Readings Flashcards

Question

Describe mental health trends in Canada and variations between sub-populations. What is the suicide rate?

Answer 1

Mental health varies considerably among Canadians, with some sub-populations being much more likely to report low self-rated mental health. For example, for the period of 2010 to 2013, _adults who identified as bisexual were close to three times more likely, and adults who identified as gay or lesbian, were approximately twice more likely, to report low self-rated mental health than adults who identified as heterosexual._ These higher rates could be linked to internalized stress related to gender expectations and experienced discrimination.3 In Canada, _suicide rates remained stable from 2000 to 2017. On average, 11 Canadians die by suicide every day.14 In 2017, the suicide rate among males was three times higher than the rate among females. Suicide rates were highest among middleaged males.14 Some Indigenous communities are disproportionally affected._Areas with a relatively high Inuit population had a 6.5 times higher suicide rate than areas with a low concentration of Indigenous peoples.3 Suicide rates in areas primarily inhabited by First Nations and Métis peoples were also significantly higher (four and three times, respectively) than in areas with a non-Indigenous peoples majority.3 The impacts of _intergenerational trauma_ can ultimately manifest in poor mental health and practices that may place individuals at risk for suicide. However, it is important to note that not all Indigenous communities experience high suicide rates. For example, over 60% of First Nations bands had a suicide rate of zero.15 _Protective factors can include opportunities to speak and learn one’s traditional language, cultural identity, and connection to the land.16, 17_

Answer 2

Most cases of skin cancer are preventable. You can reduce your risk of getting skin cancer by following these safety tips: _Cover up_. When the UV Index is 3 or higher, protect your skin as much as possible. Wear light-coloured, long-sleeved shirts, pants, and a wide-brimmed hat made from breathable fabric. When you buy sunglasses, make sure they provide protection against both UVA and UVB rays. _Limit your time in the sun_. K_eep out of the sun and heat between 11 a.m. and 3 p.m._ The UV index in Canada can be 3 or higher during those times. When your shadow is shorter than you, the sun is very strong. Look for places with lots of shade, like a park with big trees, partial roofs, awnings, umbrellas or gazebo tents. _Always take an umbrella to the beach._ _Use the UV Index forecast_. Tune in to local radio and TV stations or check online for the UV index forecast in your area. _When the UV index is 3 or higher, wear protective clothing, sunglasses, and sunscreen, even when it’s cloudy_. *Factors affecting UV index = cloud cover, altitude, aerosols, air pollution (SO2, NO2), snow cover.* _Use sunscreen_. Put sunscreen on when the UV index is 3 or higher. Use sunscreen labelled “broad spectrum” and “water resistant” with an _SPF of at least 30_. _Drink plenty of cool liquids (especially water) before you feel thirsty_. If sunny days are also hot and humid, stay cool and hydrated to avoid heat illness. Dehydration (not having enough fluids in your body) is dangerous, and thirst is not a good indicator of dehydration. _Avoid using tanning equipment_. _There is no such thing as a ‘healthy’ tan_. Using tanning equipment damages your skin and increases your risk of developing melanoma, the deadliest form of skin cancer. Ask your doctor, nurse or pharmacist if any of the medications you are taking could be harmful to you if you are exposed to UV rays. The best way to find skin cancer in its early stages is to _examine your skin often_. See your doctor right away if you notice any of the following: abnormally dark or discoloured patches or spots bleeding, crusting or change in the colour, size or shape of a mole. Also, better _workplace policies_ **Health effects from UV:** BCC, SCC, melanoma, cataracts, keratinic actinosis, seborrheic keratosis, elastosis/skin agin. **Risk factors for skin cancer:** Sun exposure, skin type, moles, tanning bed, males, photosensitizing meds, personal + family history.

Answer 3

Canadian Antimicrobial Resistance Surveillance System (CARSS) Canadian Integrated Program for Antimicrobial Resistance Surveillance (CIPARS) Canadian Nosocomial Infection Surveillance Program (CNISP) Enhanced surveillance of antimicrobial-resistant gonorrhea program (ESAG) Canadian Tuberculosis Laboratory Surveillance System National Microbiology Laboratory of the Public Health Agency of Canada (the Agency) Laboratory for Foodborne Zoonoses

Answer 4

Vaccinate MMRV DTaP-IPV HBV-HPV Screen HBV, HCV, HIV, schisto/strongy, IDA, dental pain, vision, cervical Ca. • **Vaccination (against measles, mumps, rubella, diphtheria, tetanus, pertussis, polio, varicella, hepatitis B and human papillomavirus)**and**screening (for hepatitis B, tuberculosis, HIV, hepatitis C, intestinal parasites, iron deficiency, dental pain, loss of vision and cervical cancer**) should be routinely provided to at-risk immigrants. Detecting and addressing malaria, depression, posttraumatic stress disorder, child maltreatment, intimate partner violence, diabetes mellitus and unmet contraceptive needs should be individualized to improve detection, adherence and treatment outcomes. Measles, mumps and rubella _Vaccinate all adult immigrants without immunization records using one dose of measles–mumps–rubella vaccine. Vaccinate all immigrant children with missing or uncertain vaccination records using age-appropriate vaccination for measles, mumps and rubella._ Diphtheria, pertussis, tetanus and polio _Vaccinate all adult immigrants without immunization records using a primary series of tetanus, diphtheria and inactivated polio vaccine (three doses), the first of which should include acellular pertussis vaccine_. Vaccinate all immigrant children with missing or uncertain vaccination records using age-appropriate vaccination for diphtheria, pertussis, tetanus and polio. Varicella _Vaccinate all immigrant children \< 13 years of age with varicella vaccine without prior serologic testing._ Screen all immigrants and refugees from tropical countries ≥ 13 years of age for serum varicella antibodies, and vaccinate those found to be susceptible. Hepatitis B _Screen adults and children from countries where the seroprevalence of chronic hepatitis B virus infection is moderate or high_ (i.e., ≥ 2% positive for hepatitis B surface antigen), such as Africa, Asia and Eastern Europe, for hepatitis B surface antigen, anti-hepatitis B core antibody and antihepatitis B surface antibody. Refer to a specialist if positive for hepatitis B surface antigen (chronic infection). Vaccinate those who are susceptible (negative for all three markers). Tuberculosis _Screen_ children, adolescents \< 20 years of age and refugees between 20 and 50 years of age from countries with a high incidence of tuberculosis as soon as possible after their arrival in Canada with a tuberculin skin test. If test results are positive, rule out active tuberculosis and then treat latent tuberculosis infection. Carefully monitor for hepatotoxity when isoniazid is used. HIV _Screen for HIV_, with informed consent, all adolescents and adults from countries where HIV prevalence is greater than 1% (sub-Saharan Africa, parts of the Caribbean and Thailand). Link HIV-positive individuals to HIV treatment programs and post-test counselling. Hepatitis C _Screen for antibody to hepatitis C_ virus in all immigrants and refugees from regions with prevalence of disease ≥ 3% (this excludes South Asia, Western Europe, North America, Central America and South America). Refer to a hepatologist if test result is positive. Intestinal parasites Strongyloides: Screen refugees newly arriving from Southeast Asia and Africa with serologic tests for Strongyloides, and treat, if positive, with ivermectin. Schistosoma: Screen refugees newly arriving from Africa with serologic tests for Schistosoma, and treat, if positive, with praziquantel. Malaria _Do not conduct routine screening for malaria._ Be alert for symptomatic malaria in migrants who have lived or travelled in malaria-endemic regions within the previous three months (suspect malaria if fever is present or person migrated from sub-Saharan Africa). Perform rapid diagnostic testing and thick and thin malaria smears. Depression I_f an integrated treatment program is available, screen adults for depression using a systematic clinical inquiry or validated patient health questionnaire (PHQ-9 or equivalent)._ Individuals with major depression may present with somatic symptoms (pain, fatigue or other nonspecific symptoms). Link suspected cases of depression with an integrated treatment program and case management or mental health care. Post-traumatic stress disorder _Do not conduct routine screening_ for exposure to traumatic events, because pushing for disclosure of traumatic events in well-functioning individuals may result in more harm than good. Be alert for signs and symptoms of post-traumatic stress disorder (unexplained somatic symptoms, sleep disorders or mental health disorders such as depression or panic disorder). Child maltreatment _Do not conduct routine screening for child maltreatment._ Be alert for signs and symptoms of child maltreatment during physical and mental examinations, and assess further when reasonable doubt exists or after patient disclosure. A home visitation program encompassing the first two years of life should be offered to immigrant and refugee mothers living in high-risk conditions, including teenage motherhood, single parent status, social isolation, low socioeconomic status, or living with mental health or drug abuse problems. Intimate partner violence _Do not conduct routine screening for intimate partner violence_. Be alert for potential signs and symptoms related to intimate partner violence, and assess further when reasonable doubt exists or after patient disclosure. Type 2 diabetes mellitus _Screen immigrants and refugees \> 35 years of age from ethnic groups at high risk for type 2 diabetes_ (those from South Asia, Latin America and Africa) with fasting blood glucose. Iron-deficiency anemia Women _Screen immigrant and refugee women of reproductive age for iron-deficiency anemia (with hemoglobin)_. If anemia is present, investigate and recommend iron supplementation if appropriate. Children Screen immigrant and refugee children aged one to four years for iron-deficiency anemia (with hemoglobin). If anemia is present, investigate and recommend iron supplementation if appropriate. Dental disease _Screen all immigrants for dental pain._ Treat pain with nonsteroidal anti-inflammatory drugs and refer patients to a dentist. Screen all immigrant children and adults for obvious dental caries and oral disease, and refer to a dentist or oral health specialist if necessary. Vision health Perform age-appropriate screening for visual impairment. If presenting vision \< 6/12 (with habitual correction in place), refer patients to an optometrist or ophthalmologist for comprehensive ophthalmic evaluation. Contraception _Screen immigrant women of reproductive age for unmet contraceptive needs soon after arrival to Canada_. Provide culturally sensitive, patient-centred contraceptive counselling (giving women their method of choice, having contraception on site and fostering a good interpersonal relationship). Vaccination against human papillomavirus _Vaccinate 9- to 26-year-old female patients against human papillomavirus ._ Cervical cytology _Screen sexually active women for cervical abnormalities by Papanicolaou (Pap) test._ Information, rapport and access to a female practitioner can improve uptake of screening and follow-up.

Answer 5

1. Awareness 2. Relevance 3. Awareness of solutions 4. Capacity to change 5. Cost-benefit analysis 6. action, decision

Answer 6

The Task Force recommends NOT performing a screening pelvic examination to screen for noncervical cancer, pelvic inflammatory disease, or other gynecological conditions in asymptomatic women. | (**Strong recommendation; moderate-quality evidence**)

Answer 7

At the 2011 meeting of the Rotterdam Convention in Geneva, the Canadian delegation surprised many with a refusal to allow the addition of chrysotile asbestos fibers to the Rotterdam Convention.[5][6][7][8] Hearings are scheduled in the EU in the near future to evaluate the position of Canada and decide on the possibility of a punitive course of action.[9][10][11] In continuing its objection, Canada is the only G8 country objecting to the listing. Kyrgyzstan, Kazakhstan and Ukraine also objected. Vietnam had also raised an objection, but missed a follow-up meeting on the issue.[12] In taking its position, the Canadian Government contrasted with India, which withdrew its long-standing objection to the addition of chrysotile to the list just prior to the 2011 conference. (India later reversed this position in 2013.)[13] Numerous non-governmental organizations have publicly expressed criticism of Canada's decision to block this addition.[14][15][16][17][18] In September 2012, Canadian Industry minister Christian Paradis announced the Canadian government would no longer oppose inclusion of chrysotile in the convention.[19] Eight of the largest chrysotile producing and exporting countries opposed such a move at the Rotterdam Conference of Parties in 2015: Russia, Kazakhstan, India, Kyrgyzstan, Pakistan, Cuba, and Zimbabwe.[13]

Answer 8

**Indicators of eradicability:** (mnemonic they can't **HID**e) **H**umans are essential for the life cycle of the agent (i.e., no other vertebrate reservoir, no environmental amplification) effective **I**ntervention a sensitive/specific practical **D**iagnostic tool is available to detect transmission **Other considerations for pursuing eradication:** Cost-effectiveness analysis social and political commitment public health importance equity

Answer 9

Multivariable - multiple confounders/variables controlled for + Either Logistic regression - binary outcome being assessed (eg alive/dead) Linear regression - continuous outcome (eg blood pressure) Cox proportional hazards - hazard data Poisson regression - rate outcome

Answer 10

**Public Health Unit** Enforcement of water and food safety regulations (including restaurant food safety) Assessment of local environmental risks Monitoring and follow-up of reportable diseases Investigation of environmental contamination, clusters of disease **Municipal Government** Waste disposal, recycling, water and sewage treatment/collection/distribution **Provincial and Territorial Government** Water and air quality standards Industrial emission regulation Toxic waste disposal **Federal Government** Designating and regulating toxic substances Regulating food products (e.g. Health Canada (drugs), CFIA) Setting policy for pollutants that can travel across provincial boundaries International Multilateral agreements (e.g. Kyoto Protocol, UN Convention on Climate Change, International Joint Commission)

Answer 11

Trends in colorectal cancer _Colorectal cancer incidence rates are declining in males and females._ The recent declines are likely due in part to increased use of colorectal cancer screening which can identify and remove precancerous polyps, which can in turn reduce incidence. _Death rates have also been declining_. Most of this decline is likely driven by decreased incidence, as well as by improved diagnosis and treatment. Chances (probability) of developing or dying from colorectal cancer It is estimated that about _1 in 14 Canadian men will develop colorectal cancer_ during their lifetime and 1 in 32 will die from it. It is estimated that about _1 in 18 Canadian women will develop colorectal cancer_ during their lifetime and 1 in 37 will die from it.

Answer 12

Key Information Public health importance _Syphilis is of considerable public health importance in Canada as evidenced by a steep increase in rates since 2014_. Left untreated, syphilis has many associated complications. _Gay, bisexual and other men who have sex with men (gbMSM)_ are disproportionately affected. Higher rates are still reported in this population although an increasing number of outbreaks in heterosexual populations have been reported in Canada since 2017. _Congenital syphilis is also re-emerging with the highest number of cases ever being reported in 2018 and 2019._ Note: Syphilis infections are reportable to local public health authorities in all provinces and territories. Screening _Routine screening is recommended for people with risk factors for syphilis and for pregnant people._ Screening is of particular importance in pregnancy for the prevention of congenital syphilis and its impact on pregnancy outcomes. _Universal screening is recommended for pregnant people during the first trimester or at first prenatal visit._ _Repeat screening at 28 to 32 weeks and again at delivery is recommended for pregnant people at ongoing risk of infection or reinfection and in areas experiencing outbreaks of syphilis._ _Consider screening more frequently pregnant people at ongoing risk of infection_. _Screen all woman who deliver a stillborn infant after 20 weeks gestation._ Diagnostic testing Syphilis is usually diagnosed through serology regardless of suspected stage of infection. Interpretation of serology results can be complex, and different testing algorithms may be used by provinces and territories. Consult with your local laboratory regarding testing protocols. Treatment Infectious syphilis (primary, secondary and early latent stages): Long-acting Benzathine Penicillin G 2.4 million units intramuscular as a single dose. Longer duration syphilis (late latent and tertiary syphilis): Three (3) weekly doses of Benzathine penicillin G-LA 2.4 million units IM. Neurosyphilis requires more aggressive treatment with intravenous antibiotics, and should be managed by, or in consultation with, an infectious disease specialist. Follow-up _Post treatment serologic testing is used to assess treatment response_. It should be done at recommended intervals, which vary depending on stage of infection. Partner notification T_est and treat sexual or perinatal contacts._ The trace-back period will depend on the stage of infection of the index case.

Answer 13

Collection Retention Use (Analysis, interpretation, dissemination) Disclosure Destruction

Answer 14

The federal Toxic Substances Management Policy puts forward a preventive and precautionary approach to deal with substances that enter the environment and could harm the environment or human health. A Candidate Substance is scientifically assessed based on consideration of: 1) CEPA-toxic or equivalent; [Canadian Environmental Protection Act (CEPA)] 2) Predominantly Anthropogenic; 3) Bioaccumulative; and 4) Persistent. If all aspects are met, the substance is deemed for _Virtual Elimination from the environment (track 1)_. If the aspects are not all met, _Life-cycle management_ (track 2) to prevent or minimize release into the environment is initialized.

