MPH Review: Round 2 Flashcards
1
Q
Define Public Health
A
Science and art of preventing disease, prolonging life, and promoting health and efficiency through organized community effort- Winslow
2
Q
What are the two fundamentals of Epidemiology
A
Diseases do not occur by chance
Diseases are not distributed randomly through a population- indicates how/why the disease process occurred
3
Q
What are the objectives of epidemiology?
A
Identify etiology and risk factors Determine extent within a community Study history and prognosis of disease Evaluate existing and new preventative/therapeutic measures Foundation for policy
4
Q
What were the three most prevalent disease in 1910?
What were the three most prevalent diseases in 2010?
A
Pneumonia/Influenza, TB, GI
Heart Dz, CA, Other
5
Q
Mortality from all diseases declined by _% between 1900 and 2010?
A
54%
6
Q
What are today’s risk factors for causing death?
A
Heart Dz
CA
CVA
COPD
7
Q
What are today’s lifestyle risk factors?
A
Tobacco/ETOH Nutrition Obesity Inactivity Exposures
8
Q
What do immunizations do?
A
Prevents: DIDOST Invasion Destruction Damage Over stimulation Opportunistic infections Toxin susceptibility
9
Q
What are the 3 types of immunity?
A
Active- developed Abs/response from exposure or vaccine leading to memory
Passive- Abs transferred as immune globulins and only last a short time w/out memory.
Herd- protection from those around w/ Abs/response cells and prevent diseases from developing
10
Q
What are the three components of vaccines?
A
Adjuvant- enhances vaccine to reduce amount of active component required and fewer doses due to stronger immune response
Residual- materials used to grow virus or bacteria in a vaccine
Preservatives/Stabilizers: prevent contamination and maintain potency in multi-dose vials
11
Q
What are the three forms of adjuvant in vaccines?
A
Shingris
Heplisav
FLUAD
12
Q
What is the primary form of adjuvant used in US vaccines?
A
Alum
13
Q
What are the three types of residual materials found in vaccines?
A
ABX
Egg protien
Gelatin
14
Q
What are the four types of preservatives/stabilizers used in vaccines?
A
Thimerosal
Formaldehyde
MSG
Pheyoxyethanol
15
Q
For PTs ages 2-59mon, what is the standard vaccine schedule for pneumoccocal vaccines?
A
PCV 13- 2, 4, 6, 12-15mon
16
Q
What is the catch up dose schedule for pneumococcal vaccines in non compromised PTs?
A
1-4 doses depending on age and past doses
1-2 doses for kids 60-71 months with underlying conditions
17
Q
If PPSV23 has been given previously, how long must be waited prior to giving PCV 13 in a compromised, hemoglobinopathy, asplenia, renal failure/syndrome PT?
A
8 wks
Then 5 years before giving PPSV 23
18
Q
If PCV 13 series is completes or at least one dose is given at 6yrs or older, what is the next step for vaccinations?
A
None are needed
19
Q
What form of the pneumococcal vaccine is given to PTs w/ Diabetes, Heart Dz or Lung Dz?
A
PPSV 23
20
Q
What is the vaccine regiment for immune compromised, HIV, hemoglobinopathy, asplenia, chronic renal failure/syndrome?
A
PCV 13 Wait 8 wks PPSV 23 Wait 5 yrs PPSV 23
21
Q
What is the pneumococcal vaccine schedule for PTs with CSF leaks or cochlear implants?
A
PCV 13
Wait 8wks
PPSV 23
22
Q
Define Contraindication to a vaccine
A
Condition that increases the risk of a serious adverse reaction
23
Q
What are the four true contraindications?
A
Anaphylactic reaction
Encephalopathy
Pregnancy
Immunocompromised
24
Q
Define Precaution
A
Condition that may increase the risk of an adverse reaction or affect the vaccines ability to produce immunity
25
What are the four precautions?
Prior allergic reaction
Illness
Pregnancy/breast feeding
Hx of Guillain-Barre
26
Which vaccines are recommended during pregnancy?
Optimally, when are these given?
Inactivated influenza
Tdap
During every pregnancy
27-36wks
27
Define Adverse Reaction
Effect caused by vaccine
Confined to local injection site
Body reactions of fever, malaise, irritable, rash
Gelatin, eggs, ABXs reactions
28
Define Adverse events
Any event following a vaccination
| May be a true reaction or coincidence
29
Adverse events after vaccines include ?
