 cancers in Canada, as well as cervical cancer.
- Lung cancer
-Small cell is linked to smoking, fast-growing
-Risk factors are tobacco smoke, radon, air pollution particulate matter, occupational exposures, and other toxin exposures - Breast cancer
-1 in 8 women will be diagnosed, 1 in 33 women will die from it
-Mostly in women over age 50
-Risk factors are female sex, early menarche, late menopause, first pregnancy after 30, family history, BRCA1/BRCA2/HBOC, alcohol, HRT - Colon cancer
-90% are adenocarcinomas
-Risk factors are IBD, age over 50, male sex, family history, familial disease such FAP and Lynch syndrome, diet high in red meat, polyps, alcohol, obesity, sedentary lifestyle - Prostate cancer
-1 in 9 men will be diagnosed
-Risk factors are age, family history, African ancestry, diet high in red meat, family history, hereditary genetic mutation
Cervical cancer
-Incidence decreasing due to Pap smears
-70% of cervical cancers are caused by HPV Type 16 and 18
-Risk factors are young sexual debut, multiple sexual partners, partner with multiple sexual partners, smoking, immunosuppression, multiparity
-One dose HPV recommended for age 9-20, two dose for age 21-26
Discuss the epidemiology of obesity, obesity prevention, and metabolic syndrome.
- In Canada, almost two in three adults and one in three children and youth are overweight or living with obesity.
- One in three adults are obese
- Interventions to prevent:
- Individual level: behaviour modification, improved diet, physical activity, bariatric surgery
- Community level: social marketing, school based intervention, menu labelling, work-based programs for adults
- Policy: subsidy program for health food or physical activity, urban planning, regulate food advertising, taxation, zoning unhealthy food
Metabolic syndrome: Clustering of 5 risk factors that increase a person’s risk of CVD and diabetes
- increased waist circumference
- increased blood pressure
- increased plasma triglycerides
- increased fasting blood glucose
- decreased high-density lipoprotein cholesterol
Discuss cardiovascular disease, risk factors, and prevention.
Cardiovascular disease precursors: hypertension, diabetes, dyslipidemia, obesity
Cardiovascular disease outcomes: ischemic heart disease, myocardial infarction, stroke, arrhythmia, heart failure
Risk factors: smoking, poor diet, sedentary behaviour, age, sex, family history, ethnicity, education level, income
Interventions: CHEP guidelines for hypertension health behaviour management:
o Alcohol consumption: reduce or abstain from alcohol consumption to prevent hypertension
o Physical activity: 30-60 minutes of moderate-intensity dynamic exercise 4-7 days per week
o Weight: maintain a healthy body weight (BMI: 18.5-24.9, and waist circumference < 102 cm for men and < 88 cm for women)
o Diet: consume a diet that emphasizes fruits, vegetables, low-dairy fat products, whole grain foods rich in dietary fibre, protein from plant sources
o Sodium: reduce sodium intake toward 2000mg a day
o Smoking: advise patients to quit smoking
o Stress: reduce stress if it is present
Discuss risk factors and a strategy for approaching dementia.
Dementia risk factors: Low education, midlife hypertension, obesity, hearing loss, smoking in later life, depression, physical inactivity, diabetes, social isolation
National Dementia Strategy:
- Prevention through research and awareness of modifiable and protective factors, effective interventions
- Advanced therapies and find a cure
- Improve the quality of life of people living with dementia and caregivers
Define injury prevention and discuss its epidemiology.
-Preventing occurrence of injuries and limiting related impact on health (e.g., disability, death)
-Eliminating hazards and managing risk while still allowing communities to be healthy and active
-Injury is the leading cause of death amongst individuals ages 1-34 years and responsible for 6% of all deaths in Canada
-Leading cause of injury death by age: infants = suffocation, children = MVC, drowning, choking, adolescents = MVC, 20-64 = suicide, 65+ = falls
-Increasing burden of poisonings due to opioid crisis
-Among youth (aged 15 to 24), suicide is the second leading cause of death
-Suicide is 5-20X more common in some First Nations and Inuit communities
-Of all violent crime, ~25% is from family violence with ~70% of victims being women and girls (2016)
-8 in 10 victims/survivors of police-reported IPV in 2022 were women and girls, with rates of IPV more three times higher among women and girls than among men and boys
-Risk factors for family violence: Women, age (children, elderly), Indigenous, people with disabilities, LGBT+ individuals, history of child abuse or neglect, substance use, stress
-Chronic stress from ACES/violence leads to obesity, hypertension, cardiac disease, cancer
Discuss the epidemiology, risk factors, and prevention of falls.
-Between 20-30% of seniors fall each year
-Amongst seniors, falls are the leading cause of injury-related hospitalizations
-Risk factors: elderly, cognitive impairment, balance/gait deficits, vision impairment, substance use, polypharmacy, limited social network, environmental hazards, poor weather, malfunctioning assistive devices
-Outcomes: Fractures (95% of hip fractures are from falls), depression, social isolation
Interventions: falls risk assessment, exercise programs, assistive devices, home modification, management of acute and chronic illness including vision, medication deprescribing
Discuss Vision Zero and interventions to address road safety.
Vision Zero: strategy to eliminate all traffic fatalities and severe injuries while increasing safe, health, equitable mobility for all. Recognizes that people make mistakes and aims to ensure those mistakes do not result in deaths.
Safe users: Helmets, graduated licensing, distracted driving, impaired driving
Safe vehicles: Crumple zone, winter tires, seatbelts, child restraint devices
Safe infrastructure (speeds, roads): Top contributor to MVC fatalities, risk of serious injury doubles every 5 km over 60, traffic calming, public transit, cycling infrastructure, pedestrian-centred intersections
What are the most common organisms that cause foodborne illness each year in Canada?
In order of hospitalizations
- Norovirus
- Salmonella
- Campylobacter
- E. Coli O157
2,3 and 4 cause bloody diarrhea, along with Yersinia enterolytica and Shigella
Greatest cause of death is Listeria
Describe some of the key learnings from the 2003 SARS outbreak.
Naylor report - need for a federal public health agency, led to the establishment of PHAC. Defined the core functions of public health in Canada.
Walker report - need for better public health and IPAC capacity, led to the establishment of PHO and PIDAC
Campbell report - no individual failures/blame, but showed there was a broken public health system and the system failed during the outbreak. Emphasized the importance of the precautionary principle. Need to be better prepared for future infectious disease threats.
Discuss the NACI-recommended infant vaccine schedule.
DTaP-IPV-Hib vaccine should be given at 2, 4, 6 and 12 to 23 months of age.
Booster of DTaP-IPV at 4 to 6 years of age (school entry), and booster of Tdap at 14 to 16 years of age
Booster of Hib at or above age 5 for children with chronic diseases that predispose to Hib: asplenia, cochlear implant, primary immunodeficiency, hematopoetic stem cell transplant, solid organ transplant, malignant hematologic disorder, HIV
Name and briefly describe some different types of viral hemorrhagic fevers
Chikungunya
Dengue
Ebola
Hantavirus
Lassa fever
Marburg virus
Rift valley fever
Yellow Fever
Discuss how to interpret Hep B bloodwork
o Surface antigen (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
o Surface antibody (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)
o Core antigen (HBeAg): soluble protein “envelope” contained in the viral core; presence indicates high% infectivity
o Core antibody (anti-HBc): antibodies produced in response to HBcAg; indicates current (IgM) or previous (IgG) HBV infection
Surface antigen HBsAg Surface antibody Anti-HBs Core antigen HBeAg Core antibody Anti-HBc Interpretation
IgM IgG
Negative Negative Negative Negative Negative Susceptible
No viral exposure and no immunization
Negative Positive Negative Negative Negative Immune due to vaccination
Negative Positive Negative Negative Positive Immune due to infection
Positive Negative Positive Positive Negative Acute infection
Positive Negative Positive Negative Positive Chronic infection
Negative Negative Positive Negative Negative Resolve infection, false positive, low level chronic infection, or resolving acute infection and chronic developing
What are the pros and cons of an infant vs adolescent Hepatitis B routine immunization program?