Answer 15

Collective Impact is a collaborative, multi-partner approach that brings together a group of collaborating organizations from different sectors to commit to a common agenda designed to produce significant changes in their community. 5 core conditions of the Collective Impact model **Common agenda** A common agenda requires a shared vision for change that includes a common understanding of the problem, a joint approach involving agreed upon actions and a common set of outcomes. **Shared measurement** All participating organizations agree on the ways success will be measured and reported, with a short list of common indicators identified and used for learning and improvement. **Mutually reinforcing activities** Collaborating organizations work as a team on coordinated actions that support each other. Mutually reinforcing activities ensure that each collaborator’s specific set of activities in which they excel are aligned towards achieving the common agenda and shared measures. **Continuous communications** All players engage in frequent and structured open communication to build trust, assure mutual objectives, and create common motivation. **Backbone** The backbone organization guides and supports the Collective Impact collaborating organizations as they work collectively to reach their common agenda. The backbone leads the collection of data and develops shared measurement systems that serve the needs of the collaborative. The backbone organization also leads communications and brings partners and key external stakeholders together to share information and seek opportunities for alignment with other community efforts.

Answer 16

Evidence-based guidance to optimize and support children’s early media experiences involves four principles: **minimizing, mitigating, mindfully using and modelling healthy use of screens.** Screen time can include time in front of a TV, gaming console, computer, tablet or cell phone. Children can learn many good things from technology, but learn more from spending time with you. Technology can take away from time that could be spent playing and being with family. Children that have too much screen time are at risk for becoming **_overweight, sleep-deprived, less school-ready, less attentive, and less able to self-soothe_.** Very little physical energy is exerted during screen time. _Set Limits to Screen Time_ Setting limits to screen time helps build healthy habits for the future. It is important to create rules and to share these rules with other adults in your child’s life. For your child's safety when using tablets, computers or phones, look for apps that provide parental controls which can help block sites and enforce time limits. Screen time for children younger than 2 years is not recommended. For children aged 2 to 5 years, limit routine or regular screen time to less than 1 hour per day. _Be a Good Example_ Set a good example by modeling healthy screen time habits. Cell phones and other devices take your attention away from your child which can be dangerous. Your child is more likely to act-out in order to get your attention when you are distracted. Engaging your child using play and books is better for your child’s brain and social development than screens. _Creating Healthy Habits_ Keeping devices in a common area can help you control when and how your child uses screen time. It is important for you to know how your child is using technology. Screens and television programs that are not meant for children can have a negative effect on their development. Watch and talk to your child while they are using screens. Choose content that is right for your child’s age. Turn off screens one hour before bed to help your child fall asleep easier. Turn off screens during mealtimes and other times when they are not necessary.

Answer 17

−Y a-t-il des différences entre les groupes ? Les groupes sont-il comparables? Y a-t-il des tendances dans le temps? Validité interne −Dues au hasard? Erreur aléatoire (pas de différence statistiquement significative) −Dues à un biais ? oSélection (échantillonnage, représentativité, couverture, données manquantes – exhaustivité des cas) oInformation (définition du problème, méthode et outils de collecte) oConfusion −Dues à une causalité inverse? −« Réelles » ? (différence statistiquement significative non expliquée par un biais) oLe choix de la méthode statistique est approprié pour les données? **−Si différence « réelle »,** −Plausibilité d’un lien de causalité ? −Quelle est la signification « clinique » / populationnelle du résultat (au-delà de la signification statistique)? −Quelle est l’interprétation des données? Modification réelle vs artéfactuelle du paramètre? −Quelles sont les explications possibles (Mnémonique BEDEET, ou Agent-Hôte-Environnement? oBiologiques (ex: développement d’une antibiorésistance) oÉpidémiologique (ex: chgmt comportement, mesure de santé publique, ↑ suspicion ou recherche de soins, ↑ déclaration) oDémographique (ex: augmentation de la taille de la population, diminution des naissances) Vérifier si données standardisées oÉconomique (ex: changement de prix d’une intervention, investissements) oÉcologique (ex: changements climatiques) oTechnologiques (ex: nouveau test, nouveau traitement, nouvelle intervention de prévention – vaccination ou dépistage, nouvelles indications de test / traitement, erreurs de laboratoire) −Quelles sont les explications possibles (séquence de la recherche de soins à la déclaration du cas) oDemande de soins par la personne: influencé par les campagnes de sensibilisation, médias, etc. oSuspicion clinique par le professionnel de la santé: influencé par les formations, conférences, publications etc. oTest: ∆ indications cliniques, ∆ performance, ∆ seuil de positivité, nouvelle technologie, erreur de labo oDéfinition de cas: ∆ critères diagnostiques, ∆ classification des maladies (CIM-10 vs CIM-9), ∆ indicateurs utilisés oTraitement: performance, ∆ technologie, ∆ critères d’inclusion / exclusion → taux de survie, durée de la maladie oDéclaration à la santé publique ou inscription dans une base de données: exhaustivité des cas? batch reporting? surveillance active vs passive? −À quelle population cette association s’applique-t-elle? Peut-elle être généralisée? Validité externe −Quelles sont les limites, les éléments manquants ou les prochaines étapes pour raffiner la compréhension du phénomène?

Answer 18

**CSEP 0-1** 30 min/day tummy time, interactive floor-based play (more is better) **CSEP 1-4** 180 min PA/day at any intensity (preschoolers should include 60 min/day energetic play) Limit recreational screen time to 1h/day **CSEP 5-17** 60 min MVPA/day, VPA 3x/wk, muscle/bone strengthening 3x/wk, several hrs/day of light PA Limit recreational screen time to 2h/day **CSEP 18+** 150 min MVPA/wk in bouts of 10+min, muscle/bone strengthening 2x/wk 65+: add activities to enhance balance and prevent falls

Answer 19

Babesiosis Lyme disease Anaplasmosis Rocky mountain spotted fever

Answer 20

- Focus on harm / Priority on immediate goals / Pragmatic - Human rights / Person centered / Autonomy / Involve people who use drugs - Trauma informed - Maximize intervention options

Answer 21

Zoster (pregnant) HPV (pregnant) BCG Live zoster LAIV (pregnant) MMR (pregnant) Smallpox (unless post-exposure/outbreak) Oral typhoid Varicella (pregnant) Yellow fever

Answer 22

**YOUR LIMITS** Reduce your long-term health risks by drinking no more than: _• 10 drinks a week for women, with no more than 2 drinks a day most days • 15 drinks a week for men, with no more than 3 drinks a day most days_ _Plan non-drinking days every week to avoid developing a habit._ **SPECIAL OCCASIONS** _Reduce your risk of injury and harm by drinking no more than 3 drinks (for women) or 4 drinks (for men) on any single occasion._ Plan to drink in a safe environment. Stay within the weekly limits outlined above in Your limits. **WHEN ZERO’S THE LIMIT** Do not drink when you are: _• driving a vehicle or using machinery and tools • Taking medicine or other drugs that interact with alcohol • Doing any kind of dangerous physical activity • Living with mental or physical health problems • Living with alcohol dependence • Pregnant or planning to be pregnant • Responsible for the safety of others • Making important decisions_ **DELAY YOUR DRINKING** Alcohol can harm the way the body and brain develop. Teens should speak with their parents about drinking. If they choose to drink, they should do so under parental guidance; never more than 1–2 drinks at a time, and never more than 1–2 times per week. They should plan ahead, follow local alcohol laws and consider the Safer drinking tips listed in this brochure. Youth in their late teens to age 24 years should never exceed the daily and weekly limits outlined in Your limits.

Answer 23

**Risk factors:** a _prior suicide attempt_ _mental illness like depression_ a sense of _hopelessness or helplessness_, this means that you believe your life or current situation won’t improve misuse of _alcohol or substances_ _chronic (long-term) physical pain or illness_ _trauma_, for example: violence victimization, like bullying childhood abuse or neglect suicide by a family member or friend events that affect multiple generations of your family Other factors that can increase the risk of suicide include: _significant loss_, including: personal (relationships), social, cultural, financial (job loss) _major life changes or stressors,_ such as: unemployment, homelessness, poor physical health or physical illness, the death of a loved one, harassment, discrimination _lack of access to or availability of mental health services_ _personal identity struggles_ (sexual, cultural) _lack of support from family, friends or your community_ _sense of isolation_ **Protective factors:** _positive mental health and well-being_ _a sense of hope, purpose, belonging and meaning_ _social support_ _healthy self-esteem and confidence_ in yourself _asking for help_ if you’re having thoughts of suicide a _sense of belonging and connectedness_ with your: family, friends, culture, community Other ways to help protect against risk of suicide include: a _strong identity_ (personal, sexual, cultural) _access to appropriate mental health services and support_ _good coping and problems-solving skills_, and the _ability to adapt to change and new situations_ _supportive environments where you’re accepted and valued_ (school, workplace, community) _positive relationships_ (peers, family, partner) PH interventions: Restrict means (Control access to painkillers/pesticides, Restrict access to firearms, Erect barriers in place where suicide by jumping) Access to MH care Restrictive alcohol policies Responsible media reporting Public education + awareness School based education (MH literacy, suicide risk awareness, skills training) HCW training, suicide screening Gatekeeper training Helplines Crisis intervention supports Postvention Targeted interventions (Trans, indigenous) Addres upstream factors (SDoH, childhood abuse, unemployment, poverty, cultural continuity, social equity and supports etc) Bullying prevention

Answer 24

In order to be eligible for medical assistance in dying, you must meet all of the following criteria. You must: be eligible for health services funded by the federal government, or a province or territory (or during the applicable minimum period of residence or waiting period for eligibility) generally, visitors to Canada are not eligible for medical assistance in dying be at least 18 years old and mentally competent. This means being capable of making health care decisions for yourself. have a grievous and irremediable medical condition make a voluntary request for medical assistance in dying that is not the result of outside pressure or influence give informed consent to receive medical assistance in dying

Answer 25

Trends in breast cancer The breast cancer incidence rate in women in Canada _rose between 1984 and 1991. The rate has fluctuated since then, with an overall small decrease_. The _increase until the early 1990s occurred partly because mammography was used more often, which meant that more cases of breast cancer were found_. The reasons for the later fluctuation are not clear but may include long-term changes in hormonal factors, like if a woman started having her menstrual periods when she was young, breastfeeding and oral contraceptive use. The _slight decrease in rate in 2002 coincided with a large drop in the use of HRT among postmenopausal women when its role in breast cancer was publicized._ The _breast cancer death rate peaked in 1986 and has been declining since_. This reduction in death rates _likely reflects the impact of screening and improvements in treatment for breast cancer._ Chances (probability) of developing or dying from breast cancer It is estimated that about _1 in 8 Canadian women will develop breast cancer_ during their lifetime and _1 in 33 will die from it_.

Answer 26

**Step 1: Identify key questions to be answered** The first step in a situational assessment is to determine what you need to inform planning decisions. Use the three broad questions and sub-questions below to shape the direction of the situational assessment and develop your research questions. 1. _What is the situation?_  What impact does the current situation have on health outcomes, quality of life and other societal costs, such as noise, air pollution or increased healthcare spending?  Which groups of people are at higher risk of health problems and poorer quality of life?  Which settings or situations are high risk, or pose a unique opportunity for intervention?  How do local stakeholders perceive the situation? What is their capacity to act? What are their interests, mandates, current activities?  What are the needs, perceptions and supported directions of key influential community members, and the community-at-large? 2. _What influences are making the situation better and worse?_  What high-risk or negative health behaviours by various groups of people are affecting the situation?  Which underlying causes or conditions are driving these behaviours (e.g. individual, community, organizational or system-level causes)? Are there protective factors that can help avoid or alleviate the situation (such as ensuring walkable communities or encouraging strong parent-child relationships)?  Which strengths and weaknesses present in your organization may affect your course of action? Which opportunities and threats in your environment may affect your course of action? 3. _What possible actions can you take to address the situation?_  What are other organizations doing, or what have they done in the past, to address this situation? Specifically, what local policies, programs and environmental supports are being developed or implemented within the community? What evaluation data are available for these activities?  What is the best available evidence that exists to support various courses of action? **Step 2: Develop a data gathering plan** Questions you develop in the first step will determine data needed. Too much data can become overwhelming; however, you also want a comprehensive plan. Therefore, it is a good idea to develop a data gathering plan to organize sources of data, tasks, and persons responsible. Ensure your data gathering plan includes _diverse types of data (e.g. community health status indicators, environmental scans, or best practices); different methods of data collection (e.g. surveys, document review, and literature review); and varied sources of data (e.g. partner organizations, community, and government)_. Some sources of information to consider to define the situation include _Community Health Status Reports produced by public health units, Rapid Risk Factor Surveillance System (RRFS),5 Canadian Community Health Survey (CCHS), 6 and the Public Health Agency of Canada (PHAC) Infobase. 7_ The National Collaborating Centre for Methods and Tools (NCCMT) has created evidence search pyramids8 for major health areas including mental health, injury prevention and environmental health. The search pyramids support the use of more highly-synthesized forms of information, such as guidelines and reviews. Using these more highly-synthesized sources can help save you time.9 You can use the pyramids to find literature in your field that has been pre-appraised for methodological quality. It is also important to critically appraise the literature you find, if it has not already been appraised. The Critical Skills Appraisal Program (CASP) has developed eight free and publicallyavailable critical appraisal tools10 designed for methodological quality assessment of research. Consider using these to evaluate the literature located by your search. In terms of specific sources of highly-synthesized evidence as described in the search pyramids, see the National Guidelines Clearinghouse11 and Turning Research Into Practice database for guidelines (summary-level evidence),12 and Health Evidence for reviews (syntheses).13 Health Evidence offers a registry of systematic review-level evidence that is pre-appraised and offers quality scores of strong, moderate, or weak for every review included in its regisry. For examples of programs and interventions, visit the Canadian Best Practices Portal, which may indicate some programs that offer outcome or evaluation data.14 **Step 3: Gather the data** Now that you have identified the research questions and developed a data gathering plan, the next step is to collect data. It is important to note that there are two types of data collection - primary and secondary data collection. Primary data is data that you and your situational assessment team collect yourselves; for example, via surveys, key informant interviews or focus groups. When collecting primary data it is important to ensure that people collecting the data have the right skills to do so properly. Ensure that your primary data collectors are trained, since this increases their confidence and ability to collect data consistently and correctly. Also ensure that data collection is standardized and done ethically, including documenting informed consent. Secondary data is collected by someone else; for example, by the provincial or federal government, a researcher, or a partner organization. A literature search is also an example of secondary data collection. If you are carrying out a literature search, document your search strategies, including search terms, and your inclusion and exclusion criteria. As another example of secondary data, Analytic Services at Public Health Ontario developed an interactive database, called Snapshots,15 using core indicators developed by the Association of Public Health Epidemiologists in Ontario (APHEO). These online dashboards provide information on indicators from a variety of data sources for Ontario and specific public health unit regions. **Step 4: Organize, synthesize and summarize the data** The amount of data generated during a situational assessment can be overwhelming. One of the easiest ways to organize information is to arrange the data according to your original key questions (step 1). For example, if your question was ‘What groups of people are at higher risk of health and quality of life problems’, organize findings that answer this question together. Using the Ecological Model16 to organize findings could help identify connections of the policy and environmental contexts with the social and individual contexts, allowing you to determine areas you want to address. Two widely-used models in the private sector that may help you understand your findings are SWOT or Force Field Analyses. A SWOT (Strengths, Weaknesses, Opportunities, Threats) analysis or a Force Field Analysis can help to determine facilitators and barriers to improving the situation. The Introduction to Planning Health Promotion Programs Workbook 4 provides more information about how to conduct a SWOT or Force Field Analysis. If possible, summarize findings in a paragraph or five to six bullet points. This will offer others a quick understanding of results and can be useful in any communication products that you develop. **Step 5: Communicate the information** A lot of time and effort has gone into your situational assessment. Make sure the results are not lost in a report! Colleagues, partner organizations and decision makers are all interested in your findings. Therefore, it is important to communicate key findings to each of your stakeholders in a manner that is understandable to each distinct audience. Consider which information each of your different stakeholders needs to know, and how you can best convey it to them. One strategy is to develop a communication plan which includes your key audience, communication objectives, channels, and communication products. You can sometimes use the same communication products for different audiences – as long as their communication style and your communication objectives for each audience are aligned. **Step 6: Consider how to proceed with planning** It is now time to utilize your findings and decide on your next steps. Consider: • How do you perceive your ability to affect the situation with the available time, financial resources and mandate? • What are the gaps in data quality or quantity, relative to stakeholder expectations? • How might that restrict your ability to make evidence-informed decisions about goals, audiences, objectives, strategies, activities and resources? • What are your next steps in the planning process? Will you proceed now, or must you revisit research questions, project scope or resources?