```
Inflammation
Hypersensitivity
Cellulitis
SIRVA
Derm
```
30
What are the four types of dermatologic adverse events from vaccines?
```
Benign Cutaneous Eruption-
Generalized vaccinia
Non-viral pustulosis
Accrurual papuloveicular eruption
Erythema multiforms
```
31
What is the name of the adverse reaction from smallpox vaccine involving the heart?
Myopericarditis
32
What are the five forms of nurological adverse events from vaccines?
Acute Disseminated Encephalomyelitis
Transverse myelitis
Gullain-Barre Syndrome
Brachial Plexus Neuritis
Febrile seizure
33
What year and act lead to the creation of VAERS?
National Childhood Vaccines Injury Act of 1986
34
What are the three things VAERS helps detect?
New/rare events- post-Hep B alopecia
Increased rates of known events- post-measles thrombocytopenia
PT risk factors- myopericarditis
35
# Define Latency Period
Define Incubation Period
Time from infection to infectiousness, shorter than incubation period
Time from infection and onset of Sxs but transmission can occur
36
Define fine Communicable Period
Time period an agent can be transferred from infected host to susceptible host
37
Incubation and Communicable period of Measles
14 days for rash
From 4 days prior to 4 days after rash
38
Incubation and Communicable period of Hep A
28-30 days
Latter half of incubation to few days after juandice onset
39
Incubation and Communicable period of Smallpox
7-17 days
Onset of fever Sxs to separation of the scabs
40
What events take place during a "Quarantine"?
Individual- ASx healthy but exposed
Duration- incubation period
Location- home
Basis of Action- rarely used, police power
41
What events take place during an "Isolation"?
Individual- sick
Duration- communicable period
Location- hospital
Basis of Action- common, standard
42
What are the three parts to the epidemiologic triad?
What is the other, fourth part?
Susceptible Host
Causative agent
Environment
Vector
43
Define Primary/Definitive Host
Organism that a pathogen reaches maturity and reproduces in
44
Define Secondary/Intermediate Host
Organism that harbors a sexually immature parasite and is required for completion of life cycle
45
Define Dead End/Accidental Host
Organisms that don't allow transmission to a definitive host (humans/horses for West Nile)
46
Define Natural Reservoir
Organisms/environment that a pathogen naturally lives and reproduces or one that is depended upon for survivial
47
A reservoir is usually what key thing for a parasite?
Living host of a certain species often without causing disease
48
Define Carrier
Organism that has become infected with a pathogen but doesn't show any S/Sxs
49
Define Convalescent Carriers
Capable of spreading diseases following a period of illness
50
What are the modes of transmission
Direct: contact, droplet
Indirect: airborne, vehicle, vector
51
What are three microbes transmitted through direct contact?
Herpes
Syphilis
Hookworm
52
What are three microbes transmitted through droplet spread?
How far do they travel?
Pertussis
Meningococcal
Mumps
Less than 1 meter
53
What are three microbes that are transmitted by vehicle borne?
Salmonella
HCV
MRSA
54
What are three microbes that are transmitted by mechanical and biological vector borne?
Mechanical: Shigellosis/Bacillary dysentery, Plague
Biological: malaria, dengue
55
What type of transmission is a fly carrying shigella from latrines to food?
Indirect vector borne, mechanical transmission
56
What type of transmission is staphylococcal poisoning from a single meal?
Indirect vehicle borne transmission, single exposure
57
What type of transmission is a person sneezing on you in the hallway?
Direct transmission, droplet spread
58
What type of transmission is a cook with poor hand washing and contaminates a salad?
Indirect vehicle borne transmission
59
What type of transmission is a person with TB who repeatedly coughs on a plane?
Airborne transmission
60
What type of transmission is a child with impetigo who hugs you?
Direct transmission, person-to-person
61
Define Incidence
Number of new cases of a disease that occur in a specific time period on a population
62
What is the numerator and denominator of incidence
Numerator: number of new cases of a disease
Denominator: average population at risk during a time interval
63
Incidence is a measure of events and thus a measure of ?
Risk
64
Define Incidence Density
Number of new events per person-time
65
Define Prevalence
Proportion of people in a population who have a disease at a specific point in time
66
Define Point Prevalence
Prevalence of a disease at a single point in time
| A proportion
67
Define Period Prevalence
All cases during a certain period
68
Incidence is the ?
| Prevalence is the ?