Infant program
* 90% of infants who are infected with HBV go on to develop cirrhosis (~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
Describe how to manage infants born to an HB infected mother.
- Infants born to a mother with acute or chronic hepatitis B infection
o Unknown status: if maternal HBV status is not available within 12 hours of delivery administer HBV vaccine and give HBIg if there is any suspicion that the mother is infected
o Infected mother: administer monovalent HB vaccine and HBIg within 12 hours of birth followed by complete series
Do not be test infant for HBsAg prior to 9 months of age, in order to avoid detection of passive anti-HBs from HBIg administered at birth and to maximize the likelihood of detecting late HB virus infection
Testing should be conducted 1-4 months after the last dose of vaccine is administered
If HBsAg is present, the child will likely become a chronic carrier
List and briefly describe the AIDS-defining illnesses
Candidiasis
M. tuberculosis
Pneumocystis jirovecii pneumonia
Coccidiomycosis
Cryptococcosis
Histoplasmosis
Toxoplasmosis
Kaposi’s sarcoma
Burkitt’s lymphoma
What are the contraindications to influenza immunization?
- Anaphylaxis, suspected hypersensitivity or non-anaphylactic allergy to previous influenza vaccine or its components, exception of egg.
- Egg-allergic individuals may be vaccinated against influenza without prior influenza vaccine skin test and with the full dose, irrespective of a past severe reaction to egg, and without any extraordinary precautions
- Guillain-Barré Syndrome within six weeks of influenza vaccination
- Live-attenuated influenza vaccine (LAIV) is contraindicated in:
Children < 24 months of age, due to increased risk of wheezing.
Severe asthma defined as on oral or high-dose inhaled steroids, active wheezing, or medically attended wheezing in 7 days prior
Pregnant women
Immune compromising conditions, due to underlying disease, therapy, or both, as the vaccine contains live attenuated virus
New in 2020, NACI now recommends LAIV as an option for children 2 – 17 with HIV. It remains contraindicated in adults
Why is the seasonal influenza vaccine important for individuals in direct contact with poultry infected with avian influenza during culling operations?
● These vaccines are already approved and available.
● Vaccination against seasonal influenza infection for selected groups at increased risk of exposure to animal influenza viruses could be considered as a way of reducing the probability of human co-infections with both animal and human influenza viruses. Fewer such infections will reduce the opportunities for viral reassortment through antigenic shift and the emergence of influenza viruses with pandemic potential.
Describe the evolution of Influenza A.
o Antigenic drift
- Influenza A has an RNA genome, which is more prone to errors during replication because RNA polymerase lacks proofreading ability.
- High mutation rate due to error-prone RNA replication, and short generation time (rapid replication cycle) speeds up evolution.
Minor changes/mutations in viral surface glycoproteins lead to emergence of new strains of influenza
Responsible for seasonal influenza (i.e., annual influenza epidemic) as previous year’s infection or vaccination provides only partial immunity to new antigens; subtype does not change
o Antigenic shift
Major changes in hemagglutinin and/or neuraminidase subtypes that have never or have not recently been circulating in humans
Responsible for pandemic influenza because a substantial portion of the world’s population has no immunity, can result in a new subtype (e.g. H1N1)
- Influenza A can infect multiple species (humans, birds, pigs, etc.).
- If two different influenza A viruses infect the same host cell, they can swap genetic segments, creating a new hybrid strain.
This sudden genetic reassortment can lead to pandemic strains, like the H1N1 “swine flu” pandemic in 2009.
- Antigenic Drift (Frequent Small Mutations)
As the virus replicates, small random mutations occur in its hemagglutinin (HA) and neuraminidase (NA) proteins, which are the main targets of the immune system.
Over time, these mutations accumulate, causing gradual changes in the virus, allowing it to evade immune responses.
This is why flu vaccines need to be updated regularly.
Explain the vaccination criteria to be considered immune from measles.
Children under 18: 2 doses of measles vaccine after the age of one
Adults over 18: 0 doses if born before 1970, 1 dose if born after 1970
Health care workers: 2 doses of measles vaccine after age one
Military personnel: 2 doses of measles vaccine after age one
Travelers: 1 doses if born before 1970, 2 doses if born after 1970
Students in post-secondary institutions: 1 dose if born before 1970, 2 doses if born after 1970
In the event of an outbreak, immunocompetent individuals with 1 dose only should receive a second dose while awaiting serology results. Health care workers should be excluded while awaiting serology results. Children who have not received second dose should be excluded until they receive second dose.
Exclusion is from 5 to 21 days after last exposure to case.
List 15 health conditions that increase a person’s risk for invasive pneumococcal disease.
Immunocompromising medical conditions:
Congenital immunodeficiencies involving any part of the immune system, including B-lymphocyte (humoral) immunity, T-lymphocyte (cell) mediated immunity, complement system (properdin, or factor D deficiencies), or phagocytic functions
Immunocompromising therapy, including use of long-term corticosteroids, chemotherapy, radiation therapy, and post-organ transplant therapy
HIV infection
Hematopoietic stem cell transplant (recipient)
Malignant neoplasms, including leukemia and lymphoma
Solid organ or islet transplant (recipient)
Nephrotic syndrome
Non-immunocompromising medical conditions:
Chronic kidney disease, particularly those with nephrotic syndrome, on dialysis or with renal transplant
Chronic liver disease, including biliary atresia and hepatic cirrhosis due to any cause
Functional or anatomic asplenia, including sickle cell disease and other hemoglobinopathies, congenital or acquired asplenia, or splenic dysfunction
Chronic cerebrospinal fluid (CSF) leak
Cochlear implants, including those who are to receive implants
Chronic neurologic conditions that may impair clearance of oral secretions
Chronic heart disease, including congenital heart disease and cyanotic heart disease
Diabetes mellitus
Chronic lung disease, including asthma requiring medical care in the preceding 12 months
Environmental or living conditions for individuals:
Who are underhoused or experiencing homelessness
Who live in communities or settings experiencing sustained high IPD rates
Who smoke
With substance use disorders (i.e., cocaine use and injection drug use)
With alcohol use disorder
Who are in residential care, including long-term care homes and residential care homes for children with complex medical needs
Describe how oral poliovirus vaccine can cause disease
OPV can cause illness identical to polio in 2 ways:
1, OPV consists of live, weakened poliovirus that rarely can cause paralysis in the vaccine recipient or their close contacts (referred to as vaccine-associated paralytic polio or VAPP). The risk of VAPP is estimated at one in 750,000 with the first dose of OPV and one in 2.4 million for all doses of OPV.