Answer 27

Passive: - Notifiable diseases - Hospital and billing data - Vital statistics Active: - Cencus - Surveys like CCHS - Impact

Answer 28

**Social Determinants of Health** Smoking Rate Overweight and Obesity Rate — Youth, Adults Fruit and Vegetable Consumption Rate Physical Activity Rate During Leisure Time **Health System Resources — Health System Inputs and Characteristics** Family Medicine Physician Supply Registered Nurses/Nurse Practitioners (RNs/NPs) Employed in a PHC Setting Uptake of Information and Communication Technology (ICT) in Primary Health Care **Access to Comprehensive, High-Quality Health Services — Health System Outputs** Population With a Regular Medical Doctor Difficulties Obtaining After-Hours Primary Health Care **Appropriate, Effective and Safe — Health System Outputs** Smoking Cessation Advice From a Regular Medical Doctor Eye Examinations in Adults With Diabetes Influenza Immunization for Seniors Colorectal Cancer Screening Ambulatory Care Sensitive Conditions (ACSCs) Hospitalization Rate Medication Lists in Primary Health Care Using a Computerized System [https://www.cihi.ca/sites/default/files/phc\_handout\_en.pdf](https://www.cihi.ca/sites/default/files/phc_handout_en.pdf)

Answer 29

False positive Pregnancy Lyme disease Pinta Yaws Non-treponemal test in previously positive Rheumatologic disorder False negative Too early Lab error Immunosuppression (RPR) Late latent/tertiary (RPR)

Answer 30

**Risk factors for obesity:** SES Immigration status Ethnicity Education Income Rural residence Low physical activity Poor diet Alcohol consumption Screen time Inadequate sleep **Risk factor for CVD:** Hypertension Age FHx Ethnicity Education level Income High cholesterol Obesity Smoking DM Stress Alcohol Low physical activity

Answer 31

PROS: Reducing head injuries CONS: Risk compensation Reducing cycling, physical activity Costs of helmets Distraction from more effective interventions (separating cars and bikes)

Answer 32

a. Quelle est la différence de risque? = Risque chez les exposées – Risque chez les non-exposées = (16,2-10,6) par 100 000 = 5,6 par 100 000 b. Quelle est la fraction attribuable chez les exposées? Interprétez cette valeur = (Risque chez les exposées – Risque chez les non-exposées) / Risque chez les exposées = Différence de risque / Risque chez les exposés = (5,6 par 100 000 / 16,2 par 100 000) = 34,57 % Interprétation : Un peu plus du tiers (ou 34,57%) des cancers du sein chez les femmes inactives pourraient être évités si toutes les femmes inactives atteignaient un niveau élevé d’activité physique. c. Quelle est la fraction attribuable dans la population? Interprétez cette valeur Incidence dans la population (par 100 000) : = (0,8 x 16,2) + (0,2 x 10,6) = 15,1 par 100 000 Fraction attribuable dans la population : = (Risque dans la population – Risque chez les non exposées)/Risque dans la population = (15,1-10,6)/15,1 = 29,8 % Interprétation : Environ 3 cancers du sein sur 10 pourraient être évité chez les femmes de plus de 50 ans si toutes les femmes atteignaient un niveau d’activité physique élevé. d. Combien de cas seraient prévenus si toutes les femmes de 50 ans et plus avaient un niveau élevé d’activité physique? Nombre de femmes de plus de 50 ans = 21% x 8 000 000 = 1 680 000 femmes Nombre de cas prévenus = Nombre de femmes de 50 ans x proportion d’inactives x différence de risque = 1 680 000 x 80% x 5,6 par 100 000 = 75 cas OU = Nombre de femmes de 50 ans x risque populationnel de cancer x fraction attribuable population = 1 680 000 x 15,1 par 100 000 x 29,8% = 75 cas

Answer 33

**Health impacts** NOISE-INDUCED HEARING LOSS NOISE-INDUCED SLEEP DISTURBANCE INTERFERENCE WITH SPEECH COMPREHENSION HIGH ANNOYANCE AN **APPROACH** FOR ASSESSING THE HEALTH IMPACTS OF NOISE IDENTIFICATION OF HUMAN RECEPTORS IN PROJECT AREAS ASSESSMENT OF BASELINE NOISE ASSESSMENT OF PROJECT-RELATED NOISE MITIGATION ASSESSMENT OF RESIDUAL IMPACTS SOUND LEVEL MONITORING **Examples of mitigation measures** 1. Erect a sound barrier around construction site 2. Alter routes of construction vehicles into area to reduce need for reversing alarms 3. Use machinery with improved technological effiiciency to reduce noise production 4. Alter orientation and design of construction site to maximize physical distance between construction and residents 5. Reduce the maximum blast noise produced in exchange for increased number of blasts (evidence-based) **Examples of indicators** 1. Noise complaints made by residents to local council about construction noise 2. % of residents reporting sleep disturbance pre and post construction commencement 3. % of residents reporting extreme annoyance pre and post construction commencement 4. % change in background noise levels in decibals before and after construction commencement

Answer 34

KEY MESSAGES/POINTS • In Canada, the _incidence rate of TB is higher_ among Aboriginal people than the foreign-born and Canadian-born non-Aboriginals, but the greatest burden of disease, as measured by the number of cases, occurs in the foreign-born. • Status Indians in Manitoba and Saskatchewan and the Inuit in Nunavut have the highest incidence rates among Aboriginals in Canada. • In the 1980s, after decades of decline, the incidence of TB among the Inuit began to level off. However, beginning in the late 1990s and continuing until 2010, rates increased, resulting in _Canada’s own “U-shaped curve of concern”._ • _Determinants of TB infection and disease in the Aboriginal people of Canada differ with respect to comorbidities, genetic factors, transmission factors and the social determinants of health when compared to the rest of Canada._ • _**Social determinants of health**, including lack of food security, housing, health care access, education and income_ are seen with higher frequency in Aboriginal groups in Canada. • **Programmatic issues** in TB prevention in Aboriginal groups in Canada that can be strengthened include _strong TB partnerships with communities, increased community awareness, improving adherence to TB medications and underscoring the importance of effective contact investigation._ • According to the most recent statistics released in 2012, the current rate of TB among the Canadian-born Aboriginal population is 26.4 per 100,000. Across Canada rates of new active and retreatment TB cases for the Aboriginal population were as follows: North American Indian 22.2 per 100,000 (188 cases), Inuit 198.6 per 100,000 (116 cases) and Métis 7.5 per 100,000 (26 cases).

Answer 35

**Canadian Blood Services or Hema-Quebec** (asymptomatic human cases) **Notifiable disease surveillance system** (clinically symptomatic human cases) **Canadian Wildlife Health Cooperative** (dead birds) **Canadian Food Inspection Agency** (equine cases) **Mosquito surveillance** (positive mosquito pools/total pools tested in Saskatchewan, Manitoba, Ontario and Quebec) **National Microbiology Laboratory** (California serogroup testing)

Answer 36

Air pollutants overview - **see attached image** Air pollution describes a collection of airborne pollutants that contribute to our air quality. The term “pollutants” recognizes that these substances are undesirable because of their impact on human health, the environment and the economy. These air pollutants are all very different. They differ in their chemical composition, reaction properties, emission sources, how long they last in the environment before breaking down, their ability to move long or short distances, and their eventual impacts. However, they also share a number of similarities, and so can be grouped into four general categories: Criteria Air Contaminants and related pollutants (e.g. SO2, NOx, Volatile Organic Compounds, etc..) Persistent Organic Pollutants (POPs)(e.g. dioxins and furans) Heavy Metals (HM) (e.g. mercury) Toxics (e.g. benzene) **Criteria Air Contaminants** and related pollutants are cause to air issues such as smog and acid rain. They are produced in varying quantities by a number of sources, including the *burning of fossil fuels.* **Persistent Organic Pollutants** are a collection of pollutants that can last in the environment for long periods of time and are capable of travelling great distances. Similar to heavy metals, POPs are of particular concern because they can enter the food supply, bioaccumulate in body tissues, and have significant impacts on human health and the environment, even in low concentrations. **Heavy metals** are basic metal elements such as mercury and lead. This group of pollutants can be transported by the air and enter our water and food supply. Although trace amounts of some metals are needed by our body, heavy metals are poisonous in low concentrations and can bioaccumulate in body tissues. **Toxic Pollutants** form a broad category of pollutants that are poisonous or toxic to human health and the environment. Although this category has some overlap with the other types of air pollutants presented here (CAC, HM, POPs etc), it also includes many more pollutants that have been determined to be toxic. The Canadian Environmental Protection Act, 1999 (CEPA 1999; schedule 1) provides a list of pollutants of concern that are subject to legislative control and management. CEPA 1999 has also legislated that these pollutants be reported to the National Pollutant Release Inventory (NPRI).

Answer 37

**FEDERAL** 1. Setting and administering _national standards for the health care system through the Canada Health Act_ 2. Provides _health care funding to the provinces and territories through the Canada Health Transfer + tax support for health-related costs_ 3. Provide certain _direct health care services to some population groups_ 4. Responsible for the _regulation of certain products e.g. food, pharmaceuticals, chemicals, pesticides, medical devices_ 5. Supports health _research_ 6. Supports health _promotion and protection_ 7. Supports disease _monitoring and prevention_ **Or by agency:** health protection (Health Canada) public health (PHAC) medical research (CIHI) regulation (biologics and genetic therapies directorate) finance and delivery to special groups (FNIHB) international liaison funder (20% through Canada Health Transfer) **PROVINCIAL LEVEL** _Administration of their health insurance plans_; _Planning and funding of care in hospitals_ and other health facilities; _Services provided by doctors_ and other health professionals; Planning and implementation of _health promotion and public health initiatives_; and _Negotiation of fee schedules_ with health professionals. _Fund supplementary benefits for certain groups_ (e.g., low-income residents and seniors), such as drugs prescribed outside hospitals, ambulance costs, and hearing, vision and dental care, that are not covered under the Canada Health Act. As well, each province and territory has an _independent workers' compensation agency_, funded by employers, which funds services for workers who are injured on the job. [https://www.canada.ca/en/health-canada/services/canada-health-care-system.html](https://www.canada.ca/en/health-canada/services/canada-health-care-system.html) [https://www.canada.ca/en/health-canada/services/health-care-system/reports-publications/health-care-system/canada.html#a4](https://www.canada.ca/en/health-canada/services/health-care-system/reports-publications/health-care-system/canada.html#a4)

Answer 38

MVT Suffocation Drowning Burns Falls Poisoning Fiream Struck by/against

Answer 39

**Discrete data** - Nominal (M/F) - Ordinal (likert scale) **Continuous data** - Interval-scale data (not true 0 e.g. celcius) - Ratio-scale data (with real 0 value e.g. kelvin))

Answer 40

_Vaping can increase your exposure to chemicals that could harm your health (e.g. cause lung damage)._ _Vaping could also expose you to nicotine, which is addictive._ There are also concerns about the appeal of vaping products among youth and their potential to promote tobacco use. If you are a smoker, vaping is a less harmful option than smoking. **Health risks of vaping with nicotine** _Nicotine is not known to cause cancer. It is approved for use in nicotine replacement therapies, such as the patch or nicotine gum. However, there are risks linked to nicotine._ Nicotine is a highly addictive substance. _Vaping with nicotine could:_ _lead to dependence_Footnote1 _cause nicotine addiction among users who would not have started using nicotine otherwise (e.g. smoking)_ _Children and youth are especially susceptible to the harmful effects of nicotine, including addiction. They may become dependent on nicotine with lower levels of exposure than adults_.Footnote2 Nicotine: _can affect memory and concentration_ _is known to alter teen brain development_ Exposure to nicotine during adolescence may causeFootnote3Footnote4 _reduced impulse control_ _cognitive and behavioural problems_ _Vaping may predispose youth to addiction to nicotine and possibly other drugs._Footnote5Footnote1 **Nicotine poisoning** Vaping liquid containing nicotine is poisonous, particularly to young children. Even in small amounts, vaping liquid containing nicotine can be very harmful if: swallowed absorbed through the skin T_here have been fatalities as well as non-fatal nicotine poisoning caused by children swallowing vaping liquid._ When buying a container of vaping liquid with nicotine, look for one that has a child-resistant closure and a 'poison' hazard symbol. The closure and symbol are required by law. They help protect children in three ways: The closure makes it harder for a child to gain access to the liquid in the container. The poison hazard symbol reminds parents and caregivers to keep the product out of sight and reach of children. Children are taught that the hazard symbol means Danger! Do not touch. Tips to handle vaping liquids safely Store out of sight and reach of young children and pets. Store vaping liquid in a cool, dry place where it cannot be confused for food, drinks, or medicine. Close the container securely after each use. Wash your hands immediately after handling vaping liquid. If someone has swallowed vaping liquids, seek emergency medical attention or call 9-1-1. Read more about household chemical safely. **Health risks of other chemicals in vaping** There are health risks linked to other chemicals found in vaping products. Vaping substances have fewer and different chemicals than in tobacco products. _Vegetable glycerine and propylene glycol are the main liquids in vaping products_. These are considered safe for use in many consumer products such as cosmetics and sweeteners. However, the _long-term safety of inhaling the substances in vaping products is unknown and continues to be assessed_. _Chemicals used for flavour in vaping products are used by food manufacturers to add flavour to their products. While safe to eat, these ingredients have not been tested to see if they are safe to breathe in._ There is no burning during vaping but the vaping process needs the liquid to be heated. This can create new chemicals, such as formaldehydes. Some contaminants (e.g. nickel, tin, aluminum) might also get into the vaping products and then into the vapour. The amount of substances (including nicotine) a person can be exposed to by vaping is affected by the: battery power type of vaping device settings on the device combination of internal components type of vaping liquid and amount of nicotine user behaviour patterns user's experience with vaping Using vaping products with higher power and temperature settings can produce more chemicals. Some of these chemicals and contaminants are linked to negative health effects. However, the amount of chemicals and contaminants in vapour is normally at much lower levels than in cigarette smoke. We are still learning more about how vaping affects health. The long-term health impacts of vaping are unknown. However, _there is enough evidence to justify efforts to prevent the use of vaping products by youth and non-smokers._ Popcorn lung There is a concern that people who vape might get 'popcorn lung' from being exposed to diacetyl. Diacetyl is a flavouring chemical used to give butter-like and other flavours to food products, as well as vaping products. However, _there have been no reports of popcorn lung occurring due to vaping._ This disease is named popcorn lung because workers in popcorn plants developed it after inhaling heated flavours such as diacetyl. Popcorn lung, or popcorn worker's lung, is: a chronic disease that damages the small airways in the lung the common term for the medical condition known as bronchiolitis obliterans While once common in vaping products, steps have been taken to reduce its use. **Second-hand vapour** _Second-hand vapour is not harmless but it does contain far fewer chemicals than second-hand smoke_. Bystanders can be exposed to vapour that is exhaled by users. _The health effects from exposure to second-hand vapour are still unknown. However, the risks are expected to be much lower compared to smoke from a tobacco product._ We recommend that users be cautious around non-users and youth. There is some evidence that e-cigarette use increases the level of nicotine and other chemicals on indoor surfaces.Footnote1 **Device malfunctions** _Vaping devices are regulated under the Canada Consumer Product Safety Act._ Although uncommon, another risk to consider involves _defective batteries or defective vaping products that have caused fires and explosions_. If you notice a safety problem with a vaping device or vaping liquid, you can report the problem: to the manufacturer or retailer using our online consumer product safety reporting page For more information on product safety requirements and how to protect yourself, read about vaping product safety and regulation. Batteries and vaping devices Lithium-ion batteries and vaping devices can pose a hazard if they are not properly: used stored carried charged _Tips to prevent injuries from batteries and vaping devices_ _Do not modify your device._ _Buy batteries that are compatible with your device._ _Buy batteries from a trusted source._ _Do not carry lithium-ion batteries in your pocket or anywhere they can come into contact with loose coins, keys or other metal objects. Lithium-ion batteries can overheat, catch fire or even explode when in contact with metal objects. Incidents have caused serious injuries._ _Keep spare batteries in a protective case._ _Read the manufacturer's instructions for storing and recharging your device._ _Do not exceed the recommended charging time._ Read more about battery safety. **Vaping and pregnancy** While vaping products contain fewer harmful chemicals than cigarettes, they may still contain nicotine. Talk to your health care provider about your options of quitting nicotine during pregnancy.