Risk of getting a Dz
Odds of having it in a population
69
What is the prevalence equation
P= Incidence x Dz Duration
70
High prevalence can indicate what two things
Low prevalence can indicate what three things
High risk/incidence
Prolonged survival w/out cure
Low incidence
Rapidly fatal
Rapid recovery
71
Define Herd Immunity
Appicable to contagious dseases, indirect protection from dzs for those not immune
72
Define Herd Immunity Threshold
Reached when critical proportion of the population becomes immune and Dz may no longer persist
73
Define Basic Reproduction Number
Average number of new cases in a susceptible, well mixed population
74
What is measles' Ro and HIT?
What is pertussis' Ro and HIT?
What is influenza Ro and HIT?
12-18 92-95%
12-17 92-94%
1.5-1.8 33-44%
75
Quarantine is covered by what Executive Order and for which diseases?
```
EO 13295
TB
Cholera
Diphtheria
Plague
Smallpox
Yellow fever
HVFs
SARS
```
76
What are the four groups of people that fall under the exclusion from work?
Health care
Day care
Food handler
Law enforcement
77
What is the mission of Occupational Health
Promote health and safety of the workplace and community by focusing on education and surveillance aiming to restore health and productivity
78
What is the primary role of occupational health in a military setting?
Protect service members and DoD civilians
79
What are the four reasons for Occupational Health
Compliance w/ laws
Healthy workforce
Maintain productivity
Decrease costs
80
What is the purpose of OSHA
1970
Federal laws governing OccHealth
Created NIOSH
81
What is the purpose of ExecOrder 12196
1980
| Required compliance w/ OSHA except for military battlefield noise
82
What is the purpose of CFR 1910 and 1960
Labor laws providing standards for working environments
83
What is the purpose of DODI 6055.5M
Medical surveillance, recognize health risks and hearing conservation
84
What is the purpose of service regulations
Documents that provide legal and regulatory base of army Occupational safety and health program
85
_____ are HEPA filter surgical masks
N-95 respirators/TB masks
86
What are the reproductive workplace hazards?
Blood- HIV and hepatitis
Airborne- rubella, zoster
Physical- vibrations between 5-10Hz
87
When is the reference/initial audiogram performed?
Within 30 days of initial exposure to hazardous noises after a 14hr period w/out noise and is the first valid hearing test
88
Dead bodies do not pose a communicable disease hazard except for when?
Death from cholera
| Viral hemorrhagic fevers or Epidemic typhus (louse-borne)
89
What are the four infectious sources of mortality consistently associated with humanitarian emergencies?
Diarrhea
ARI
Measles
Vector-bonre (malaria)
90
What is the goal of diarrhea disease case management?
Preventing death from dehydration and circulatory collapse
91
When are ABX used in diarrhea diseases?
Moderate-Severe Cholera
Dysentery (Bacillary, Amoebic)
Giardiasis
92
What are the WHO recommendations for oral rehydration during diarrhea management?
Osmolality between 200-310
| Equal glucose/sodium
93
What are the S/Sxs of influenza
```
Fever
Dry cough
Myalgia
Coryza
Sore throat
Kids- GI Sxs
```
94
Characteristics of Influenza A
Primary reservoir in aquatic birds and humans
Can infect swine, seals, horses
Causes seasonal epidemics
Only one known to cause pandemics
95
Characteristics of Influenza B
Infects humans and swine
Seasonal epidemics
Mostly antigenic drift
96
What form of influenza infects cattle?
Influenza D
97
What are the H and N parts of Influenza A
Hemagglutinin- binds to respiratory cells
Neuraminidase- releases new virions from cells
98
Epidemic and pandemics of Influenza A are due to ?
Antigenic Shifts
99
When is flu season in the Northern and Southern hemispheres?
```
N= Oct-Mar
S= Apr-Sept
```
100
What two factors effect how well Influenza does/does not transmit?
Humidity- high w/ low humidity
| Temps- high w/ low temps
101
Define Trivalent and Quadrivalent vaccines
Tri= Two influenza A, One B
Quad= Two As, Two Bs
102
What is the leading cause of mortality in children under 5?
What factor makes this microbe dangerous?