- If the strain of poliovirus in the OPV circulates in populations with low vaccine coverage, or replicates in an immunocompromised host, it can undergo mutations and revert to a form that causes paralytic disease indistinguishable from wild polio. This is called vaccine-derived poliovirus (VDPV). If VDPV circulates in the community resulting in several detections, it’s referred to as circulating vaccine-derived poliovirus (cVDPV). Genetic sequencing can be used to distinguish the OPV vaccine strains from VDPV. Canada stopped using OPV and began using IPV exclusively as of 1996. cVDPV occurs when a routine immunization program is poorly conducted or there is low vaccination coverage, leaving a significant proportion of the population susceptible to poliovirus
Explain the classification of poliovirus confirmed cases.
Wild virus
* Imported: travel in or residence in a polio-endemic area 30 days or less before onset of symptoms
* Import-related: epidemiologic link to someone who has travelled in or resided in a polio-endemic area within 30 days of onset of symptoms
* Indigenous: no travel or contact as described above. There have been no indigenous cases of poliomyelitis in Canada since 1977
Vaccine-associated virus
* Recipient: the illness began after the patient received OPV
* Contact: case was shown to have been in contact with an OPV-recipient and became ill 7 to 60 days after the contact was immunized
* Possible contact: case had no known direct contact with an OPV-recipient and no history of receiving OPV, but the paralysis occurred in an area in which a mass vaccination campaign using OPV had been in progress 7 - 60 days before the onset of paralysis
* No known contact: case had no known contact with an OPV-recipient and no history of receiving OPV, and the paralysis occurred in an area where no routine or intensive OPV immunization had been in progress
Explain your approach to risk assessment of rabies exposure.
Factors to Consider
Animal
- How prevalent is rabies in the species of animal involved in the exposure? (In North America, rabies occurs mainly in bats, foxes, skunks, raccoons and stray dogs and cats.)
- Is the animal a domestic pet, wild animal or stray animal? (Domestic dogs and cats are less likely to be rabid than stray dogs or cats)
- Is the wild animal available for testing? (In the event of exposure to a fox, skunk, raccoon or bat in areas where rabies is known to occur in these animals, post-exposure prophylaxis should begin immediately unless the animal is available for rabies testing and rabies is not considered likely. Post-exposure prophylaxis should not be delayed beyond 48 hours while waiting for test results in wild animals.)
- Is the dog, cat or ferret available for observation? (If the dog, cat or ferret is healthy after a 10-day observation period, the animal would not have been shedding rabies virus in their saliva and would not have been infectious at the time of the exposure.)
- If the dog, cat or ferret is available, is it clinically healthy? (If the dog, cat or ferret has or develops signs of rabies, post-exposure prophylaxis should be initiated as soon as possible.)
- Was the animal behaving unusually? (Abnormal behaviour in a domestic pet may indicate that the animal is rabid. Generally, it is not possible to assess animal behaviour in wild animals.)
- If the animal is a domestic pet, what is the vaccination status of the animal? (Domestic pets with up-to-date rabies vaccination are unlikely to be infected with rabies.)
- If the animal is a domestic pet, has it been exposed to wild or outdoor animals? (Rabies may be transmitted to domestic pets during exposure to rabid wild or outdoor animals. Indoor animals have little opportunity to be exposed to rabid animals.)
Geographic
- In what geographic area did the exposure occur?
- How prevalent is rabies in the involved species in the geographic area?
- How prevalent is rabies in other animal species in the geographic area?
Exposure
- What was the type of exposure: bite, non-bite (e.g., salivary contact on open skin or mucous membrane), or bat? (Transmission rarely occurs from non-bite exposures. Exception is bats, as bites can be inapparent. Petting a rabid animal or handling its blood, urine or feces are not considered exposures.)
- Can a bite or saliva exposure into a scratch, wound or mucous membrane be ruled out? (Rabies transmission occurs most commonly through a bite.)
- What were the circumstances of the exposure (e.g., provoked or unprovoked attack)? (An unprovoked attack is more likely to indicate that the animal is rabid.)
Person
- What is the age of the exposed person? Is the exposed person able to provide a reliable history? (The history obtained from a child or cognitively impaired adult may be difficult to interpret and, potentially, unreliable.)
- What is the location and severity of the wounds? (Bites on the face, neck or hand are considered higher-risk exposures due to the density of nerve endings in these areas. More severe bites may suggest the animal is rabid and also provide more opportunity for transmission.)
What are the guidelines for following up to ensure adequate serological response in people with syphilis?
Primary syphilis: 4-fold drop at 6 months, 8-fold drop at 12 months
Secondary syphilis: 8-fold drop at 6 months, 16-fold drop at 12 months
Early latent syphilis: 4-fold drop at 12 months
What factors increase the probability of transmission of tuberculosis? What factors increase risk of progression to active TB disease?
- Bacterial burden (smear positivity)
-Cavitary disease or upper lung disease seen on Chest X-ray (NB: bacilli are encased by macrophages in granulomas in lung due to cell-mediated immune response that occurs approx 3-8 weeks after infection) - Laryngeal disease
- Amount and severity of cough
- Duration of exposure of the contact
- Proximity of the contact to the case
- Crowding and poor room ventilation
- Delays in case receiving effective treatment
Highest risk of progression to active TB disease:
- Child, elderly, or immunocompromised contact
- HIV
- Silicosis
Other high-risk: immunosuppressed, transplant, cancer
Discuss when to screen for TB infection, which test to use, and how to interpret in different populations.
Use IGRA for children between age 2 and 10 who have received the BCG vaccine, and for people above 10 who received the BCG vaccine older than 1 year of age. Also when there are not people available who are trained to read TSTs, people are unlikely to return for TST reading, or TST contraindication.
In all other situations TST is preferred.
TST is considered positive above 5 mm for people with HIV, recent contact with TB case, evidence of untreated disease on Xray, transplant patients, people on immunosuppressant drugs, and severe CKD
TST is considered positive at 10 mm for all others.
Discuss the treatment for TB disease, and the criteria for drug-resistant disease and potential reasons for drug-resistant TB.
Goals of treatment are to prevent resistance, kill bacilli, prevent relapse and ensure overall health
Treatment: RIPE
Intensive: Rifampin (turns things orange), isoniazid (risk of hepatitis), pyrazinamide (hepatotoxicity), ethambutol (vision, can be removed once susceptibility testing is back) x 2 months
Continuation: Rifampin, isoniazid, +/- ethambutol x 4 months
Also give pyridoxine to prevent peripheral neuropathy
MDR-TB is resistant to rifampin and isoniazid
preXDR-TB is resistant to rifampin, isoniazid, and fluoroquinolones
XDR-TB is resistant to rifampin, isoniazid, fluoroquinolones, and bedaquiline or linezolid
Reasons for drug-resistant TB: inadequate dosing, incorrect treatment, treatment interruptions, inadequate supervision, poor adherence, living in a country with drug resistant TB
NB: TST/IGRA should also be used to support diagnosis of TB disease in children under the age of 12
Describe strategies for controlling TB
Prevention: Screening high-risk population such as those with HIV infection, BCG vaccine program in high-incidence Northern communities
Diagnosis: Early identification of TB cases, Identification of LTBI in high risk groups such as health care workers
Treatment: Rapid initiation (<72 h) of treatment of pulmonary TB cases with RIPE regimen, public funding of TB medications, Direct observed therapy program, Treatment of LTBI in those at high risk of conversion to active disease
Contact tracing: Evaluation of close contacts of active TB cases, window treatment for exposed children under the age of 5 (with INH or RFP)
Surveillance: National surveillance system Canadian TB Reporting System
Targeted programs: CXR on immigration medical exam for foreign born Canadians, medical surveillance for recently arrived refugees and asylum seekers
Addressing SDOH: Supportive housing programs for marginally housed populations
Other: Public Health/Health Protection legislation
What agents can possibly be used for bioterrorism?