Answer 41

Based on the recommendation for integrating PCH interventions into every HCP contact with women of reproductive age, the World Health Organization [13] identified the following evidence-based interventions: * Prevention of pregnancy in adolescence; * Prevention of unintended pregnancies; * Promotion of birth spacing; * Optimizing pre-pregnancy weight; * Promotion of healthy nutrition including supplementation/food fortification, such as folic acid intake; * Promotion of vaccination of children and adolescents. Furthermore, services for women with special risk factors that increase the risk for preterm birth include: * Screening for, diagnosis and management of mental health disorders and prevention of intimate partner violence; * Prevention and treatment of sexually transmitted infections (STIs), including HIV/AIDS; * Promotion of tobacco use cessation and restriction of exposure to second hand smoke; * Screening for, diagnosis and management of chronic diseases, including diabetes and hypertension

Answer 42

pricing carbon pollution, taking action in each sector of the economy, adapting to climate change, and supporting clean technologies, innovation and job creation

Answer 43

Tooth decay Increase body weight Increased risk of diabetes Increased risk of dyslipidemia and hypertension

Answer 44

Emerging infectious disease: - An infectious disease that has newly appeared in a population - or that has been known for some time but is rapidly increasing in incidence or geographic range.

Answer 45

* *Seven components of influenza surveillance in Canada** 1. Geographic Spread of Influenza/Influenza-like Illness Activity (P/T MoH) 2. Laboratory-Confirmed Detections (Provincial PH labs) 3. Syndromic Surveillance (Sentinel Practitioners, FluWatchers) 4. Outbreak Surveillance (P/T MoH) 5. Severe Outcomes Surveillance (P/T MoH, IMPACT, CIRN - Canadian Immunization Research Network) 6. Strain Characterization and Antiviral Resistance Testing (NML) 7. Vaccine Monitoring (PHAC, Sentinel practitioners, CIRN) _The FluWatch program consists of a network of labs, hospitals, doctor's offices and provincial andterritorial ministries of health. Program objectives are:_ **Detect** : to detect and respond to outbreaks and other events of public health concern. **Inform** : to use the data and information to create, improve and apply to public health programsand policies to control the flu. **Enable** : to make sure that the information gathered on the flu in Canada supports internationalflu monitoring and is ready in case of a global outbreak. **Flu-like-illness (ILI) definition:** _Sudden onset_ of flu symptoms with _fever and cough and with one or more of the following:_ sore throat, joint pain, muscle aches, or fatigue which is likely due to the flu. Children younger than 5 years old might also have symptoms like nausea, vomiting and diarrhea. Patients younger than 5 years old or 65 and older might not have a fever. **4 levels of ILI activity**: no activity, sporadic, localized, widespread **Lab-confirmed flu outbreak**: Where there are 2 or more cases of ILI within 7 days, and at least 1 lab-confirmed case of flu in the same setting (on the same floor, or in the same unity or ward). **Flu-like illness (ILI) outbreak in school/work**: More than 10% absenteeism that is likely due to ILI. Each week, the _Immunization Monitoring Program Active (IMPACT)_ network reports the number of **children** admitted to hospital with the flu (paediatric cases) to FluWatch. The _Canadian Immunization Research Network (CIRN)_ reports the number of **adults** admitted to the hospital with the flu each week from participating hospitals across Canada FluWatch receives information each week from the **National Microbiology Laboratory** on: the _specific strains of the flu virus (influenza) that are circulating_ in people in Canada _how those strains compare to the flu viruses that the seasonal flu shot_ can protect against that doctors prescribe to prevent and treat flu **WHO continuum of pandemic phases** 1. Interpandemic phase 2. Alert phase 3. Pandemic phase 4. Transition phase

Answer 46

The IHI Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance. It is IHI’s belief that new designs must be developed to simultaneously pursue three dimensions, which we call the “Triple Aim”: Improving the **patient experience of care** (including quality and satisfaction); Improving the **health of populations**; and Reducing the per capita **cost of health care**. For quadruple aim, add **provider wellbeing**

Answer 47

Systems thinking Personal mastery Mental models Shared vision Team learning

Answer 48

To track how health dollars are being spent, we maintain these databases: **National Health Expenditure Database (NHEX),** the primary source of health spending information in Canada **Canadian MIS Database (CMDB),** the primary source of information on staffing, cost, workload and provision of health services **Canadian Patient Cost Database (CPCD),** the data source used to estimate costs by patient group **OECD Health Database (Canadian Segment),** maintained by CIHI and Statistics Canada, the data source that includes a consistent series of internationally comparable data for most of the 1,200 variables contained in the Organisation for Economic Co-operation and Development (OECD) database

Answer 49

The process of enabling people to increase control over, and to improve, their health. **Values**: (mnemonic RISE) **R**espect, **I**nclusion, **S**ocial justice and equity, **E**mpowerment, **Characteristics**: - **holistic** - **strengths-based**, enhancing - **participatory** approaches, - **complimentary** strategies, amplifying - based on **SDoH**.

Answer 50

Occupational exposure limits (OELs) for noise are typically given as the maximum duration of exposure permitted for various noise levels - those **vary per provinces**. They are often displayed in exposure-duration tables like Table 1A and Table 1B. The OELs depend on two key factors that are used to prepare exposure-duration tables: the **criterion level** and the **exchange rate**.

Answer 51

BCG vaccination has historically been provided in several provinces/territories of Canada. _With declining rates of TB in many settings and concern about the risk-benefit ratio associated with a live, attenuated vaccine, BCG is currently only recommended in certain high-incidence communities in Canada._ _BCG is currently recommended in Canada for infants in high-incidence settings and also may be administered to travellers returning for extended stays to a high TB incidence country where BCG is routinely given._ Major Shifts in Recommendations BCG is not recommended for adults, such as health care workers, before travel to high-incidence settings. Recommendations _BCG vaccination is recommended in high-incidence communities for infants in whom there is no evidence of HIV infection or immunodeficiency_. If vaccination is delayed beyond 6 months of age, a TST (tuberculin skin test) should be done and documented as negative before vaccination. For infants aged between 2 months and 6 months, an individual assessment of the risks and benefits of tuberculin skin testing prior to BCG vaccination is indicated. _For infants born in Canada who will be moving to and staying for extended periods of time in a country with high TB incidence and where BCG vaccination is still standard practice, vaccination is recommended soon after arrival in the high-incidence country_

Answer 52

2018 Public Health Emergency Preparedness and Response Capabilities **15 Preparedness and Response Capabilities** 1. Community Preparedness 2. Community Recovery 3. Emergency Operations Coordination 4. Emergency Public Information and Warning 6. Information Sharing 13. Public Health Surveillance and Epidemiological Investigation 12. Public Health Laboratory Testing 11. Nonpharmaceutical Interventions (PHSM) 8. Medical Countermeasure Dispensing and Administration 9. Medical Materiel Management and Distribution 10. Medical Surge 7. Mass Care 5. Fatality Management 14. Responder Safety and Health 15. Volunteer Management **6 Domains of preparedness:** _Community Resilience_: Preparing for and recovering from emergencies _Incident management_: Coordinating an effective response Information _Management_: Making sure people have information to take action _Countermeasures and Mitigation_: Getting medicines and supplies where they are needed _Surge Management_: Expanding medical services to handle large events _Biosurveillance_: Investigating and identifying health threats

Answer 53

Perfluorooctane sulfonate Perfluorooactanoic acid Synthetic chemical used in consumer products and fire-fighting foams for their water and oil repellant. Regulated in water as of 2018 with MAC. Adverse effect on liver and endocrine disruptor.

Answer 54

In summary: Discontinuation of airborne precautions considers the following criteria: - establishment of an alternative diagnosis, - clinical improvement, - adherence to effective therapy, - sputum smear and/or culture conversion, - drug-susceptibility tests that indicate fully sensitive organisms or low clinical suspicion of drug resistance. ***Mnemonic: Won, Two, Three*** Clinical improvement (won-1) On adequate treatment (as per lab testing) for 2 weeks (2) Three consecutive negative smears (3) Health care organizations and individual health care workers (HCWs) have a shared responsibility to apply effective tuberculosis infection prevention and control measures. The risk of health care associated transmission of M. tuberculosis varies with the type of setting, HCW occupational group, patient care activity, patient/resident/client population and the effectiveness of tuberculosis (TB) infection prevention and control measures. _The most important contributors to health care associated transmission of M. tuberculosis are patients with unrecognized, respiratory TB disease_. Hence, the most important element of any TB management program is rapid diagnosis, isolation and start of effective therapy for these patients. _Remote and isolated health care settings in which at-risk populations are cared for should have access to resources to facilitate implementation of essential administrative, environmental and personal protective controls._ Major Recommendations All health care settings should have a TB management or infection prevention and control program supported at the highest administrative level. This involves a hierarchical approach to infection prevention and control measures categorized as administrative, environmental and personal protection controls. Airborne precautions should be initiated immediately for everyone with suspected or confirmed respiratory TB disease admitted to a hospital. **The criteria for discontinuation of airborne precautions include the following**: _establishment of an alternative diagnosis, clinical improvement, adherence to effective therapy, sputum smear and/or culture conversion, and drug-susceptibility tests that indicate fully sensitive organisms or low clinical suspicion of drug resistance._ U.S. National Institute for Occupational Safety and Health (NIOSH)-certified respirators (N95 or higher filter class) should be used by HCWs providing care for or transporting patients with suspected or confirmed respiratory TB disease. Masks should be used by patients/people with suspected or confirmed respiratory TB disease when outside an airborne infection isolation room. _Baseline tuberculin skin testing (TST) is recommended for all HCWs in health care and community care settings. Recommendations for periodic and serial (repeated) TST for HCWs vary with the setting. Interferon-gamma release assays are not recommended for serial testing._

Answer 55

WNV control components: surveillance, breeding ground control, mosquito control, education _Cover exposed skin_ When you are outside, wear: long pants and loose-fitting shirts with long sleeves socks and a hat (try a mosquito net over your hat to protect your head light-coloured clothing (mosquitoes are attracted to dark colours) _Use insect repellent_ When you are outside, you should use insect repellents (bug sprays and lotions) that contain the chemicals DEET or Icaridin. How can you reduce mosquito habitats near your home? Mosquitoes lay eggs in standing water (water that does not move or flow). _Get rid of standing water around your home_ by following these tips: drain or dry off water in: old tires (even tire swings) rainwater barrels children's toys flowerpots wading pools clean eavestroughs regularly to prevent clogs that trap water tip fishing boats and gear onto their sides to drain replace the water in outdoor pet dishes and bird baths at least 2 times a week _Put screens on your windows and doors to keep mosquitoes out of your home._ How should you handle dead animals and wild birds? _If you find a dead animal or bird, do not handle the body with your bare hands._ Always wear rubber gloves when touching any dead bird or animal. _Report dead birds that you suspect have West Nile virus._ If you hunt or skin wild animals, remember that West Nile virus can spread through blood-to-blood contact. To help protect yourself from diseases the animal might have: _always wear gloves when you handle dead animals_ _always make sure any open wounds on your hands are covered_ _wash your gloved hands, and then wash your bare hands every time you handle a dead animal_ There is no evidence that people can get West Nile virus from eating fully cooked infected birds or animals.

Answer 56

1. We recommend _blood pressure measurement at all appropriate primary care visits_. (**Strong recommendation; moderate quality evidence**) 2. We recommend that blood pressure be measured according to the _current techniques_ described in the Canadian Hypertension Education Program (CHEP) recommendations for office and out-of-office blood pressure measurement.\* (**Strong recommendation; moderate quality evidence**) 3. For people who are found to have an elevated blood pressure during screening, the _CHEP criteria for assessment and diagnosis of hypertension should be applied to determine whether the patient meets diagnostic criteria for hypertension_.\* (**Strong recommendation; moderate quality evidence**)

Answer 57

Ground-level Ozone (O3) Fine Particulate Matter (PM2.5) Nitrogen Dioxide (NO2) Mnemoni Nope! - NO2 - 03 - PM

Answer 58

MEASLES OUTBREAK Two or more confirmed cases linked, either epidemiologically or virologically or both. CONTACT A contact is defined as any individual who has: • spent any length of time in a room or enclosed space with a confirmed measles case during that case’s infectious period (i.e. approximately 4 days before rash onset to 4 days after rash onset); or • spent time in a room previously occupied by a measles case, during that case’s infectious period, within 2 hours after that individual left the room/space. SUSCEPTIBLE INDIVIDUAL An individual considered susceptible to measles meets the following criteria: • lack of documented evidence of vaccination (one dose for adults 18 years of age and older, born in 1970 or later; two doses for children 12 months to 17 years of age) after the first birthday and given at least 4 weeks apart for MMR vaccine, or 6 weeks apart for MMRV vaccine; • lack of laboratory evidence of prior measles infection; and • lack of laboratory evidence of immunity (i.e. “reactive” or “positive” anti-measles IgG antibody or a previous measles antibody level of ≥200 mIU per ml) (2). Canada has been free of endemic measles since 1998. Maintaining elimination of this disease will require _enhanced surveillance activities_, _identifying and improving immunization coverage in susceptible populations_, and _providing education_, both to the public and to health professionals, on the importance of immunization. Essential components of case investigation include _confirming the diagnosis_, _obtaining vaccination histories_, _identifying the sources of infection_, and _assessing the risk for transmission._ Susceptible contacts that refuse or cannot receive MMR vaccine or immune globulin may be excluded from childcare facilities, schools, and post-secondary educational institutions at the discretion of the Medical Officer of Health; and _may be required to self-isolate from work places, or other group settings, including travel. If exclusions occur, the period of exclusion should extend from 5 days after the first exposure and up to 21 days_ after the last exposure. _The following are general messages that could be useful in any measles outbreak:_ • Measles is a highly infectious disease. Its symptoms include fever, red eyes, runny nose, drowsiness, irritability and a red blotchy rash that begins on the face. • Measles affects all age groups but generally the disease is more severe in infants and adults. Measles during pregnancy can result in a higher risk of premature labour and low infant birth weights. • Immunization is the best defence against this disease. Canadians are reminded to keep all vaccinations up-to-date. • People who may have been exposed, who are not immunized and are experiencing symptoms should contact their health care provider or public health authority to determine the best course of action. As a general rule, people who are sick should stay at home to reduce the risk of spreading an infectious disease.

Answer 59

Threshold limit value TLV-TWA - (Time Weighted Average): time weighted average concentration for 8 hours to which almost all workers can be exposed daily without adverse effect over a working lifetime TLV-STEL - (Short Term Exposure Limit): 15-min TWA exposure that shouldn't be exceeded at any time during work day. TLV-C - (Ceiling): the concentration of a substance that should not be exceeded at any time during work

Answer 60

**Examples of anti-blackness:** - interpersonal racism can be overt (e.g. harassment, violent attacks),10 or subtle and pervasive in the form of daily indignities. - racial profiling; overpolicing (e.g. surveillance, harassment, excessive use of force) - underpolicing (e.g. under-responsiveness, abandonment) of Black over-representation of Black people in criminal justice systems - overrepresentation of Black youth and children in child welfare systems - systemic discrimination and undertreatment in hospitals and other healthcare systems; - low representation or absence of Black people in leadership positions across institutions and systems. **Consequences:** - Chronic stress, trauma - Impact on physical and mental health - Individual, family, organization - Reduce access to the material and social resources needed to achieve and maintain good health over a lifetime - Inequities in access to education, income, employment, housing, and food security can drive inequities in health and wellbeing.

Answer 61

**Health indicators** are measures designed to: - **summarize information** about a given **priority health** topic - **comparable** information across different geographic, organizational or administrative boundaries - **relevant, meaningful, actionable** information - can **track progress** over time - **scientifically valid**, **feasible** **Metric**: Information that is quantifiable and is reported as a number. Has value and many uses, but cannot be compared. **Health indicator:** Puts metrics into some kind of context, usually using a ratio (per X) and is designed to ensure comparability (e.g., by being risk-adjusted or standardized). Directionality may or may not exist. **Health system performance indicator:** A health indicator that has a desired direction (e.g., lower is better).