Measles
Stays airborne for 2hrs
103
What criteria needs to be met for a Measles Outbreak to be declared
Three or more confirmed cases linked in time and space
104
What are the top three complications that can arise from measles?
Diarrhea
Ottitis media
Pneumonia
105
What effect does measles have on the body that is not seen in MMR vaccinated PTs?
Amnestic effect on Abs for +2mon
106
What complication can arise from measles 7yrs after an infection?
Subacute Sclerosing Panencephalitis
107
Regardless if uncomplicated, non-severe or complicated case of measles, what is always given during treatment?
Vit A
108
What vaccination is assigned the highest priority during a disaster/emergency situation?
Measles
109
Who is the target population during the emergency phase for measles vaccines?
6mon-14yrs
If vaccinated between 6-9mon, re-vaccine at 9mon
110
Who is the target population if there's an insufficient vaccine available?
Undernourished 6mon-12yrs
All kids 6-23mon
Kids 24-59mon
111
What are NOT considered contraindications for receiving a measles vaccine?
```
Malnutrition
Fever
Resp infection
Diarrhea
HIV
TB
```
112
Criteria for mild traveler's diarrhea
Tolerable, not distressing
Tx w/ Loperamide or Bismuth subsalicylates
113
Criteria for Moderate traveler's diarrhea
Distressing or interfering
Tx w/ Loperamide or
Adjunct to ABX
114
Criteria for Severe Traveler's Diarrhea
Incapacitating or prevents activities
May use Loperamide,
Should use ABX
115
Acute traveler's diarrhea is treated ?
When is micro testing indicated?
When is multiplex molecular Dx preferred?
Empirically
Severe/persistent or empiric failures
Persistent/chronic Sxs
116
What medication is used empirically as first line for SE Asia/India travel to cover fluoroquine resistant Campylobacter/ETEC
Azithromycin or,
| Cipro
117
What is the preferred regime for dysentery or febrile diarrhea
Azithromycin
118
When is Rifaximin NOT used?
Suspicion for Campylobacter, Salmonella, Shigella, or invasive bacteria
119
Chemoprophylaxis is not routinely recommended for Traveler's Diarrhea, but if requested by the PT, what is used?
Bismuth subsalicylate
| 2oz or 2 tabs 4x/day
120
ABX are NOT recommended for Traveler's Diarrhea, but possible use if what criteria are met?
What is the best option if an ABX is necessary
Immune suppressed
Crohns
UC
Chronic diarrhea
Rifaximin
121
PO2 at 10,000 ft is __% of that at sea level
70%
122
What causes altitude sickness?
Mild/moderate hypoxia
123
What are the S/Sxs of less severe acute Mtn Sickness?
```
HA
Fatigue
Loss of appetite
Nausea
Insomnia
```
124
What medication is used for prophylaxis and treatment for Altitude Sickness?
Acetazolamide 125mg BID
Tx: 250mg BID
125
What travel vaccines are recommended for wide spread risks?
Hep A
| Typhoid
126
What travel vaccines are recommended for geographic risks?
Yellow fever
Meningococcal
Polio
JEV
127
What travel vaccines are recommended for Duation/Activity risks
Hep B
| Rabies
128
What routine vaccines are recommended for childhood?
```
MMR
Vericella
DTap
Polio
HiB
Hep A/B
PCV
Rotavirus
Influenza
```
129
What routine vaccines are recommended for adolescents/Adults?
```
Tdap
Meningococcal
HPV
Influenza
Pneumococcal
Vericella/Zoster
MMR
```
130
Define Flaviviradae viruses
Single stranded RNA virus found in arthropods (ticks and mosquitoes)
131
What are the two primary hosts of JEV?
Pigs and wading birds
132
What type of mosquito carries JEV?
| When does it prefer to feed?
Culex mosquito
| Evening/night
133
What is the leading cause of childhood viral neurological infection and disability in Asia?
JEV
134
How old does a PT need to be to get JEV?
2mon
135
What are the two sources of medical intelligence?
Strategic- NMCI
Tactical- S2/G2
136
What info is provided by NMCI
```
Assessments
Service assessments
Trends/forecasts
Indications/warnings
Facility database
```
137
What is the NMCI method for assessing disease risks?
Realistic + Endemicity= Potential attack rate
Potential attack + typical severity= Operational impact
138
Focus of NMCI risk assessments are on what three areas?