Highest priority
Anthrax
Botulism
Plague
Smallpox
Tularemia
Viral hemorrhagic fever
Brucella
Q fever
Hantavirus
Nipah virus
Describe the recommendations for RSV prophylaxis
NACI
If available, a dose of the RSV monoclonal antibody nirsevimab is recommended for all infants entering, or born during, their first RSV season. Increased risk = immunocompromised, premature born before 37 weeks, social deprivation due to bring FNIM.
Nirsevimab is recommended over palivizumab.
Pregnant people can opt for RSV vaccine at 32-36 weeks to protect unborn child, but not as effective as monoclonal antibody.
For older adults, especially those at higher risk, one dose of either RSVpreF or RSVPreF3 is optimally administered just before the start of the RSV season. Older = 75+, or 60+ who are in LTC.
Additional doses are not yet recommended.
List and describe 10 types of bias
Bias - Systematic deviation of a study’s result from a true value leading to an overestimation (positive bias) or underestimation (negative bias) of the measure of association
Information bias - systematic error in measurement or in collection of study participant information, producing differential accuracy of information by level of exposure, outcome, co-variate (e.g., recall, reporting, observer)
Measurement/misclassification bias: systematic error in classifying subjects with regard to exposure or outcome status
Recall bias: can occur when there is differential recall about past exposure status between those who have the outcome and those who don’t, typically cases recall exposures more accurately than non-cases
Interviewer bias: can occur when the interviewers’ awareness of the subjects outcome status influences how they solicit, record, or interpret information on the subjects exposure status
Selection bias - systematic error in a study resulting from manner in which subjects are selected or from factors that influence ongoing participation in the studying
Sampling bias: can occur when some members of a population are systematically more likely to be selected in a sample than others
Attrition bias: can occur when significant losses to follow-up result in a sample systematically different from the original in terms of exposure frequency or outcome susceptibility
Volunteer bias: can occur because those who volunteer for studies tend to be systematically different from the general population
Nonresponse bias: can occur because of systematic differences between those who participate in studies and those who do not
Publication bias: can occur when the outcome of an experiment or research study influences the decision whether to publish or otherwise distribute it
Incidence-prevalence bias: results from using prevalent cases in a case-control study, because cases must have survived until the point of study recruitment
Healthy worker effect - form of selection bias, generally workers will have less disease than the general population so workers are pre-selected to be healthier, workers who become ill often will retire/quit (self-select out of the workforce)
The population studied would, other things being equal, have a lower mortality rate than the comparison general population (standardized mortality ratio often < 1.0 or not statistically significant)
Can lead you to conclude that a harmful exposure is not harmful
Explain a framework for critically appraising quantitative studies.
Critical appraisal - Systematic evaluation of a study
ODDCHAIR
Objectives: study hypothesis
Design: appropriateness of the design to study question
Definitions: subjects, intervention, exposure, outcomes (PICO)
Collection: measurement tools, sources of bias
Handling: confidentiality, ethics approval
Analysis: appropriate statistical testing
Interpretation: results, internal and external validity, relevance
Reporting: publication bias, conflicts of interest
Describe the process of making GRADE recommendations.
Ratings are High, Moderate, Low, and Very Low.
Recommendations can be Strongly for, Weakly for, Weakly against, Strongly against
o Grade is reduced for: publication bias, inconsistency of results, indirectness of evidence, imprecision, and risk of bias
o Grade is increased for: large magnitude of effect, dose-response gradient, and when all residual confounding is expected to reduce the effect size
What are the different data collection methods in qualitative research?
- Participant observation: Field strategy that simultaneously combines document analysis, interviewing, direct participation and observation and introspection
- Interviews: structured conversation and a purpose
- Individual interviews: structured, unstructured, semi-structured, in-depth
- Group interviews: focus groups, consensus panel (Delphi), natural group, community interview
- Nominal groups: highly structured technique designed to keep personal interaction at a minimum level during the process of new idea generation, while maximizing the individual contribution of each respondent. Avoids problems of group dynamics seen with Delphi and focus groups
- Focus groups: collect data through group interaction on a topic determined by the researcher. It is the researcher’s interest that provides the focus, whereas the data themselves come from the group interaction
- Documents: text (media articles, research articles, diaries, etc.), photographs, videos
List and describe 8 types of sampling in qualitative research.
o Typical case sampling: sampling the usual cases of a phenomenon
o Deviant case sampling: sampling the most extreme cases of a phenomenon
o Critical case sampling: sampling cases that are predicted to be particularly illuminating, based on theory or previous research
o Maximum-variation sampling: sampling as wide a range of perspectives as possible to capture the broadest set of experiences
o Confirming-disconfirming sampling: sampling cases whose perspectives are likely to confirm or challenge the researcher’s understanding of the phenomenon
o Theoretical sampling: used in grounded theory approach, sampling cases whom the researchers predict would add new perspectives to those already represented in the sample
o Purposive sampling: sampling cases who have the most information about the topic (subtypes: critical case, opportunistic - follows new leads, stratified purposeful sampling)
o Snowball sampling: sampling cases of interest from people who know people who know which cases are information rich
o Convenience sampling: saves time, money and effort at the expense of information and credibility
What are the possible sources of surveillance data?
o Clinical data: lab, diagnoses, prescriptions
o Surveys: CCHS
o Insurance data: MD claims, drug claims
o Administrative data: hospital discharge
o Vital statistics: births, deaths
o Registries: cancer, trauma
o Digital media: social media, news media
Explain the different between QALYs and DALYs.
Quality-Adjusted Life Year measures the quantity and quality of life lived.
Disability-Adjusted Life Year measures the health gap between the current state of population health and an ideal situation where everyone reaches the age of standard life expectancy in perfect health.
-QALY measures health gains due to intervention, whereas DALY measures health loss due to illness, disability, or premature death.
-Higher QALY and lower DALY are better
- QALY focuses on quality and quantity of life, whereas DALY focuses on disease burden (disability + early death).
- QALY is used in healthcare cost-effectiveness analysis, whereas DALY is used in public health and global disease burden studies.
- QALY: Patient-centered (individual quality of life), DALY: Population-centered (overall impact of disease).
List 12 categories of health indicators and one example for each.
Demographics - Age
Socio-economic status - Income
Living and working conditions - Work stress
Geography - Urban vs. Rural vs. Remote
Mortality and Morbidity - Cause of death
Health and Wellness - Self-rated health
Health Services Seeking Behaviours - Screening
Health Behaviour - Tobacco use
Elements of behaviour change - Awareness of climate change
Social environment - Food affordability
Natural and built environment - Presence of green space
Socio-political aspects of environmental change - Access to early warning information
What is social network analysis?
-Definition: 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?)
Describe the legislative standards and responsibilities at different levels for drinking water.
Federal
- Responsible for water for national parks armed forces, border crossings, First Nations
- Legislation: Canada Water Act, Canadian Environmental Protection Act, Fisheries Act
- Health Canada has created Canadian Drinking Water Quality Guidelines, which outlines basic parameters of water systems and maximum allowable concentrations of substances and contaminants
- Health Canada also has Guidelines for Recreational Water Quality for any body of water used for recreation
Provincial: Responsible for oversight of drinking water quality, and performance monitoring
Municipal: Providers of water, funding for infrastructure
What is source water protection?