Answer 62

**Low dose computed tomography (LDCT)** For adults aged _55-74 years_ with _at least a 30 pack-year\* smoking history who currently smoke or quit less than 15 years ago_, we recommend _annual screening with LDCT up to three consecutive times_. Screening should _ONLY be carried out in health care settings with expertise in early diagnosis and treatment of lung cancer._ **Weak** recommendation; **low quality** evidence.\*pack-year defined as the (average number of cigarette packs smoked daily) x (number of years smoking) For all other adults, regardless of age, smoking history or other risk factors, we recommend not screening for lung cancer with LDCT. Strong recommendation; very low quality evidence. Chest x-ray (CXR) _We recommend that chest x-ray not be used to screen for lung cancer, with or without sputum cytology._ **Strong** recommendation; **low quality** evidence.

Answer 63

**In summary:** - **acknowledge current state of health = direct result of previous policies** + implement healthcare rights - **measure health outcomes** gaps + publish progress - address health care needs for **off-reserve** aboriginal - fund **healing centers** - recognize value of **aboriginal healing practices** - increase number and retention of aboriginal **HCW** + provide cultural competency training for all HCW - require **med/nursing students** to take a course on Aboriginal health issues 18. We call upon the federal, provincial, territorial, and Aboriginal governments to _acknowledge that the current state of Aboriginal health in Canada is a direct result of previous Canadian government policies, including residential schools_, and _to recognize and implement the health-care rights of Aboriginal people_ as identified in international law, constitutional law, and under the Treaties. 19. We call upon the federal government, in consultation with Aboriginal peoples, to _establish measurable goals to identify and close the gaps in health outcomes and to publish annual progress reports and assess longterm trends_. Such efforts would focus on indicators such as: infant mortality, maternal health, suicide, mental health, addictions, life expectancy, birth rates, infant and child health issues, chronic diseases, illness and injury incidence, and the availability of appropriate health services. 20. In order to address the jurisdictional disputes concerning Aboriginal people who do not reside on reserves, we call upon the federal government to _recognize, respect, and address the distinct health needs of the Métis, Inuit, and off-reserve Aboriginal peoples_. 21. We call upon the federal government to _provide sustainable funding for existing and new Aboriginal healing centres to address the physical, mental, emotional, and spiritual harms caused by residential schools_, and to ensure that the funding of healing centres in Nunavut and the Northwest Territories is a priority. 22. We call upon those who can effect change within the Canadian health-care system to _recognize the value of Aboriginal healing practices_ and use them in the treatment of Aboriginal patients in collaboration with Aboriginal healers and Elders where requested by Aboriginal patients. 23. We call upon all levels of government to: i. _Increase the number of Aboriginal professionals working in the health-care field_. ii. Ensure the _retention of Aboriginal health-care providers in Aboriginal communities_. iii. _Provide cultural competency training for all healthcare professionals._ 24. We call upon medical and nursing schools in Canada to require _all students to take a course dealing with Aboriginal health issues_, including the history and legacy of residential schools, the United Nations Declaration on the Rights of Indigenous Peoples, Treaties and Aboriginal rights, and Indigenous teachings and practices. This will require skills-based training in intercultural competency, conflict resolution, human rights, and anti-racism.

Answer 64

Influenced by trauma informed care, anti-racism, cultural humility Cultural awareness, sensitivity, competence, safety **Awareness** - acknowledging a difference between cultures **Sensitivity** - understanding different needs for different cultures, respecting the differences **Competency** - having the skills to provide what is needed for these differences (debatably not achievable by those outside the culture) **Safety** - self-reflection, examining power imbalances and injustices, and humility can improve safety, this is an outcome perceived by the patient/population involved

Answer 65

Integration in local health networks: - Bring population health perpective in health assessment and planning - Better integration of health services, from prevention to palliation - Greater clinical focus than public health focus - Public health funding susceptible to urgent healthcare needs - Distraction from other critical PH partnership - Boundary misalignment Regionalization - Better integration in emergency preparedness, maternal child health, flu. - Population health assessment and surveillance - Transition costs - Boundary misalignment - Loss of critical mass of public health capacity and authority

Answer 66

Geometric mean is often used in _skewed distributions_, it is calculated by transforming observations to a _log scale_ to make a distribution of observations more symmetric. The geometric mean is the antilog of the arithmetic mean of the logs.

Answer 67

Most provinces and territories have an **electronic immunization registry for their jurisdiction**, in order to: identify children who are due or overdue for a vaccine provide health care professionals with a patient's up-to-date vaccination status measure immunization coverage and help assess immunization programs We do a survey every 2 years to track coverage for all vaccines recommended by the National Advisory Committee on Immunization. For example, to calculate vaccination coverage for pertussis (whooping cough) in 2-year-olds, we: 1. divide the number of 2-year-old children who received the recommended 4 doses of pertussisvaccine before age 2 by the total number of children aged 2 2. multiply the result by 100, to get the percentage **Childhood National Immunization Coverage Survey** (cNICS) cNICS measures coverage for all vaccines given to infants, children and teens every second year. **Survey of Vaccination during Pregnancy** The Survey of Vaccination during Pregnancy measures the uptake of pertussis and influenzavaccination in pregnant women. Survey of Vaccination during Pregnancy 2019 **Adult National Immunization Coverage Survey** (aNICS) aNICS measured coverage for vaccines recommended for adults. As of 2018, it was merged into theSeasonal Influenza Vaccination Coverage Survey. **Seasonal Influenza Vaccination Coverage Survey** The Seasonal Influenza Vaccination Coverage Survey measures coverage for the flu shot in adultsevery year. Every second year, it measures other adult vaccines as well.

Answer 68

Prevention _We recommend asking children and youth (age 5–18 yr) or their parents about tobacco use by the child or youth and offering brief\* information and advice, as appropriate during primary care visits\*\*, to prevent tobacco smoking among children and youth_ (**weak recommendation, low-quality evidence**). Treatment _We recommend asking children and youth (age 5–18 yr) or their parents about tobacco use by the child or youth and offering brief\*information and advice, as appropriate during primary care visits \*\*, to treat tobacco smoking among children and youth_ (**weak recommendation, low quality evidence**).

Answer 69

**Reduce the incidence of Early Childhood Caries (ECC**)  Fluoride varnish applications  Xylitol (a non-sugar substitute) to reduce oral bacterial transmissibility between mother and child  Oral health education/promotion  Building capacity in the physician and allied public health workforce **Reduce the incidence of dental caries in school-age children**  Topical fluoride applications  Pit and fissure sealants  Oral health education/promotion  Dental screening **Improve and maintain the oral health of seniors**  Topical antimicrobials (e.g. chlorhexidine, fluoride varnish)  Addition of oral health checks in general health examinations  Training of professionals in long-term care  Improved oral health policy in long-term care facilities **Increase access to dental care in order to reduce health disparities**  Effective public health programs  Reducing barriers to accessing dental care  Community water fluoridation

Answer 70

Opioid-related deaths have had a serious impact on life expectancy for both sexes, but more so for males in British Columbia and Alberta, contributing to decreases in life expectancy in both provinces from 2016 to 2017. With respect to Indigenous peoples, Inuit were estimated to have a shorter life expectancy at birth, up to 14 years shorter for males, and up to 11 years shorter for females, compared to the overall Canadian population. It is important to see these data in context; the lasting legacy of colonization and intergenerational trauma have led to systemic health inequities for First Nations, Inuit, and Métis peoples.

Answer 71

High blood pressure (≥ 130/85 mm Hg, or receiving medication) High blood glucose levels (≥ 5.6 mmol/L, or receiving medication) High triglycerides (≥ 1.7 mmol/L, or receiving medication) Low HDL-Cholesterol (\< 1.0 mmol/L in men or \< 1.3 mmol/L in women) Large waist circumference (≥ 102 cm in men, 88 cm in women; ranges vary according to ethnicity)

Answer 72

PATOS PICE **1.Planifier la planification** a) Clarifier le mandat b) Préciser les attentes c) Clarifier le processus décisionnel d) S’entendre sur les ressources disponibles pour planifier - budget, temps, nombre de personnes, expertise, données, matériel, ressources informatiques e) Planifier l’échéancier f) Préciser les rôles et les responsabilités de chacun g) Répartir les tâches **2.Assess** a) Définition du problème b) Contexte - PESTELEEMO - FFOM (SWOT) c) État de santé de base de la population - Données de surveillance - Besoins de la population (besoin perçu, exprimé, etc.) d) Recension des interventions existantes - Littérature scientifique, littérature grise, documentation, projet de recherche e) Recension des ressources disponibles f) Priorisation des besoins de la population **3.Team** a) Experts b) Partenaires c) Penser aussi aux opposants potentiels - Préciser les méthodes de coordination, les processus décisionnels, les rôles et les responsabilités **4.Objectifs** a) Énoncer b) Prioriser **5.Solutions possibles** a) Dresser un inventaires b) Prioriser **6.Plan de programme** a) But et objectifs b) Groupe cible c) Stratégies d) Activités e) Tâches f) Ressources g) Indicateurs h) Modèle logique **7.Implantation** a) Plan d’action - Rôles et responsabilités: Qui fait quoi? - Échéancier - Ressources / Budget - Procédure de communication a) Projet pilote / Incrémentale / Subite b) Gestion du changement c) Intensité / Continuité / Flexibilité **8.Communication** **9.Évaluation** a) Structure b) Processus c) Résultats (incluant effets inattendus)

Answer 73

**Groups of Canadians More Likely to be Living in Low Income** Children Vulnerable Groups Indigenous People People with Disabilities Recent Immigrants Single Parents Unattached Individuals Aged 45–64 **Low income cut-offs** (relative measure) - considered low income if family spend 20% more on food, shelter and clothing than the average family, data goes back to 1976. **Market basket measure** (absolute measure) - considered low income if does not have enough money to buy specific goods and services in its community, more sensitive to differences in cost of living, data starts in 2002. **Low income measure** (relative measure) - low income if income is below 50% of median household income, data goes back to 1976, frequently used for international comparisons.

Answer 74

"The 12-step program" 1. _Confirm outbreak and diagnosis_ Are there more cases than expected in a given area in a given time interval among a specific group of people? Is further investigation needed? 2. _Consider immediate control measures_ 3. _Assemble an outbreak response team_ 4. _Establish and maintain communications_ 5. _Establish_ **_case definition_ - PPTLS** (standard set of criteria for determining if a person should be classified as part of an outbreak, such as lab diagnosis, symptoms, person, place, and time; may be divided into confirmed, probable, and suspect/possible) 6. _Identify cases and contacts_, and obtain information Line list Active surveillance 7. _Organize data in terms of person, place, and time_ (descriptive epidemiology) 8. _Define the population at risk_ 9. _Develop and test hypotheses_ Case-control, cohort, environmental sampling, or 10. _Implement control measures_: The chosen control strategies should take into account epidemiology, study findings, environmental sampling, and theory; practically, control strategies will also be influenced by jurisdictional authority, legal roles, political sensitivity, timeliness of outbreak detection, interpersonal issues, and available resources Control source (e.g., insecticidal spraying, food recall) Interrupt transmission (e.g., education or policy to change behaviour, isolation; see case and contact management) Modify host response (e.g., vaccination) 11. _Monitor the response_ 12. _Summarize in a report_ Case definitions **confirmed: high specificity, low sensitivity** probable **suspect: low specificity, high sensitivity** When declare outbreak over? return to baseline last time individual may have been exposed to implicated source has been identified sufficient time has elapsed for potentially exposed individuals to become ill and be reported to investigating public health authorities When declare outbreak over? return to baseline last time individual may have been exposed to implicated source has been identified sufficient time has elapsed for potentially exposed individuals to become ill and be reported to investigating public health authorities

Answer 75

_Treatment of active TB should include two effective drugs at all times, and in the initial phase (first 2 months) at least three effective drugs are recommended._ _Treatment should be guided by the results of drug sensitivity testing, which should be performed for all patients with culture-confirmed disease._ _All patients with active TB in Canada should be treated with a regimen of isoniazid (INH), rifampin (RMP), pyrazinamide (PZA) and ethambutol (EMB) initially_. _If the isolate causing disease is fully susceptible to all first-line drugs, the EMB can be stopped, and PZA should be given for the first 2 months. After that it is recommended that only INH and RMP be given for the remainder of therapy – usually another 4 months._ _Therapy is prolonged to 9 months if there are risk factors for relapse. These include persistent presence of cavity on the chest x-ray after 2 months or at the end of effective anti-TB therapy, persistent smear and/or culture positivity after 2 months of therapy, or HIV coinfection_. Providers who are initiating TB therapy should provide comprehensive, patient-centred care and be able to monitor that 100% of prescribed doses are taken. _Directly observed treatment (DOT) is one method to achieve this and is recommended at a minimum for patients with risk factors for non-adherence, or population groups with historically increased rates of treatment failure or relapse or with inadequate rates of treatment completion, defined as default rates of 5% or greater_. It is recommended that all jurisdictions across Canada have the capacity to provide DOT. Therapy can be given 5 days per week in the initial 2 months, then three times per week if DOT is used, to facilitate treatment supervision. Therapy that is self-administered should be taken daily. Fixed-dose combination (FDC) preparations of multiple TB medications are not recommended. Treatment of active disease in pregnant or breastfeeding women should be the same as the standard regimen. The same drugs, dosing and duration as in the standard regimen are recommended for treatment of active disease in patients with renal insufficiency. However, prolonged dosing intervals are recommended for PZA and EMB from daily to three times per week. Therapeutic drug monitoring (TDM) is not available in Canada but is available in the United States. The impact of TDM on important outcomes is unknown. Nevertheless, TDM should be considered for patients with renal or hepatic insufficiency, HIV coinfection or known malabsorption.

Answer 76

[http://airquality-qualitedelair.ccme.ca/en/](http://airquality-qualitedelair.ccme.ca/en/)

Answer 77

National Security Community Safety Emergency Management Internal Services

Answer 78

**Principles of good governance** (*mnemonic A-LIST*) Accountability, Leadership, Integrity, Stewardship, Transparency. **Functions of PH governance:** 1. Policy development - Lead and contribute to the development of policies that protect, promote, and improve public health 2. Resource stewardship - assure the availability of adequate resources (legal, financial, human, technological, and material) to perform essential public health services 3. Continuous quality improvement - routinely evaluate, monitor, and set measurable outcomes for improving community health status 4. Partner engagement - build and strengthen community partnerships through education and engagement to ensure the collaboration of all relevant stakeholders 5. Legal authority - exercise legal authority as applicable by law and understand the roles, responsibilities, obligations, and functions of the governing body, health officer, and agency staff 6. Oversight & responsibility for public health performance in the community by providing necessary leadership and guidance to support the public health agency in achieving measurable outcomes https: //www.ncbi.nlm.nih.gov/pmc/articles/PMC4355716/

Answer 79

**TRIGGERS FOR INVESTIGATION** Suspected or confirmed foodborne illness outbreak Food test result Food inspection finding Complaints from consumers, industry, other government departments or associations Company-initiated recall Recall in another country CFIA audit/assessment/evaluation findings Referrals from other branches within the CFIA Referrals from other federal/provincial/territorial, municipal and international governmentdepartments or food safety organizations (for example, the International Food Safety AuthoritiesNetwork) law enforcement or the medical community Traditional or social media **CFIA 5 steps of food safety investigations** 1. Trigger; 2. Food safety investigation; 3. Health risk assessment; 4. Recall process; issue recall, inform the public 5. Follow-up; steps taken to remediate + prevent The _recalling firm is responsible for contacting all of its clients_ (for example, distributors or retailers)that have or may have received the recalled food. The _CFIA's role is to inform the publi_c, oversee implementation of the recall, provide guidance and verify that industry has effectively removed recalled food from the marketplace.

Answer 80

_Colorectal cancer incidence rates are declining in males and females_. The recent declines are likely due in part to increased use of colorectal cancer screening which can identify and remove precancerous polyps, which can in turn reduce incidence. _Death rates have also been declining._ Most of this decline is likely driven by decreased incidence, as well as by improved diagnosis and treatment. It is estimated that about _1 in 14 Canadian men will develop colorectal cancer during their lifetime_ and 1 in 32 will die from it. It is estimated that about _{1 in 18 Canadian women will develop colorectal cancer during their lifetime} and 1 in 37 will die from it.