Attack rates
Severity
Operational impact
139
When/where was the largest epidemic of malaria since Vietnam?
Somalia due to non-compliance with prophylaxis
140
Which two species of malaria have the potential for relapse?
P Vivax
| P Ovale
141
Other than Anopheles, how is malaria transmitted?
Blood products
| Organ transplants
142
Define Hypnozoites
Dormant stages of Vivax or Ovale
143
What 3 malaria meds have a long half life and are taken weekly?
Mefloquine
Chloroquine
Fafenoquine
144
Which medication's off label use is primary phophylaxis against malaria?
Primaquine
145
# Define malaria Suppressive therapy
What 3 meds are used for this?
Effective at killing erythrocytic stage and providing a clinical cure
Doxy, Mefloquine, Chloroquine
146
What med must also be taken with all suppressive meds?
Primaquine or Tafenoquine for PART against dormant liver stages
147
# Define Casual chemoprophylaxis
What 3 drugs are used here?
Targets blood and liver stages of malaria
Tafenoquine, Primaquine, Malarone
148
What two drugs are the only approved drugs that act on dormant hypnozoites in liver
Primaquine
| Tafenoquine
149
What are the ABCDEs of malaria prevention?
```
Awareness
Bite prevention
Chemoprophylaxis
Dx
Emergency Tx standby
```
150
What chemical family does permethrin belong to?
Pyrethroid
151
How does permethrin kill bugs?
Interferes w/ Na channels leading to spasms/death
152
Sequence of sun screen, pain and DEET
DEET then paint
| Sunscreen then DEET
153
What mosquito carries dengue fever?
When does it feed and in what areas?
Aedes, Albopictus
Day time mosquito in urban areas
154
How are Leptospirosis infections acquired?
Direct/indirect contact w/ urine
155
What is the most common reservoir for Leptospirosis
Brown rat
156
What happens to a Leptospriosis infection if in a human?
What med taken weekly reduces infection?
Dead end host
Doxy
157
Characteristics of gonorrhea
Second most commonly reported communicable disease
| Second most prevalent STI in US
158
How is gonorrhea screening conducted in men and women?
Men- NAAT on urine
| Women- vaginal swabs
159
What are the last class of treatment drugs recommended for gonorrhea
Cephalosporin
160
What is the current treatment combo recommended for gonorrhea?
Ceftriaxone 250mg
| Azithromycin 1g
161
Define Expedited Partner Therapy
Treatment approach where partners of PTs who tested positive get treatment w/out medical evaluation
162
What two circumstances are expedited partner therapy recommended?
Health department unavailable
| Concern about prompt eval/Tx
163
What two meds are used during expedited partner therapy?
Cefixime
| Azithromycin
164
Characteristics of Chlamydia
Most frequent bacterial STD in US and 10x more prevalent
165
What is estimated to be the most costly non-viral STI?
C Trachomatis
166
What is an intense autoimmune disease which causes multiple inflammatory lesions in brain and spinal cord?
Acute Disseminated Encephalomyelitis
167
What is the screening method for chlamydia in men and women?
Men- NAAT on urine
| Women- vaginal swabs
168
What is the recommended treatment for chlamydia?
Azithromycine 1g PO or,
Doxy 100mg PO 2/day x 7 days
Alternative- Erythromycin 500mg Q4D x 7 days
Ofloxacin 300mg BID x 7 days if pregnant
169
When is follow up testing recommended for chlamydia?
If treated w/ Erythromycin or if Sxs recur/persist
170
What are the two most high risk forms of HPV?
HPV 16
| HPV 18
171
When is HPV vaccination done?
11-12yrs
As early as 9
Catch up 13-26
27-45 can be done if a joint agreement
172
When are non-compromised PTs vaccinated for HPV?
2 doses if under 15
| 3 doses if at or over 15
173
What are NOT contraindications for getting HPV vaccine?
Abnormal Pap
Genital warts
HPV infection
174
Define Food Infection
Organism in food and multiplies until enough are present to cause sickness
175
Examples of indirect transmission?
Vector borne
| droplet is direct transmission
176
Define food intoxication
Toxin is in a food and causes the illness, not the microbe
177
What is an example of a naturally occurring chemical or an introduced chemical?