Source water: surface water (river, lakes), ground water (fresh water beneath Earth’s surface), and aquifers (sand/gravel bedrock saturated with water)
Threats to source water:
Natural - rainfall, wildlife
Manmade - agricultural runoff, mining, recreation, urban development, wastewater
Source water protection: Protection of surface water and ground water from vulnerabilities, through methods such as restricting access, restricting development, inspection programs, waste management, storm water and landfill runoff diversion
Outline an approach to addressing contaminants in drinking water
- Confirm accurate information (with testing lab or system operator)
- Assemble team by notifying relevant authorities (PHU, Ministry of Health, Ministry of Environment)
- Investigate system by re-sampling
- Gather data (turbidity, chlorine residuals)
- Operationalize corrective action - increase disinfection, flush lines, repair equipment, issue public notice
E. Coli and fecal coliforms require immediate action
Low chlorine residuals require urgent action
Chemical contaminants require investigation, especially at low levels
List and describe the steps in drinking water treatment
Some People Can Find Safe, Fresh Drinking Water
S - Screening: Water forced through screens to remove debris
P - Pre-chlorination: Addition of chlorine to source water to stop biological growth
C - Coagulation: Positively charged chemicals bind to negatively charged debris
F - Flocculation: Gentle mixing increases bound particle size to form floc
S - Sedimentation: Floc settles out at the bottom of the water supply
F - Filtration: Clear water passes through filters to remove particles including bacteria, parasites, viruses, chemicals
D - primary Disinfection: Kills or inactivates bacteria, viruses and pathogens before water enters the distribution system
W - Wait, secondary disinfection: Longer-lasting treatment as water moves through pipes
Compare and contrast primary disinfection methods.
Chlorine
-Pros: Cheap, easy to monitor chlorine residuals
-Cons: Harmful byproducts (chloroform, trihalomethane), can impact taste/odor, does not inactivate crypto
Ozone
-Pros: High quality disinfectant, inactivates crypto, good taste/odor
-Cons: Expensive, energy-intensive, requires secondary disinfection as no residual
UV radiation
-Pros: Inactivates crypto, simple, good taste,
-Cons: No residual so needs secondary disinfection, large particles can shield microorganisms from disinfection, can be expensive
Explain the 3 types of drinking water advisories and give examples. When might you issue a precautionary boil water advisory? When can a BWA be ended?
Do not use: Issued when there is a contaminant that can have harmful effects from dermal or inhalational exposure. e.g. gasoline, hazardous waste
Do not consume: Issued when there is a contaminant, typically chemical, that could cause concern with ingestion but not dermal exposure e.g. heavy metals, nitrates
Boil water advisory: Issued when there is a microbe contaminant, or turbidity (which suggests microbe contaminant. Includes bacteria, viruses, parasites
Reasons to consider issuing precautionary BWA: planned repairs that may cause a significant pressure drop, persistent presence of total coliforms despite remediation, minor equipment malfunction, changes to source water, unexpected changes to pressure, turbidity or residuals, broken water main
Can end BWA when:
-2 negative sets of bacterial samples at least 24 hours apart
-Operational malfunction corrected
-Outbreak ended
Provide recommendations for private well owners for ensuring safe drinking water.
-Test every 6 months
-Locate well far from septic tanks, manure, farmyards, petroleum tanks, pesticide storage
-Treat water if test results show contamination
-Regularly maintain well
For which drinking water contaminants is the goal concentration zero?
- Arsenic (causes cancer)
- Lead (neurocognitive effects in young children)
- Total coliforms (indicator of well-functioning drinking water treatment system)
- E. coli (indicates presence of fecal contamination)
- Haloacetic acid (chlorine byproduct, causes liver cancer)
Describe the federal legislation and responsibilities for food safety.
Safe Food for Canadians Act: Food safety oversight, authority to CFIA to take enforcement actions, licensing requirements, traceability
Food and Drug Acts: Regulates any item sold as a food or drink that doesn’t make a health claim, includes food labelling, advertising, packaging
Health Canada is responsible for oversight of Food and Drugs Act
CFIA is responsible for oversight of Safe Food for Canadians Act, and investigates foods responsible for foodborne illness outbreaks, and initiates food safety recalls
PHAC does public health surveillance and coordination during cross-provincial foodborne illness outbreaks
Provinces and Territories: Enact and enforce food safety laws within jurisdiction, including inspection programs, food handler requirements, etc.
What are the incubation periods of the common enteric illnesses?
Short:
Salmonella (12-36 hours)
Vibrio cholera (12 hours)
Bacillus cereus toxin (1-16 hours)
Clostridium perfringens toxin (6-24 hours)
Clostridium botulinum toxin (12-72 hours)
Norovirus (12-48 hours)
Medium:
Campylobacter (2-5 days)
Shigella (1-4 days)
Yersinia enterocolitica (3-7 days)
Shiga toxin E. coli (1-4 days)
Cryptosporidiosis, cyclosporiasis,and giardia (around 7 days)
Long:
Listeria (2-3 weeks)
List 5 food safety controls.
Preparation: temperature (keep out of danger zone 4-60ºC), cooking kills heat-sensitive bacteria (in general target 74 C), pasteurization (mild heat to inactive pathogens)
* Storage: refrigeration (slows most microbial growth except Listeria and Yersinia), freezing (reduces bacterial numbers but no effect on spores)
* Preservation: canning (seal in sterile container), curing (using nitrites to prevent microbial growth in meats)
* Irradiation: ionizing radiation to prevent microbial growth, done for flour, wheat
* Sanitation: to keep surfaces and equipment clean
* Other: employee training, pest control, food storage, recalls
“Clean, Separate (Cross-Contaminate), Cook, Chill”
List 8 reasons to start a food safety investigation. What are the steps of a food safety investigation?
- Suspected or confirmed foodborne illness outbreak
- Food test result
- Food inspection finding
- Complaints from consumers
- Company-initiated recall
- Recall in another country
- CFIA assessment
- Referral from other jurisdiction
Step 1: Trigger
Step 2: Food safety investigation (Food, lab, epi)
Step 3: Health risk assessment (HI DR EARC, Hazard identification, Hazard characterization, Exposure Assessment, Risk Characterization)
Step 4: Decision made and recall process
Step 5: Follow-up
Describe the key components of the IMS system.
Incident Management System (IMS): organizational structure to coordinate response in an emergency (interoperable across jurisdictions)
Key components include organizational chart (sections, units) and after-action report (documents incident response and recommends improvements)
Key functions:
-Commander (in charge), supported by safety, information (comms) and liaison officers
-Finance and administration chief (pays)
-Logistics chief (gets), includes human resourcing
-Operations chief (implements)
-Planning chief (prepares), monitors and surveils help guide response
Single command is one jurisdiction, whereas Unified command is multijurisdictional but with one spokesperson.
Incident Action Plan outlines objectives to be completed within the Operational Period which is usually less than 24 hours. The chiefs all meet following the operational period.
Emergency Operations Centre (EOC): Facility where Incident Command is organized and coordinated
What is an urban heat island?
Urban heat island: area that is routinely hotter than surrounding areas as it generates and retains heat from buildings, human and industrial activities, and other factors.