Answer 81

The deprivation index is built from six socioeconomic indicators drawn from the 1991, 1996, 2001, 2006, 2011 and 2016 censuses, including the 2011 National Household Survey (NHS). These indicators were selected because of their known relationship with health status, because of their association with both the material and the social aspects of deprivation, and because of their availability by EA/DA. These indicators are:  The proportion of the population aged 15 years and over _without a high school diploma or equivalent_;2  The _employment to population ratio_ for the population 15 years and over;  The _average income of the population_ aged 15 years and over;  The proportion of the population aged 15 and over _living alone_;  The proportion of the population aged 15 and over who are _separated, divorced or widowed_;  The proportion of _single-parent families._

Answer 82

PPV = _(sensitivity x prevalence)_ / [(sensitivity x prevalence) + ((1 – specificity) x (1 – prevalence))] NPV = _(specificity x (1 – prevalence))_ / [(specificity x (1 – prevalence)) + ((1 – sensitivity) x prevalence)]

Answer 83

CAC Chromium, Arsenic, Copper

Answer 84

Ottawa model 3As: Ask, advise, act US model 5As: ASK, ADVISE, ASSESS (willingness to quit), ASSIST, ARRANGE Motivational interviewing “5 Rs”: Relevance, Risks, Rewards, Roadblocks, Repetition

Answer 85

**Alcohol & Substance Use (see Tobacco Use below)** *Effects* When under the influence of alcohol, individuals are less likely to adopt safe sex practices and there is an increase in _unintended pregnancies_ [26,159,221]. Alcohol use in pregnancy is the cause of _Fetal Alcohol Spectrum Disorder (FASD)_, a permanent developmental disability [5,26,160,161]. Alcohol and substance use increases the _risk of preterm birth, low birth weight and small for gestational age babies, placental abruption and intrauterine growth restriction_ [5,162,163]. Heavy alcohol consumption and street drugs can cause _fertility problems_ including impotence, alterations in sperm quality for men and disrupted menstrual and ovulation cycles for women [159,162]. *Recommendations* **_Screen all individuals of reproductive age, for at-risk alcohol consumption and drug misuse_** [26,160,161,163]. Identify at-risk drinking and drug misuse before pregnancy, to allow time to address substance misuse [5,26]. _Particular attention should be made to women of advanced maternal age and young women as they may be more at-risk for alcohol use during pregnancy_ [164]. Provide _consistent messaging that abstinence from alcohol and substances is the safest choice for those who are or may become pregnant_ [26,161,165,166]. Using a _harm reduction approach_, counsel all sexually active individuals of reproductive age who use alcohol and/or other substances, to make informed decisions regarding alcohol and substance use and to consistently use an effective form of contraception [159,162]. There is no confirmed safe amount of alcohol use during any stage of a pregnancy [26]. There are many different effective screening tools related to alcohol use, some intended for specific ages or populations; however none have been tested for preconception health specifically. The _T-ACE screen (like CAGE but instead of guilt its tolerance - needing more than 2 drinks to feel high_ was the first validated screening questionnaire for risky drinking developed for pregnant women. **Body Weight** *Effects* Starting a pregnancy underweight, overweight or obese can negatively affect maternal and fetal health. As pre-pregnancy Body Mass Index (BMI) increases, the _risk of infertility and complications during pregnancy also increase_s [13,33,65,167,168]. Adverse outcomes associated with maternal BMI in the overweight or obese category include _gestational diabetes, gestational hypertension, excessive gestational weight gain, miscarriage, stillbirth, Caesarean section, wound infections, preterm delivery, neural tube defects, child obesity, maternal diabetes, hypertensive and thromboembolic disease_ [27,33,167]. Evidence shows that women who are physically fit before pregnancy have fewer aches and pains during pregnancy and feel they have more energy during their pregnancies [5,169]. Male obesity negatively impacts fertility, sperm quantity and quality [170,171]. *Recommendations* _Educate women of reproductive age_ about the impact of their health and weight on their own well-being and on the health and well-being of their children [32]. **Advise overweight and obese women of the increased risk of congenital abnormalities and _screen_ appropriately** [27,55]. Educate and support individuals to reach a _healthy body weight prior to a pregnancy_ occurring [27,65]. Inform all individuals to aim for at least 30 minutes of moderate exercise (that makes you sweat), five days a week, to enjoy long-term good health [5,172]. Inform men of potential impact of weight on fertility and their own well-being. Encourage men to set goals and develop a plan to reach a healthy weight [6]. **Emotional Health & Stress** *Effects* Poor preconception mental health is a significant risk factor for _pregnancy complications and low birth weight babies_ [101]. _Maternal depression during pregnancy is associated with increased odds for premature delivery and decreased breastfeeding initiation_ [173]. Women who have experienced perinatal mood disorder (PMD) during pregnancy or in the postpartum period have a greater risk of experiencing PMD in subsequent pregnancies [174,175]. _Psychosocial factors such as socioeconomic status, work status, marital status, level of education, access to prenatal care, substance abuse, ethnicity, cultural background, and quality of relationships with partners and parents have been identified as determinants of stress during pregnancy_ [61,176,177]. High levels of stress may delay conception, impact the ability to conceive and has been linked to adverse pregnancy outcomes [5,176,178,179]. _Women with psychosocial stress are also at risk for participation in high risk behaviours_. Women with high risk behaviours before pregnancy are more likely to continue them during pregnancy and _less likely to access prenatal care_ [102]. Evidence supports the association between prenatal stress and infection and inflammation during pregnancy which can lead to _low birth weight, preterm birth_, and additional adverse outcomes or pregnancy complications [61,177,178]. _Intimate partner violence as a child or adolescent increases the risk of violence during pregnanc_y [176]. Women who experience preconception or prenatal violence are 30% less likely to have adequate prenatal care. _Abuse can escalate in pregnancy_ [13,180]. *Recommendations* Promote interventions that improve the emotional health of women and reduce stress before conception to reduce the risk including perinatal mood disorders. _Intervention may include group counseling, development of coping and economic skills_ [5,179,181,182]. **HCPs should _include queries about violence in the behavioural health assessment of new patient_s, at annual preventive visits, as a part of prenatal care** and in response to symptoms or conditions associated with abuse [13,183]. **Environmental Toxins** *Effects* There are substances in the everyday environment which are known to be harmful and interfere with the endocrine system, affecting fertility and reproductive outcomes for men and women [184,185,186]. Interference with hormone action during critical periods of fetal development can cause irreversible and delayed effects that do not become evident until later in life [187,188]. _Environmental toxins (e.g., air pollutants, heavy metals, organic solvents, pesticides) may increase the risk of low birth weight, intrauterine growth restriction, preterm birth, and birth defects_ [189,190]. *Recommendations* Encourage all individuals of reproductive age to _investigate and review the harmful substances in their home and workplace environments_ so that they can adopt prevention strategies before conceiving [186]. **Medical Conditions & Genetic Risks** *Effects* _Some medical conditions (e.g., diabetes, hypertension, thyroid disease), undiagnosed, untreated, or poorly controlled, can be associated with adverse fetal outcomes_ [5,191,192]. Men and women with pre-existing medical conditions are commonly prescribed medications. Some medications can pose risk to fertility (e.g., affect sperm count and quality), can affect sperm count and quality, and are contraindicated during pregnancy (e.g., increase risk for congenital anomalies). Sometimes, the risk of not taking medication during pregnancy may be more serious than the potential risk associated with taking the medication [6,193]. *Recommendation* _I**nvestigate family history of genetic disorders** such as muscular dystrophy, hemophilia, cystic fibrosis, fragile X syndrome, congenital heart disease, phenylketonuria, dwarfism, sickle cell anemia, and Tay-Sachs disease to increase understanding of possible genetic risk and lead to enhanced pregnancy outcomes_ [191]. Individuals should have a **full medical examination to ensure _chronic conditions are under control before conceiving_. This should include exploring use of medications known to be safe for a fetus** [5,191]. Encourage individuals to speak with a genetic counsellor if they have a family history of genetic disorders [191]. **Oral health** ***Effect*** Dental caries and other oral diseases are common in women of reproductive age (\>80% of women aged 20-39 years) [191,194]. _Pregnant women with periodontal disease, which is a preventable and treatable condition, may have higher risk of delivering a preterm or low birth weight baby_ [195,196,197]. A mother with recent tooth decay can transmit the caries causing bacteria to the child [197,198,199,200]. Although not directly linked to fertility or birth outcomes, oral health in males contributes positively to physical, mental and social well-being and should be encouraged [198]. *Recommendations* Encourage individuals of reproductive age to **_visit their dental care professional for regular care to prevent chronic conditions and maintain oral health before pregnanc_y [**197,201]. **Sexually Transmitted Infections (STI)** *Effects* S_ome types of STIs, including HIV, can cause infertility in men and women, adverse pregnancy outcomes including preterm and low birth weight babies, transmission of the infection to fetus/infant, stillbirth or physical and developmental disabilitie_s [202,203,204,205]. *Recommendations* Incorporate _STI prevention as part of routine patient care_. **Screen for and treat STIs early** to prevent adverse outcomes to fertility, pregnancy and fetal health [13,202,204]. _Particular attention should be given to teens as they have the highest rates of STIs among young people_ [203,204,205]. **Tobacco Use** *Effects* Women who smoke are more likely to experience _reduced fertility_ as tobacco use can influence conception delay, ovarian function, tubal function, and uterine receptiveness [5,206,207,208]. Smoking in males is associated with erectile dysfunction, low sperm counts, poor motility, altered sperm quality which can lead to failed embryo implantation and adverse birth outcomes including low birth weight [206,207,208,209]. _Nicotine exposure during pregnancy contributes to adverse birth outcomes, such as ectopic pregnancy, miscarriage, preterm birth and stillbirth_ [163,196,206,208]. Smoking in early pregnancy is linked to _orofacial clefts in infants_, and evidence suggests that smoking could be associated with certain other birth defects [207]. _Exposure to second-hand tobacco smoke has been causally linked to cancer, respiratory, cardiovascular diseases, and to adverse effects on the health of infants and children_ [163,207]. *Recommendations* Provide **_routine screening of tobacco use for all individuals_. _Brief interventions_,** of 1-3 minutes, are effective and should be offered to every tobacco user18 . Quit attempts before conception provide an opportunity for women to use nicotine replacement therapies without concern for a developing fetus [13,163,208]. Educate all non-smokers about harms associated with second-hand smoke and harmful effects on pregnant women and unborn children [13,163]. **Vaccine Preventable Diseases** *Effects* Infection by certain vaccine preventable diseases in women can cause serious birth defects or fetal death [211]. _For rubella and varicella, the syndromes affecting the fetus and infants are most common when a non-immune woman is exposed to the virus during pregnancy, with the greatest risk to the fetus being in the first trimeste_r [212]. Attaining immunity prior to pregnancy accounts for fewer complications related to the illnesses and provides passive immunity for the baby [212,213]. Communicable disease infection of males prior to conception can affect fertility e.g., a common complication of mumps is orchitis, inflammation of the testicles [214]. *Recommendations* **_Provide routine immunity assessment and vaccination_**, if necessary, to individuals of reproductive age [213]. Women should be advised to _avoid pregnancy for at least 28 days after live vaccination_s since these vaccines cross the placenta and there is a theoretical risk to the fetus [212,213]. Ensure _partners and household contacts to a pregnant woman have up to date immunizations_ [214].

Answer 86

S Strengthen restrictions on alcohol availability A Advance and enforce drink driving counter measures F Facilitate access to screening, brief interventions and treatment E Enforce bans or comprehensive restrictions on alcohol advertising, sponsorship, and promotion R Raise prices on alcohol through excise taxes and pricing policies

Answer 87

**In summary:** **Content**: trust/solidarity, reciprocity stewardship, proportionality, equity/fairness **Process**: openness/transparency, accountability, inclusiveness, reasonableness Many of the issues encountered in pandemic preparedness and response involve _balancing rights, interests and values_. Examples include decisions over _resource allocation; prioritization guidelines for pandemic vaccine and antiviral medications; adoption of public health measures that may restrict personal freedom; roles and obligations of HCWs and persons providing medical first response, as well as their employers; the potential need for triage in the provision of critical care; and responsibilities to the global community_.21 The application of ethical reasoning to pandemic preparedness and response begins with identifying and prioritizing the ethical questions in the issue under consideration. Analysis should include reflection on the ethical considerations associated with the options, taking into account the societal versus individual interests and values that are at stake. Ethical tensions are inevitable. When weighing the options, it is important to be guided by the Canadian pandemic goals. As pandemic planning initiatives fall within the domain of public health, they are guided by a code of ethics that is distinct from traditional clinical ethics.22 Whereas clinical ethics focuses on the health and interests of individuals, public health ethics focuses on the health and interests of a population. When a health risk like a pandemic affects a population, public health ethics predominates, and a _higher value is placed on collective interests_. In practical terms, this means there should be an emphasis placed on **trust and solidarity**. Successful public health activities require relationship-building and can contribute to creating and maintaining trust between individuals, populations and health authorities. Solidarity is the notion that we are all part of a greater whole, whether an organization, a community, nation or the globe. Another important consideration is **reciprocity**, meaning that those who face disproportionate burdens in their duty to protect the public (e.g., HCWs and other workers who are functioning in a health care capacity, for example police or fire personnel who are providing medical first response) are supported by society, and that to the extent possible those burdens are minimized. The concept of stewardship is also closely related to trust. **Stewardship** refers to the responsible planning and management of something entrusted to one’s care, along with making decisions responsibly and acting with integrity and accountability. Trust, stewardship and the proper building of relationships also mean that the power conferred to government and health authorities will not be abused. For example, if restrictions are deemed essential for proper risk management, they must be effective and **proportional to the threat**, meaning that they should be imposed only to the extent necessary to prevent foreseeable harm. These restrictions should also be counterbalanced with supports to minimize the burden on those individuals affected. 21 World Health Organization. Ethical considerations in developing a public health response to pandemic influenza. The concepts of **equity and fairness** are very important to Canadians. In a pandemic context, they lead to a number of considerations. As much as possible, benefits and risks should be fairly distributed through the population. This may be difficult, however, in some circumstances, such as a pandemic that differentially affects certain populations or a very severe pandemic if resources are in short supply. Decisions should take health inequities into account and try to minimize them, rather than make them worse. Access to necessary health care may be restricted in a health crisis; however, available resources (e.g., vaccine and antiviral medications) should be distributed in a fair and equitable way. What will constitute fair and equitable distribution will be context dependent. Therefore the **transparency and reasonableness of decision-making processes** are important. Good decision-making processes are also essential for ethical decision-making. They involve the following:23,24 * **openness and transparency**—the process is open for scrutiny, and information about the basis for decisions and when and by whom they were made is publicly accessible; * **accountability**—being answerable for decisions; * **inclusiveness**—stakeholders are consulted, views are taken into account, and any disproportionate impact on particular groups is considered; and * **reasonableness**—decisions should not be arbitrary but rather be rational, proportional to the threat, evidence-informed and practical.