Ciguatera toxin
Poison, Pesticide, leeching
178
Where do a majority of chemical and parasitic food born illnesses come from?
Aquatic animals
Chemical- fish
Parasitic- mollusks
179
What are the top 5 pathogens leading to illness but not hospitalization?
```
Norovirus
Salmonella
Clostridium
Campylobacter
Staph A
```
180
What are the top 5 pathogens that lead to hospitalization?
```
Salmonella
Norovirus
Campylobacter
Toxoplasms
E Coli STEC
```
181
What are the top 5 pathogens that lead to death?
```
Salmonella
Toxoplasma
Listeria
Norovirus
Campylobacter
```
182
What microbe is likely to cause non-inflammatory diarrhea?
Norovirus
Salmonella non typhi
Yersinia
Shigella dysenteriae
Campylobacter
183
What criteria defines a food outbreak?
What is the exception?
Two or more people from different household who eat a common food that is confirmed through lab analysis
Botulism or chemical causes
184
What is the definition for diarrhea and the three sub-types?
Loose/water 3x in 24hrs
Acute <14 days
Persistent >14 < 30 days
Chronic >30 days
185
How long for Sxs to show after ingesting preformed toxins?
Within 6hrs
186
Facts and Sxs of Clostridium ingestion?
One of the most common in US
Occurs in cooked food improperly cooled/stored
Diarrhea and cramps 6-24hrs post-consumption
No fever/vomit
187
Facts and Sxs of Bacilius Cereus ingestion
Emetic from improperly cooked food and refrigerated
| N/V 1-5hrs post-consumption
188
Facts and Sxs of Scombroid
Improperly processed fish high in histidine
| Facial flushing, burning/pepper taste, facial rash
189
What kinds of foods do Bacillus Cereus infections come from?
Meat/veggie foods cooked and not maintained at temp
190
How is norovirus testing conducted?
PCR assay or Quantitative PCR
191
PTs w/ and without Hx of altitude sickness limits for meds?
Hx:
Consider- 8-9K
Give- +9K
AHx:
Consider- 9-11.5K
Give- +11.5K
192
What are good and poor prevention/control methods for Norovirus?
Soap and water
Alcohol is less effective due to no lipid envelope
Bleach for surfaces
193
What is the leading cause of food born illness, hospitalization and death?
Salmonella non-typhoidal
194
What countries have high incidence rates of Campylobacter?
Africa
| S. America
195
What microbe is only harbored in humans, none in animals?
Salmonella
196
How often is typhoid booster needed?
VICPS- 2yrs
| PO capsule- 5yrs
197
What is the superior method for drying hands?
Paper towels
198
What is a prime cause of food borne illnesses?
Cross contamination
199
What is the danger growth zone for bacteria?
40-140*F
200
How quickly does food need to be refrigerated?
Reduce to 40* or lower in 2hrs
| If outside temp is higher than 90* refrigerate within 1hrs
201
Define Primary, Secondary, and Tertiary Prevention
1*- prevent illness onset, imms
2*- early dx, screenings
3*- reduction of morbidity/mortality, medical treatment majority
202
What do the USPTF grades mean?
A- recommend, substantial
B- recommend, moderate
C- no recommendation, moderate certainty benefit is small
D- no rec, moderate/high certainty no benefit
I- insufficient evidence
203
What part of the post-vaccine issue sequence can lead to a PT receiving a temporary/permanent exemption from that vaccine?
Adverse event
204
Define Acute Disseminated Encephalomyelitis
Intense autoimmune disease producing multiple inflammatory lesions in the brain and spinal cord
205
Define Transverse Myelitis
Acute inflammation of gray and white matter across both sides of spinal cord
206
Define Guillain Barre Syndrome
Immune system attacks nerves in legs to arms
207
Define Brachial Plexus Neuritis
Inflammation of nerves in shoulder leading to severe arm/shoulder pain and upper arm weakness
208
Measles vaccine if traveling OCONUS
asdf
209
What are the Flaviviradae viruses?
```
Zika
Yellow Fever
Dengue Fever
West Nile
JEV/TBE
```
210
Define Attack Rate
Type of incidence rate applied to a narrowly define population
211
Define Secondary Attack Rate
In susceptible people that have been exposed to a primary case
212
What is the vector of scrub typhus?
Mite
213
WHat is worse, shifts or drifts
Shifts- causes need for new vaccines