Due to black asphalt, decreased natural land coverage from vegetation, trapping of radiation by buildings, human activities that produce heat such as driving.
Solutions include green roofs, ventilation corridors in cities, active transportation, greenhouse gas reduction.
What is a heat alert and response system?
Some communities in Canada and internationally are developing heat alert and response systems (HARS) to prepare for extreme heat events. These systems are made up of 5 parts:
- Community mobilization and engagement - determines community needs, identifies an agency to coordinate the heat response as well as stakeholders to carry out the response actions
- Alert protocol - Identifies weather conditions that could result in increased morbidity and mortality in the region. Trigger is usually a community-specific numerical value, reflecting local meteorological conditions (temperature, humidex, +/- air pollution, air masses), community needs, response capacities, and existing vulnerabilities
- Community response plan - Includes mobilizing partners, individuals, and assisting vulnerable people (e.g. opening cooling centres, cancelling outdoor events
- Communication plan - Increases awareness about heat health impacts, delivers messages to public about actions to take (e.g. “spend time indoors today”, “check on your elderly neighbours”, “reschedule your outdoor activities”, “drink lots of cool water”
- Evaluation plan - Assesses HARS activities and makes improvements. Process evaluation looks at whether the HARS was implemented as planned, and outcome evaluation looks at whether the program impacted morbidity and mortality and public awareness.
Other preventive actions to reduce heat health risks: reduce urban heat island effect, promote healthy communities and individuals, modify transportation policies, improve social capital and social networks, build climate resiliency, assess heat-health vulnerability and reduce green-house gases.
List 5 key populations disproportionately affected by STBBIs
- People living with HIV and Hep C
- Indigenous
- Gay and bisexual men who have sex with men
- People who use drugs
- Transgender persons
- People who have been incarcerated
- People who engage with sex work
List 4 groups that are at increased risk of iGAS.
- Skin breakdown
- Immunocompromised or chronic conditions
- Young children and older adults
- Peripartum women
- People who inject drugs
- Postsurgical patients
- Preceding varicella or influenza
Contacts should self-monitor for 30 days.
What are the components of influenza surveillance in Canada?
Through FluWatch
- Geographic spread of influenza like illness
- Lab confirmed influenza detection
- Syndromic surveillance
- Outbreak surveillance
- Severe outcome surveillance
- Influenza strains and antiviral resistance
- Influenza vaccine monitoring
What are the criteria for a good screening test?
“SCREEN IT”
S – Safe
C – Cost-effective (Low cost)
R – Recognizable latent or early symptomatic stage
E – Easy to perform (Simple)
E – Effective (High sensitivity & specificity)
N – Non-invasive (Acceptable to patients and clinicians)
I – Intervention available (Treatable)
T – Trustworthy results (High positive predictive value)
What are the principles of incident management systems?
MISSUIFS
Modular - Discrete related components
Interoperable - Functions across jurisdictions
Standardized - Shared structures and terminology
Simple - Eliminate elements when no longer needed
Unity of Command - Each person at every level reports to only one clearly designated supervisor
Integrated Communication - Standardized way to communicate with stakeholder
Flexible and Scalable - Can be expanded to address any size of incident
What is health promotion?
Health promotion is the process of enabling individuals to increase control over, and to improve, their health.
Discuss the risk factors for and presentation of congenital syphilis.
Risk factors: Lack of prenatal care, multiple partners, substance use disorder, homeless, incarcerated
Presentations:
-Fetal: miscarriage, stillbirth, prematurity, neonatal death
-Neonatal: Skeletal malformations, anemia, jaundice, vision problems, hearing loss
Discuss PFAS
Forever chemicals. Very long half-life, persist in environment and bioaccumulate in animals.
Found in nonstock coating, firefighting foam, electronics, clothing, carpets.
Ubiquitous in Canadian human blood samples.
Possible carcinogen, liver damage, endocrine disruptor.
May be related to prematurity, low birthweight in fetuses.
Some PFAS are banned, MAC has been set for drinking water.
Discuss wildfires.
Proximate causes: lightning (50%), drought, extreme heat, human activity
Distal causes: climate change, biodiversity loss, development
Health risk: physical and mental health, heat and smoke
Discuss health inequities faced by FNIM.
-Lower life expectancy by up to 10 years
-Increased infant mortality
-Increased rates of tuberculosis
-Increased rates of RSV
-Increased rates of intimate partner violence
Who is most at risk in the toxic drug crisis.
-Males
-Age 30-39
-Indigenous
-Homelessness
-Low educational attainment
-Trades occupation
-Concurrent disorders
Discuss food insecurity.
Household food insecurity, as this problem is measured and monitored in Canada, refers to the inadequate or insecure access to food due to financial constraints.
Food security is on the rise, almost 1 in 5 households are food insecure.
Food insecurity is a marker of material deprivation, and is tightly linked to low income.
Black and Indigenous off-reserve were more likely to food insecure.
Household food insecurity is one of the strongest predictors of poor health.
What were the major findings and recommendations from the Walport report on Covid-19?
- Canada must act now to be prepared for the next health emergency
- Greater pan-Canadian coordination of research and science advice is required
- A greater focus needs to be placed on equity and addressing social and structural determinants of health
- Indigenous health expertise must be embedded in research coordination and science advice processes
Key Recommendation:
- Ensure surveillance systems work in real time
-Improve external communication of advice from federal advisory bodies
-Improve coordination of health emergency related research
-Increase research investments to address needs of disadvantaged groups and Indigenous people
-Meaningfully engage with Indigenous communities on health data strategies
-Formalize the role of chief science advisor in legislation
Discuss factors to consider in deciding whether to evacuate a community or advise them to shelter-in-place during an emergency.
Agent factors:
- Length of exposure
- Rate of release
- Type of substance
Host factors:
- Population density
- Vulnerability to hazard (LTC, schools)
- Ability to evacuate (bedbound people in LTC)
Environment factors:
- Wind speed
- Temperature
- Air exchange rate indoors
- Time of day
Logistical factors:
- Can evacuation occur before exposure (if so, evacuate)
- Can population be adequately sheltered before exposure (if so, shelter-in-place)
- PESTLE
- Hazard vs outrage
Expertise:
- Consult with local, provincial, and federal partners
What is a health indicator?
Health indicators are measures of health and of the factors that affect health. They are numbers and statistics that can provide a basis for comparison.
What are the different types of health care quality measures?
Structural measures: Structural measures give consumers a sense of a health care system’s capacity. For example, number of physicians
Process measures: Process measures indicate what a provider does to maintain or improve health. For example, percent of people receiving mammograms.
Outcome measures: Outcome measures reflect the impact of the health care service or intervention on the health status of patients. For example, rate of nosocomial infections, or hospitalization mortality rate.
What are important priorities to consider for a national school meal program?
- Focus on health and avoidance of corporatization
- Preventing stigma through universal access
- Ensuring cultural safety
Discuss actions to take at each stage of the emergency management cycle for wildfires.
- Prevention/mitigation: Public communication on human actions that increase wildfire, climate change mitigation and adaptation
- Preparedness: Emergency response plan, stockpiling respirators
- Response: IMS, provide advice to public on who is most at risk during fires, cancel outdoor events, decrease time outdoors, respirator masks to prevent PM2.5 inhalation for those who need to be outdoors, HEPA filters indoors
- Recovery: After action repot, continue to survey for health impacts
Describe the categories of information security controls.