Answer 88

Knowledge translation includes _synthesis, dissemination, exchange, implementation._ Knowledge to action (ASSESS) A. Identify _need_. Identify, review and select knowledge (PLAN) B. Adapt knowledge to _local context_ C. Identify _barriers and facilitators_ to knowledge use. Select appropriate KT strategies (IMPLEMENT) D. Tailor and implement KT strategies (EVALUATE) E. Monitor knowledge use F. Evaluate outcomes G. Sustain knowledge use

Answer 89

**Interventions to prevent drowning** Provide safe places away from water for pre-school children Install barriers controlling access to water Teach school-age children (aged over 6 years) swimming and water safety skills Build resilience and manage flood risks and other hazards Train bystanders in safe rescue and resuscitation Set and enforce safe boating, shipping and ferry regulations Promote multisectoral collaboration Strengthen public awareness of drowning through strategic communications Establish a national water safety plan Research: advance drowning prevention through data collection and well-designed studies There are other factors that are associated with an increased risk of drowning, such as: _lower socioeconomic status_, being a member of an ethnic minority, lack of higher education, and rural populations all tend to be associated, although this association can vary across countries; _infants left unsupervised or alone with another child around water_; _alcohol use_, near or in the water; medical conditions, such as _epilepsy_; tourists unfamiliar with local water risks and features;

Answer 90

**Healthy eating habits:** *(Mnemonic: Mind your Cooking to Enjoy Others)* Be mindful of your eating habits Cook more often Enjoy your food Eat meals with others **Food choices:** Eat plenty of vegetables and fruits, whole grain foods and protein foods. Choose protein foods that come from plants more often. Limit highly processed foods. If you choose these foods, eat them less often and in small amounts. Make water your drink of choice Use food labels Be aware that food marketing can influence your choices

Answer 91

**West Nile Virus Neurological Syndrome (WNNS)** Confirmed case Clinical criteria AND at least one of the confirmed case diagnostic test criteria Probable case Clinical criteria AND at least one of the probable case diagnostic test criteria Suspect case Clinical criteria in the absence of or pending diagnostic test criteria AND in the absence of any other obvious cause Clinical criteria _History of exposure in an area where West Nile virus (WNV) activity is occurring_ (see Comments section) _or history of exposure to an alternative mode of transmission_ (see Comments section) _and onset of fever_ _and recent onset of at least one of the following:_ encephalitis (acute signs of central or peripheral neurologic dysfunction) or viral meningitis (pleocytosis and signs of infection, e.g. headache, nuchal rigidity) or acute flaccid paralysis (e.g. poliomyelitis-like syndrome or Guillain-Barré-like syndrome), or movement disorders (e.g. tremor, myoclonus) or Parkinsonism or Parkinsonian-like conditions (e.g. cogwheel rigidity, bradykinesia, postural instability) or other neurological syndromes **West Nile Virus Non-Neurological Syndrome (WN Non-NS)** Confirmed case Clinical criteria and at least one of the confirmed case diagnostic test criteria Probable case Clinical criteria and at least one of the probable case diagnostic test criteria Suspect case Clinical criteria in the absence of or pending diagnostic test criteria and in the absence of any other obvious cause Clinical Criteria _History of exposure in an area where WN virus (WNV) activity is occurring_ _or history of exposure to an alternative mode of transmission_ _and at least two of the following:_ fever myalgia anthralgia headache fatigue lymphadenopathy maculopapular rash

Answer 92

We recommend not screening asymptomatic adults (≥65 years of age) for cognitive impairment Strong recommendation, low quality evidence

Answer 93

**PTSD** is a mental disorder that may occur after a traumatic event where there is exposure to actual or threatened death, serious injury, or sexual violence **At risk groups:** Canadian Armed Forces Serving Members and Veterans Public safety personnel Health care providers Other occupations Indigenous people who work in high-stress occupations and additional considerations. Other populations: Survivors of physical, sexual and/or psychological violence Survivors of disasters LGBTQ2 Refugees and other newcomers People experiencing homelessness **FEDERAL FRAMEWORK ON PTSD—AT A GLANCE** SCOPE The focus of the Framework is on _occupation-related PTSD_. The Framework also acknowledges people affected by nonoccupation- related PTSD and broad applicability will be considered in the implementation of federal actions. PURPOSE Strengthen knowledge creation, knowledge exchange and collaboration across the federal government, and with partners and stakeholders, to inform practical, evidence-based public health actions, programs and policies, to reduce stigma and improve recognition of the symptoms and impacts of PTSD. VISION A Canada where people living with PTSD, those close to them, and those at risk of developing PTSD, are recognized and supported along their path toward healing, resilience, and thriving. GUIDING PRINCIPLES - Complement current initiatives and leverage partnerships - Advance compassionate, non-judgemental and strengths-based approaches - Base initiatives on evidence of what works or shows promise of working - Understand and respond to equity, diversity and inclusion - Apply a public health approach PRIORITY AREAS * *DATA AND TRACKING** 1. Explore strategies to support _national surveillance activities_ and examine the feasibility of using _health administrative data_ and enhanced _data linkages_ to capture and report on PTSD. 2. Continue supporting data collection on PTSD. * *GUIDELINES AND BEST PRACTICES** 1. Work with partners and engage experts to compile existing _guidance on PTSD and identify where gaps_ may exist. 2. Continue to support research to bridge PTSD-related information gaps, inform effective guidance for health care providers, and advance evidence-based decision making. * *EDUCATIONAL MATERIALS** 1. Work with partners and engage health care providers to identify current PTSD educational materials, understand the educational gaps, and seek advice on best practices for the dissemination, adaptation, and uptake of educational materials. **STRENGTHENED COLLABORATION** 1. Work with partners and stakeholders to identify the best mechanism(s) to increase collaboration among key departments, partners and stakeholders, as well as for ongoing sharing of information, including uptake of common and culturally appropriate terminology, definitions, and safe language about PTSD and trauma.

Answer 94

**How vaping is regulated federally** Vaping products manufactured, labelled, advertised, imported or sold in Canada are subject to, among others, the following Acts and their Regulations: Tobacco and Vaping Products Act Canada Consumer Product Safety Act (no health claim product) Food and Drugs Act (health claim product) Non-smokers' Health Act (second hand smoke) Cannabis Act (cannabis containing products **Tobacco and Vaping Products Act** _The Tobacco and Vaping Products Act (TVPA) became law on May 23, 2018_. While continuing to govern tobacco products as was the case under the Tobacco Act which it replaced, the _TVPA also applies to vaping products. It aims to protect Canadians from nicotine addiction and from inducements to use tobacco and, in particular for youth, from vaping products use._ Key elements of the TVPA related to vaping products include: _not allowing vaping products to be sold or given to anyone under 18 years of age_ _not allowing the sale of vaping products that appeal to youth_ _giving the federal Government the ability to make rules about:_ _industry reporting_ _manufacturing standards_ _product and package labelling (for example, health warnings)_ _banning the use of certain ingredients and flavours_ _the promotion of vaping products_ For more information about the TVPA, contact the Tobacco Control Directorate by email at hc.tcp.questions-plt.sc@canada.ca. **Canada Consumer Product Safety Act** The manufacturing, importation, advertisement and sale of _vaping products that do not make health claims_ are subject to the Canada Consumer Product Safety Act (CCPSA), while also subject to the TVPA. In addition to other authorities, the CCPSA allows the federal Government to: carry out inspections order recalls or other measures For more information about the CCPSA, contact the Consumer and Hazardous Product Safety Directorate by email at hc.cps-spc.sc@canada.ca. **Food and Drugs Act** The Food and Drugs Act (FDA) applies to _vaping products that make a health claim (help quit smoking)_. This includes products that contain nicotine or any other drugs as defined by the FDA. These products must receive an authorization from Health Canada before they can be: advertised sold in Canada commercially imported Before issuing a market authorization, Health Canada carefully reviews the evidence provided by the product sponsor. This review is done to confirm the product meets safety, efficacy and quality requirements. A valid site licence from Health Canada is also required before a vaping product can be: labelled imported packaged manufactured The TVPA also applies to these vaping products, unless specifically excluded. Notice: Implications of the Tobacco and Vaping Products Act for the Health Products Regulated Under the Food and Drugs Act Contact: Therapeutic Products Directorate at hc.policy.bureau.enquiries.sc@canada.ca for the review process and regulation of prescription health products under the Food and Drug Regulations Natural and Non-Prescription Health Products Directorate at hc.nnhpd-dpsnso.sc@canada.ca for the authorization of non-prescription drugs as well as product and site licences for natural health products **Non-smokers' Health Act** _The Non-smokers' Health Act (NSHA) addresses the issue of second-hand smoke and vapour._ This Act applies to federally regulated workplaces, such as: banks ferries commercial aircraft federal government offices For more information about the NSHA, contact the Labour Program at Employment and Social Development Canada. **Cannabis Act** _Vaping products containing cannabis are regulated under the Cannabis Act and its regulations_. The Cannabis Act became law on October 17, 2018, and establishes the framework for controlling the production, sale and possession of cannabis across Canada. _The purpose of the Act is to protect public health and public safety, by, among other things, restricting youth access to cannabis, protecting young persons and others from inducements to using cannabis, and deterring illicit activities in relation to cannabis through appropriate sanctions and enforcement measures._ _On October 17, 2019, cannabis extracts, including vaping products, became legal for sale in Canada._ In developing the regulations governing the production and sale of new cannabis products, including vaping products, Health Canada took into consideration risks associated with various routes of exposure to cannabis. Inhalation poses potential health risks because of the greater sensitivity and vulnerability of lung tissue to certain chemicals. For this reason, certain regulatory requirements pertaining to vaping products containing cannabis, are even more stringent than those for other non-inhaled cannabis products. As with vaping products containing nicotine, the safety of cannabis vaping devices (such as the batteries) is regulated under the CCPSA.

Answer 95

**Benefits:** reassurance, less radical treatment, opportunity for cure, cost-benefit, prognosis improvement. **Risks:** **-** overdiagnosis/overtreatment and anxiety if false positives, - false reassurance or recklessness if false negative, - risk of test, - resource utilization, - public confidence, - stigma, - increased health inequities

Answer 96

Before initial patient/patient environment contact Before aseptic procedure After body fluid exposure risk After patient / patient environment contact

Answer 97

Health litteracy: “The ability to access, comprehend, evaluate and communicate information as a way to promote, maintain and improve health in a variety of settings across the life-course.” **Health effects**  Need for _prevention and chronic disease self-management_, including:  making _lifestyle adjustments_  understanding and applying complex medical and _medication regimen_  knowing _where and how to access health care services_  _communicating health care information_ across the health care system - in older adult, those with low health litteracy were 2 time more likely to die within 5 years. **Benefits of adequate literacy:** increases patient safety, improves outcomes (correlates with health behaviors around eating habits, smoking, sleep, alcohol, exercise, etc), help people understand what to do to stay healthy, saves time+money, reaches more people, increases engagement **Strategies**: _universal precautions_ approach _Engage your audience_, use _plain language and clear design_, focus on _key messages_, promote _teach-back methods_, use _patient friendly resources_ to enhance teaching

Answer 98

Internal External Criterion Construct Content Face Statistical conclusion Internal - how much does the independent variable affect the dependent variable? External - how well the research applies to the "real world" Face - does it feel valid? Construct - how much your research covers the content of the construct (as opposed to things outside it) Criterion - how well your instrument measures the thing it is supposed to measure Content - covers the whole of the content in the area you are aiming to assess Statistical conclusion - doing the right sampling/tests/measures

Answer 99

2 and 4 mos - routine DTaP-IPV-Hib Pneu-Conjugate-13 Rotavirus \*some provinces add HB here, some start at birth, must have 3 doses of HB in schedule \*some provinces add Men-C-C here at 2 or 4 mos \* RSV ppx (palivizumab) if high-risk \<37 GA when born and under 6 mos at start of RSV season 6 mos - routine DTaP-IPV-Hib +/- HB Rota if 3 dose-shedule (complete series before 8 months) 12 mos - routine Men-C-C MMR Pneu-C-13 \*some provinces do Var here 15 mos - routine \*Var 18 mos - routine DTap-IPV-Hib \*MMRV \*some provinces do HAHB here 4-6 years - routine \*MMRV (if not done previously, 2 doses total)) Tdap(or DTaP)-IPV Grade 7 - routine \*HB x 2 \*HPV x 2 \*Men-C-ACYW-135 14-16 - routine Tdap When to give influenza, Anyone over 6 mos, once annually Routine adult immunizations Td - q10 years Tdap - one dose bw 27-32 wGA, one dose in adulthood, immunize as early as possible for adults who will be in close contact w young infants Recombinant zoster - 50+ yrs x 2 doses HPV 4/9 - up to and including 26yo Influenza - annually Measles + mumps - 1 dose if born in or after 1970 Meningococcal conj - 1 dose under 25 if not imm in adolescence Pneumococcal polysaccharide - 1 dose 65+ Polio - primary series if previously unimm Rubella - 1 dose if susceptible, post-delivery if susc preg Varicella - 2 doses if susceptible under age 50, no routine testing 50+ but give 2 doses if known to be seronegative Pregnancy/breastfeeding - recommended Hep B when pregnant if seronegative and high risk of exposure Influenza Pertussis Meningococcal \*during outbreak Rabies PEP (pregnancy) MMR (breastfeeding, if not immune) Varicella (breastfeeding, if not immune)

Answer 100

ADVANTAGES AND DISADVANTAGES OF THE DESIGNS **Randomised Controlled Trial** An experimental comparison study in which participants are allocated to treatment/intervention or control/placebo groups using a random mechanism (see randomisation). Best for study the effect of an intervention. _Advantages:_ unbiased distribution of confounders; blinding more likely; randomisation facilitates statistical analysis. _Disadvantages:_ expensive: time and money; volunteer bias; ethically problematic at times. **Crossover Design** A controlled trial where each study participant has both therapies, e.g, is randomised to treatment A first, at the crossover point they then start treatment B. Only relevant if the outcome is reversible with time, e.g, symptoms. _Advantages:_ all subjects serve as own controls and error variance is reduced thus reducing sample size needed; all subjects receive treatment (at least some of the time); statistical tests assuming randomisation can be used; blinding can be maintained. _Disadvantages:_ all subjects receive placebo or alternative treatment at some point; washout period lengthy or unknown; cannot be used for treatments with permanent effects **Cohort Study** Data are obtained from groups who have been exposed, or not exposed, to the new technology or factor of interest (eg from databases). No allocation of exposure is made by the researcher. Best for study the effect of predictive risk factors on an outcome. _Advantages:_ ethically safe; subjects can be matched; can establish _temporality and directionality_ of events; can measure disease _incidence_ eligibility criteria and outcome assessments can be standardised; administratively easier and cheaper than RCT; several outcomes can be assessed; retrospective study quick + inexpensive _Disadvantages:_ controls may be difficult to identify; exposure may be linked to a hidden confounder; blinding is difficult; randomisation not present; for rare disease, large sample sizes or long follow-up necessary, prospective study expensive Loss to follow-up **Case-Control Studies** Patients with a certain outcome or disease and an appropriate group of controls without the outcome or disease are selected (usually with careful consideration of appropriate choice of controls, matching, etc) and then information is obtained on whether the subjects have been exposed to the factor under investigation. _Advantages:_ quick and cheap, efficient only feasible method for very rare disorders or those with long lag between exposure and outcome; fewer subjects needed than cross-sectional studies; May evaluate multiple exposures _Disadvantages:_ reliance on recall or records to determine exposure status; confounders; selection of control groups is difficult; potential bias: _recall,_ selection. Studies _just 1 outcome_ _No incident cases, can only estimate RR with OR_ **Cross-Sectional Survey** A study that examines the relationship between diseases (or other health-related characteristics) and other variables of interest as they exist in a defined population at one particular time (ie exposure and outcomes are both measured at the same time). Best for quantifying the prevalence of a disease or risk factor, and for quantifying the accuracy of a diagnostic test. _Advantages:_ cheap and simple; ethically safe. _Disadvantages:_ establishes association at most, not causality; recall bias susceptibility; confounders may be unequally distributed; Neyman survival bias (=incidence-prevalence bias, survivors disproportionately represented) group sizes may be unequal Cannot calculate risk Temporal association cannot be determined

Answer 101

Proportional hazards Linear covariate relationship Independance

Answer 102

Acting on SDoH Control of Infectious Diseases Decline in deaths from CHD/Stroke x 1960s Healthier environments (i.e. less lead, fluoride in water) Family Planning Healthier mothers & babies Motor-vehicle safety Recognition of tobacco as a health hazard Safer and healthier foods Safer workplaces 'Universal' policies - i.e. for income, social services, healthcare Vaccination

Answer 103

Global strategy to reduce harmful use of alcohol (WHO 2010) The harmful use of alcohol is a serious health burden, and it affects virtually all individuals on an international scale. Health problems from dangerous alcohol use arise in the form of _acute (intoxication, injuries) and chronic conditions (cancer, liver ,etc), and adverse social consequences_ are common when they are associated with alcohol consumption. _Every year, the harmful use of alcohol kills 2.5 million people, including 320 000 young people between 15 and 29 years of age_. It is the _third leading risk factor for poor health globally, and harmful use of alcohol was responsible for almost 4% of all deaths in the world, according to the estimates for 2004._ The global strategy focuses on ten key areas of policy options and interventions at the national level and four priority areas for global action. The **ten areas for national action** are: _leadership, awareness and commitment;_ _health services' response;_ _community action;_ _drink-driving policies and countermeasures;_ _availability of alcohol;_ _marketing of alcoholic beverages;_ _pricing policies;_ _reducing the negative consequences of drinking and alcohol intoxication;_ _reducing the public health impact of illicit alcohol and informally produced alcohol;_ _monitoring and surveillance._ The **four priority areas for global action** are: _public health advocacy and partnership;_ _technical support and capacity building;_ _production and dissemination of knowledge;_ _resource mobilization._ **Effective public health interventions** 1. Increase in excise _taxes_ on alcoholic beverages 2. Enforcement of bans or comprehensive restrictions on exposure to alcohol _advertising_ (across multiple types of media) 3. Enforcement of _restrictions on the physical availability of retailed alcohol (via reduced hours of sale)_ 4. Enforcement of _drink-driving laws_ and blood alcohol concentration limits via sobriety checkpoints 5. Provision of _brief psychosocial intervention_ for persons with hazardous and harmful alcohol use **or SAFER** * *S**trengthen restrictions on availability * *A**dvance policies around drunk driving * *F**acilitate treatment * *E**nforce bans on advertising * *R**aise taxes