Administrative controls: Policies and procedures that maintain information security
Technological controls: Electronic algorithms that maintain information security (e.g. firewalls, passwords, encryption)
Physical controls: Physical barriers that maintain information security (e.g. building access cards, security cameras)
When might a health unit want to enact a continuity of operations plan?
- Pandemic
- Cybersecurity breach
- Power outage
- Labour disruption
- Bioterrorism incident
- Catastrophic natural event (earthquake, wildfire, flooding)
Describe your approach to a privacy breach.
Confirm and contain: confirm the breach, ensure no ongoing risk
Assess: What information was breached
Notify: Privacy commissioner, Provincial public health authorities
Investigate: Root cause analysis (fishbone diagram, 5 whys, pareto chart)
Implement change: controls, discipline
Describe your approach to a hazardous spill.
SIP-RaSN-PiE
- Secure the scene
- Hazard Identification: using knowledge of personnel, MSDS
- Notify Partners: Should include ministry of environment, first responders, municipality. ministry of health
- Rapid risk assessment: exposure assessment, context assessment, risk characterization
- Spill management: managed by first responders
- Community notification and education: includes evacuation or shelter in place orders if necessary
-Patient transport and treatment
-Evacuate or shelter in place
Describe the public health system in Canada.
Purpose: To achieve optimal health and well-being for all people living in Canada
Aims: Enhance the health status of populations, protect against health emergencies and mitigate the impacts, achieve equitable health outcomes
Essential public health functions: Health protection, health promotion, health surveillance, emergency preparedness and response, population health assessment, disease and injury prevention
Building blocks: Policies and programs, research and evidence, medical and digital health technology, human resources, financing, governments/leadership
Provide guiding principles for Canada’s public health system as discussed in the CPHO report.
Trustworthy - accountable and transparent
Evidence-informed and effective
Population health approach
Participatory - include community and citizen participation
Equity-driven
What are the goals of the Paris Agreement?
International treaty whose goal is to keep global temperature increase to 2 C (or ideally 1.5 C).
List Communities that are Disproportionately Affected by Emergencies
- People experiencing homelessness
- Populations that are racialized
- People living with mental health conditions or substance use disorders
- People with multiple and overlapping barriers to good health
- Populations that experience social, economic, environmental, or health inequities, including those related to racism, discrimination and colonization
- First Nations, Inuit, and Metis communities (specific to climate-related emergencies, such as wildfires/floods)
Define hazard, emergency, and disaster.
Hazard: An event, activity or agent that has the potential to cause damage or disruption
Types of hazards:
Meteorological - heat, cold, wildfire, hurricane, flood
Biological - infectious diseases
Geological - earthquake, landslide, tsunami, volcano
Conflict - terror attack
Technological - hazardous chemical, transport accident
Social (not a formal emergency) - toxic drug crisis, mental health, racism
Emergency: A serious event requiring immediate action to protect health and safety, and limit damage to property and environment
Disaster: Critical event that causes widespread disruption to everyday life and essential functions
What is the difference between differential exposure, vulnerability and capacity?
Differential exposure – when some populations or communities are more likely to experience a hazard than others
e.g. living in area prone to flooding
Differential vulnerability – how susceptible a population or community is to being impacted by a hazard
e.g. individuals with pre-existing mental health conditions may be more likely to experience adverse mental health impacts after emergencies
Differential capacity – unequal access to the power and resources needed to effectively react during an emergency
e.g. people with disabilities may face accessibility barriers to evacuation or other response efforts
What is a community?
Community – Takes various forms including location-based communities and social connection communities based on relationships. Also includes groups or networks with shared experiences, identities, or professional backgrounds.
What are the main UNDRIP themes?
UNDRIP can provide road map for emergency management professionals when working with First Nations, Inuit and Metis communities. The following four theme represent the minimum standards for prosperity, dignity, and well-being of Indigenous Peoples:
- The Right to Self-Determination (e,g, Assembly of First Nations advocacy for First Nations communities to assume control of their own emergency management including funding comparable to municipal services)
- The Right to Cultural Identity
- The Right to Free, Prior, and Informed Consent
- Protection from Discrimination
What are some benefits of vaccination?
-Decrease infectious disease morbidity and mortality
-Ease strain on healthcare resources
-Help strengthen health and social care infrastructure
-Lessen the incidence of some chronic conditions
-Preserve wellbeing and independence in older adulthood
-Foster greater health equity
-Mitigate the spread of antimicrobial resistance
-Reduce costs to the healthcare system
-Lower the number of work or school days missed due to illness
-Protect population health through herd immunity
-Provide early and ongoing connections with healthcare providers
-Contribute to economic productivity
Define misinformation and disinformation
Misinformation is a broad term used to refer to many types of false or misleading information, some of which may exist without malicious intent.
Disinformation is incorrect information that is created or spread specifically to deceive or mislead.
What are the roles of public health in an emergency?
- Surveillance/epidemiology of communicable diseases of PH significance
- Assessment of population health impacts
- Population-based interventions
- Public communication and education
- Leadership and coordination for specific situations/emergencies
- Community recovery
- Continuity of operations planning (COOP) and execution
Discuss the factors to consider in an exposure assessment.
Exposure assessment: Measuring or estimating human exposure to an environmental agent
Source of contamination: point, disperse
Environmental media: air, water, food, soil, product
Location: home, work, recreation
Target/vulnerable population
Route: ingestion, inhalation, dermal contact, IV
Magnitude and duration of exposure
o Methods
Indirect (estimation/modelling): questionnaires, imputation/models
Direct (measurement): continuous personal exposure monitoring, biomarkers
Discuss the health impacts of pesticides
Organophosphates and carbamates: both cause muscarinic effects (MUDDLES): miosis, urination, diarrhea, diaphoresis, lacrimation, excitation, salivation
Describe an approach to use when thinking about obtaining information about a public health issue, hazard, or risk
5 W’s
Who: Target audience/population, or population at risk
What: What exactly is the issue
Where: Location
When: Time of day, weather conditions, wind conditions, temperature, incubation period, period of communicability, etc.
Why: What is the cause of the issue, why does it exist, why is it important to address
Describe the budget cycle and components of a budget.
PLEA for it to work out!
- Preparation - Estimate costs of providing services, justify requests
- Legislative consideration and approval (e.g. Board of Health)
- Execution
- Audit: internal (review compliance, processes finances), external (external auditor reviews financial statements)
Components:
- Budget to date if showing status of budget partway through year
- Actual spending to date which should include anticipated spending
- Variance between budget and actual spending
- Projected position at year end
- Comparison to prior year spending
Highlights of areas of over or under spending
- Divide into major categories e.g. by operating and capital expenditures, program-based
Describe the balanced scorecard approach.
Balanced Scorecard for Public Health
- Provides an organization’s management with an overarching view of risks and benefits of strategic and operational decisions
- Knowledge gleaned from scorecard results can facilitate change and quality improvement, provide an accountability mechanism, and support planning
- The following framework was proposed for the development of Ontario’s first balanced scorecard for public health to measure performance in four quadrants:
Health determinants and status
- Markers that gauge the overall health of the population, tend to change slowly over time and therefore it is not realistic to expect to see change within one year
- Where there are positive changes in health status, it is hard to attribute the improvements to public health action, as other influencing factors must first be ruled out
Community engagement
* Outreach and advocacy have resulted in positive change as a result of efforts to raise awareness of important public health issues (community water fluoridation, infection prevention and control, and determinants of health) and to work with community partners to address these issues.
Resources and services
* Having staff specifically assigned to move initiatives forward contributes significantly to success in meeting identified outcomes.
Integration and responsiveness
* Example integrating a Health Equity Impact Assessment into the Business Continuity Plan
List and describe 10 ethical principles to consider when implementing a policy or program.
Trust - The foundation of all relationships, whether between persons, persons and organisations, or citizens and government.
Justice - Treating all persons and groups fairly and equitably, with equal concern and respect, in light of what is owed to them as members of society.
Respect for persons, communities and human rights - Recognizing the inherent human rights, dignity, and unconditional worth of all persons, regardless of their human condition.
Promoting well-being - Individuals, organizations and communities have a duty to contribute to the welfare of others.
Minimising harm - Consider precautionary principle, reciprocity, proportionality, and effectiveness.
Working together - Because individuals are part of a greater whole, whether an organization, a local community, a nation or the global community, collective action in the face of common threats is justified.
PROCEDURAL FACTORS (RATIO)
Responsiveness: decisions are revisited and revised as new information emerges;
Accountability: decision makers are answerable to the public for the type and quality of decisions made or actions taken;
inTersectionality: an intersectional lens is applied to deliberation and decision making.
Inclusiveness: groups and individuals who are most likely to be affected by a decision are engaged in the decision-making and planning processes to the greatest extent possible;
Openness and transparency: decisions are made in such a way that stakeholders know, in a full, accurate and timely manner, what decisions are being made, for which reasons, and what criteria were applied, and have the opportunity to provide input;
What are the Spaulding criteria?
CRITICAL Equipment/Device - Enters sterile tissues, including the vascular system. Needs cleaning followed by Sterilization. e.g. surgical instruments, biopsy instruments
SEMICRITICAL Equipment/Device - Equipment/device that comes in contact with non-intact skin or mucous membranes but does not penetrate them. Needs cleaning followed by High- Level Disinfection (as a minimum), sterilization is preferred. e.g. Respiratory therapy equipment, anaesthesia equipment
NONCRITICAL Equipment/Device - Touches only intact skin and not mucous membranes, or does not directly touch the client/patient/resident. Needs cleaning followed by Low- Level Disinfection (in some cases, cleaning alone is acceptable). E.g. ECG machines, oximeters, bedpans, urinals
Describe the composition and effects of smog and acid rain.
Smog: Mixture of pollutants but the main two components are particulate matter and ozone. Leads to poor air quality and reduced visibility
Acid rain: SO2 + NO + water -> sulphuric (SO4) and nitric acids (NO3) -> wet deposition (precipitation) and dry deposition (gases, particles). Acidifies lakes and streams making water unsuitable to some fish, and other plants and animals. Damages forest soils by stripping soil nutrients and increasing release of toxic chemicals such as aluminum.
Distinguish between substance use, abuse, and disorder.
o Substance use: The use of a psychoactive substance for various reasons including spiritual, medicinal, individual, and social. Can be beneficial, non-problematic, harmful, or substance use disorder
o Substance abuse: Problematic use of a psychoactive substance (e.g. inability to fulfil responsibilities; dangerous use; legal, societal, or family problems)
o Substance dependence: Physical, mental, and behavioural problems associated with use. Defined by tolerance, withdrawal, a desire to quit, and use despite consequences
o Substance use disorder: Range of illnesses, based on the type of substance consumed, all of which are categorized by similar DSM-5 criteria. Range in severity from mild to severe and are characterized by significant distress and impaired functioning
o Addiction: Problematic pattern of use leading to clinically significant impairment or distress. Manifested by craving, loss of control, compulsive use, use despite consequences
o Harm reduction: Policies, programmes, and practices that aim to minimize negative health, social and legal impacts associated with drug use, drug policies and drug laws
What approach would you take in responding to a cold chain breach?
Vaccine cold chain: Process used to maintain optimal conditions during the transport (including from manufacturer to distributor to depot to public health unit), storage, and handling of vaccines, within the safe temperature range of 2°C to 8°C, from manufacturer to patient including contingency plans for cooling failures
Vaccine cold chain breach: Occurs when vaccine is exposed to a temperature outside the required temperature range of +2 °C to +8 °C for any period of time
o Information to obtain during a cold chain breach:
-vaccine name, lot number, expiry date
-date and time of incident
-issue (e.g., exposure to inappropriate temperature or exposure to light)
-length of time vaccine may have been exposed to inappropriate conditions
-whether any of the affected vaccines had been administered and if so, to whom
-the room temperature where the vaccine storage unit is located
-current temperature inside the vaccine storage unit (and freezer)
-minimum and maximum temperature readings inside the vaccine storage unit (and freezer)
-presence of water bottles in the refrigerator (storing filled water bottles on the lower shelf and the door of a refrigerator will help maintain an even, stable temperature inside the refrigerator)
o Actions to take
Notify vaccine coordinator
Isolate and label vaccines with “Quarantine” and date of cold chain break
Store the vaccine at appropriate temperatures and monitor the storage unit conditions
Transfer vaccine to an alternative storage unit/cooler if storage unit has failed (breakdown, power outage, human error, etc.)
Identify the source of the failure (breakdown, power outage, human error)
Fill out appropriate forms according to jurisdictional/local guidelines
Contact jurisdictional/local public health office for further guidance
What are the public health roles for improving health equity?
Role 1: Assess and report
Assess and report on a) the existence and impact of health inequities, and b) effective strategies to reduce these inequities.
Assess and report includes public health surveillance activities, specifically “the ongoing systematic collection, analysis, interpretation and dissemination of health data for the planning, implementation and evaluation of public health action” (Choi, 2012). It also includes assessing and reporting effective strategies to reduce inequities.
Role 2: Modify and orient interventions
Modify and orient interventions and services to help reduce inequities, with an understanding of the unique needs of populations that experience marginalization.
It is essential for public health programs to reach populations that experience marginalization. Programs and services must be planned, implemented and evaluated with a consideration of equity.
Role 3: Partner with other sectors
Partner with other government and community organizations to identify ways to improve health outcomes for populations that experience marginalization.
Because most of the social determinants of health lie outside of the health sector, working with multiple partners - including government, community organizations, communities, and specific populations - is an essential part of public health practice, especially considering that differences in our health are influenced by economic and societal factors.
Role 4: Participate in policy development and advocacy
Lead, support and participate with other organizations in policy analysis and development, and in advocacy for improvements in health determinants and inequities.
Participating in policy development and advocacy is a key role for public health to improve health equity because policies that promote health improve conditions where people live, work and play.
What are the elements of IPAC?
- Risk assessment
a. Hazard/Risk identification; likelihood of exposure
b. Surveillance - Risk control
a. Routine precautions (PPE, hand hygiene, sharps disposal)
b. Transmission based precautions (contact, droplet, airborne)
c. Immunization
d. Environmental cleaning; Sterilization - Education and training
- Outbreak management
- Evaluation
What are the program elements of IPAC?
- Risk assessment
a. Hazard/Risk identification; likelihood of exposure
b. Surveillance - Risk control
a. Routine precautions (PPE, hand hygiene, sharps disposal)
b. Transmission based precautions (contact, droplet, airborne)
c. Immunization
d. Environmental cleaning; Sterilization - Education and training
- Outbreak management
- Evaluation