Answer 104

- Infant mortality - Low birth weight - Asthma - Overweight/obesity - Unintentional and intentional injuries - Lower readiness to learn (i.e., prepared for learning and formal schooling) - Impairment of functional health (e.g., vision, hearing, speech or mobility) - Emotional and behavioural problems - Dental caries

Answer 105

Campylobacter Entamoeba histolytica Shigella E Coli (EIEC, STEC, EHEC) Yersinia enterolitica Salmonella

Answer 106

Directive on Performance Management. **Performance agreements** must include: - _Clear and measurable **work objectives**, with associated **performance measures**_, that are linked to the priorities of the organization and of the Government of Canada; - _Observable and measurable **expected behaviours**_; - A _**learning and development pla**n_; and - _Sign-off by the manager and employee_ acknowledging that the content of the performance agreement has been discussed. A **mid year performance review** must include: - A _review of progress against established work objectives_; - A r_eview of whether the employee is demonstrating the expected behaviours_; - A _review of learning and development needs and activities_; - _Amendments_ to the performance agreement and learning and development plan, as required; and - _Sign-off by the manager and employee_ acknowledging that the content of the mid year review has been discussed. The **performance assessment** must include: - A **_narrative assessment of performance_** that supports the assigned performance rating(s); and - Sign-off by the manager and employee acknowledging that the content of the performance assessment has been discussed. A **learning and development plan** must be developed for each employee and include: - Employee career goals and aspirations; and - Planned activities that support the achievement of the employee\_s established work objectives, expected behaviours and continuous development. A **talent management plan** must be initiated when: - Prescribed by the organization's performance and talent management program; - Prescribed for the functional community to which the employee belongs; - Required to support _ongoing high performance_; and - Mutually agreed upon by the manager and employee. A **talent management plan** must identify the: - Employee's **career goals and aspirations**; - Employee's **strengths and areas for development**; - **Activities** to support the continued development of the employee; and - A **timeline and milestones** against which to measure the employee's progress. A **performance improvement plan** must be initiated when: - _Employee performance does not meet expectations_; or - Any time the manager determines that a performance issue needs to be documented. A **performance improvement plan** must include: - Specific **areas for improvement;** - **Actions** that will be taken by the employee to address the identified areas needing improvement; - Description of the **support** that will be provided by the manager to the employee to improve performance; and - A **timeline and milestones** against which to measure the employee's progress. **Departmental review panels** will undertake the following: - Ensuring that performance and talent management initiatives in the organization are conducted fairly and consistently; - At least annually, reviewing data on the organization\_s management of performance and talent, including progress made against individual action plans for improvement; - Making recommendations to recognize exceptional performance, as applicable, in accordance with the organizational recognition program; and - Making recommendations to the deputy head and head of human resources to improve the organization's performance and talent management programs, as appropriate.

Answer 107

**Incompetence:** Employee lacks the skills or ability to do the job.  Set out _clear, reasonable job expectations_ in company policy.  _Communicate clearly job expectations_ to all employees.  _Bring unacceptable work to the attention of the employee promptly_.  _Provide reasonable supervision, training and instruction_.  Give reasonable _warning that failure to meet these expectations could result in dismissal._  _Allow for time and opportunity to meet the job expectations_.  As a final step in the process, _if no improvement, dismiss the employee._  Keep complete written records. **Misconduct:** Employee breaks rules for keeping the work place efficient and safe.  Give the employee the opportunity to tell his/her story about the misconduct.  Collect all the relevant facts surrounding the misconduct.  Give a _verbal warning_.  Give a _written warning_.  _Suspend the employee_.  As a final step in the process, _dismiss the employee_.  Keep complete written records. **Factors to consider when disciplining:** - Frequency, impact, severity - History, mitigating circumstances, expectations - Policy / precedence

Answer 108

We recommend AGAINST screening for impaired vision in primary care settings for community-dwelling adults aged 65 years and over (**Weak recommendation, low quality evidence**). This recommendation applies to community dwelling adults aged 65 years and over who are not already under the care of a specialist ophthalmologist. It does not apply to those known to have a condition predisposed to vision impairment such as glaucoma or diabetes; who live in full-time residential care; or, who have a diagnosis of dementia.

Answer 109

Health inequities are disadvantages in health between groups that are: _1) systematic/pervasive,_ _2) unfair/unjust_ _3) modifiable/preventable._ 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. _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 conducive to health for all._ Health equity means that _all people can reach their full health potential and are not disadvantaged from attaining it because of their race, ethnicity, religion, gender, age, social class, socioeconomic status or other socially determined circumstance_. **PH roles for addressing health inequities:** ASSESS AND REPORT Assess and report on a) the existence and impact of health inequities, and b) effective strategies to reduce these inequities. MODIFY AND ORIENT INTERVENTIONS Modify and orient interventions and services to reduce inequities, with an understanding of the unique needs of populations that experience marginalization. PARTNER WITH OTHER SECTORS Partner with other government and community organizations to identify ways to improve health outcomes for populations that experience marginalization. PARTICIPATE IN POLICY DEVELOPMENT Lead, support and participate with other organizations in policy analysis and development, and in advocacy for improvement in health determinants and inequities.

Answer 110

_These include fresh/frozen tuna, shark, swordfish, marlin, , king mackerel, chilean sea bass, orange roughy and escolar_ (Note: Additional health information on escolar is available from Health Canada's Fact Sheet on escolar and CFIA's fact sheet. Canadians who like to consume these types of fish can continue to do so, but should limit their consumption to the amounts shown in the table below. Other types of fish should be chosen to make up the rest of their recommended weekly fish consumption. General Population - 150 g per week Specified Women \* - 150 g per month Children 5-11 years old - 125 g per month Children 1-4 years old - 75 g per month \* Specified women are those who are or may become pregnant or are breastfeeding. 150 grams is equivalent to approximately one cup. This advice does NOT apply to canned tuna. Information on canned tuna is provided in the next section. (2 cans per week for preg women)

Answer 111

Notice to bargain -\> direct bargaining Notice of dispute (15 days) Ministerial decision Conciliation (60 days) Termination of conciliation (21 days) Acquisition of right to strike/lockout Mediation

Answer 112

The biggest source of dioxins and furans in Canada is the _large-scale burning of municipal and medical waste_. Other major sources include: • the _production of iron and steel_ • _backyard burning of household waste_, especially plastics • _fuel burning_, including diesel fuel and fuel for agricultural purposes and home heating • _wood burning_, especially if the wood has been chemically treated Health effects associated with human exposure to dioxins include: • _skin disorders, such as chloracne_ • _liver problems_ • _impairment of the immune system, the endocrine system and reproductive functions_ • _effects on the developing nervous system and other developmental events_ • _certain types of cancers_ Minimizing Your Risk If you are concerned about exposure to dioxins and furans, consider taking the following steps: • Prepare meat and fish in a way that minimizes your exposure by trimming visible fat from food. Bake, broil, roast, barbecue or microwave _instead of frying_, and drain off extra fat after cooking • Follow the advice in Canada’s Food Guide to Healthy Eating, and _enjoy a variety of foods_. Vegetables, fruit and grains contain fewer dioxins and furans than meat, milk products and fish. • _Follow provincial/territorial government advisories about eating certain types of fish_. • _Do not burn garbage_, especially construction materials that might contain wood preservatives or plastic. • _Limit the amount of wood you burn in your fireplace_ or stove, and learn about woodburning techniques that release fewer dioxins. • _Do not smoke_, and keep your family away from secondhand smoke as much as possible.

Answer 113

Initiation Promotion Progression Metastasis

Answer 114

1. _Introduction_ of team members to each other 2. Identify relevent _skills_ of all team members 3. Assigning _roles and responsibilities_ to team members and ensuring these are understood 4. Establish _reporting processes and hierarchies_ within the team and ensure they are understood 5. Establish _goals and essential tasks_ of the whole team/unit and ensure these are shared and understood 6. _Regular team meetings_ to identify and clarify and issues with understanding of team structure and function

Answer 115

SURVEILLANCE ACTION 1: Establish and strengthen surveillance systems to identify new threats or changing patterns in antimicrobial resistance and use, in human and animal settings. STEWARDSHIP ACTION 2: Strengthen the promotion of the appropriate use of antimicrobials in human and veterinary medicine. ACTION 3: Work with the animal agriculture sector partners to strengthen the regulatory framework on veterinary medicines and medicated feeds, including facilitating access to alternatives and encourage the adoption of practices in order to reduce the use of antimicrobials. INNOVATION ACTION 4: Promote innovation through funding collaborative research and development efforts on antimicrobial resistance both domestically and internationally

Answer 116

Air pollution Arsenic Asbestos Benzene Cadmium Dioxin Fluoride Lead Mercury Hazardous pesticides

Answer 117

The goal of testing for latent tuberculosis infection (LTBI) is to identify individuals who are at increased risk for the development of active tuberculosis (TB) and therefore would benefit from treatment of LTBI. _Only those who would benefit from treatment should be tested_, so a decision to test presupposes a decision to treat if the test is positive. There are two accepted tests for identification of LTBI: the tuberculin skin test (TST) and the interferon gamma release assay (IGRA). _When interpreting a positive TST, it is important to consider much more than simply the size of the reaction. Rather, the TST should be considered according to three dimensions:_ _**size of induration**,_ _**positive predictive value** and_ **_risk of disease if the person is truly infected_**. As with the TST, IGRAs are surrogate markers of Mycobacterium tuberculosis infection and indicate a cellular immune response to M. tuberculosis. _In general, IGRAs are more specific than the TST in populations vaccinated with Bacille Calmette-Guérin (BCG), especially if BCG is given after infancy or multiple times._ _Neither the TST nor IGRAs can separate LTBI from TB disease and therefore have no value for active TB detection. Both tests have suboptimal sensitivity in active TB, especially in HIV-infected people and children._ Both tests appear to correlate well with the gradient of exposure. Both tests are associated with nonspecific variations and reproducibility issues, and borderline values need careful interpretation. _Neither IGRAs nor the TST have high accuracy for the prediction of active TB, although use of IGRAs might reduce the number of people considered for preventive treatment._ Major Recommendations Both the TST and IGRA are acceptable alternatives for LTBI diagnosis. Either test can be used for LTBI screening in any of the situations in which testing is indicated, with preferences and exceptions noted below. 1. Situations in which neither TST nor IGRAs should be used for testing Neither the TST nor the IGRA should be used for testing people who have a low risk of infection and a low risk that there will be progression to active TB disease if they are infected. However, low-risk individuals are commonly tested before exposure, when repeat testing is likely. In this situation TST is recommended (refer to recommendation 3 below); if the TST is positive then an IGRA may be useful to confirm a positive TST result to enhance specificity. Neither TST nor IGRA should be used for active TB diagnosis in adults (for children, refer to recommendation 4). Neither TST nor IGRA should be used for routine or mass screening for LTBI of all immigrants (adults and children). _Neither TST nor IGRA should be used for monitoring anti-TB treatment response._ 2. Situations in which IGRAs are preferred for testing but a TST is acceptable People who have received BCG as a vaccine after infancy (1 year of age) and/or have received BCG vaccination more than once. People from groups that historically have poor rates of return for TST reading. 3. Situations in which TST is recommended for testing but an IGRA is NOT acceptable The TST is recommended whenever it is planned to repeat the test later to assess risk of new infection (i.e. conversions), such as repeat testing in a contact investigation or serial testing of health care or other populations (e.g. corrections staff or prison inmates) with potential for ongoing exposure. 4. Situations in which both tests can be used (sequentially, in any order) to enhance sensitivity Although routine dual testing with both TST and IGRA is not recommended, there are situations in which results from both tests may be helpful to enhance the overall sensitivity: When the risks of infection, of progression to disease and of a poor outcome are high. In children (under age 18 years) with suspected TB disease, IGRAs may be used as a supplementary diagnostic aid in combination with the TST and other investigations to help support a diagnosis of TB. However, IGRA should not be a substitute for, or obviate the need for, appropriate specimen collection. A negative IGRA (or TST) does not rule out active TB at any age and especially not in young children. In addition, repeating an IGRA or performing a TST might be useful when the initial IGRA result is indeterminate, borderline or invalid, and a reason for testing persists.

Answer 118

Implement integrated suite of solutions Collaborate to drive novel approaches Strengthen multi-disciplinary evidence for decision making Address trauma and eliminate stigma Making prevention a priority

Answer 119

* Income and social status * Social support networks * Education and literacy * Employment/working conditions * Social environment * Physical environment * Personal health practices and coping skills: * Healthy child development * Biology and genetic endowment * Health services * Gender * Culture **Mnemonic: S₂E₂P₂H₂I - BCG**

Answer 120

 We recommend NOT screening adults (≥18 years) with chronic GERD, for EAC or precursor conditions (Barrett esophagus, dysplasia) (**strong recommendation; very low-certainty evidence**).

Answer 121

**Canadian Tuberculosis ( ) System** **1 = (Laboratory Surveillance)** **2 = (Reporting)** **The Canadian Tuberculosis Reporting System (CTBRS)** Provincial and territorial tuberculosis control programs participate in the CTBRS national surveillance system by reporting to the Centre for Communicable Diseases and Infection Control (CCDIC), Public Health Agency of Canada (PHAC), all new and re-treatment cases of active tuberculosis that meet the Canadian case definition. **The Canadian Tuberculosis Laboratory Surveillance System (CTLSS)** This national laboratory-based surveillance system was established in 1998 to collect timely data on _TB drug resistance across Canada_. Participating laboratories include members of the Canadian Tuberculosis Laboratory Technical Network (covering all provinces and territories). These laboratories report data annually on drug susceptibility test results for all TB isolates to the CCDIC, PHAC. Data are reported in both paper and electronic format and comprise the information found on the M. tuberculosis Complex Antimicrobial Susceptibility Reporting Form.

Answer 122

Children of families that have not applied for the benefit Children of families that are not elegible for the benefit (e.g. non-residents of Canada for tax purposes, children in foster care receiving other benefit) Who can get the Canada child benefit? You must meet all of the following conditions: - You live with a child who is under 18 years of age - You are primarily responsible for the care and upbringing of the child - You are a resident of Canada for tax purposes - You or your spouse or common-law partner must be any of the following: a Canadian citizen a permanent resident a protected person a temporary resident who has lived in Canada for the previous 18 months, and who has a valid permit in the 19th month an Indigenous person who meets the definition of "Indian" under the Indian Act You cannot get the Canada child benefit (CCB) for a foster child for any month in which Children's special allowances (CSA) are payable. You may get the CCB if you live with and care for a child under a kinship or close relationship program, as long as CSA are not payable for that child.

Answer 123

a. Quelle est la différence de risque? = Risque chez les exposées – Risque chez les non-exposées = (16,2-10,6) par 100 000 = 5,6 par 100 000 b. Quelle est la fraction attribuable chez les exposées? Interprétez cette valeur = (Risque chez les exposées – Risque chez les non-exposées) / Risque chez les exposées = Différence de risque / Risque chez les exposés = (5,6 par 100 000 / 16,2 par 100 000) = 34,57 % Interprétation : Un peu plus du tiers (ou 34,57%) des cancers du sein chez les femmes inactives pourraient être évités si toutes les femmes inactives atteignaient un niveau élevé d’activité physique. c. Quelle est la fraction attribuable dans la population? Interprétez cette valeur Incidence dans la population (par 100 000) : = (0,8 x 16,2) + (0,2 x 10,6) = 15,1 par 100 000 Fraction attribuable dans la population : = (Risque dans la population – Risque chez les non exposées)/Risque dans la population = (15,1-10,6)/15,1 = 29,8 % Interprétation : Environ 3 cancers du sein sur 10 pourraient être évité chez les femmes de plus de 50 ans si toutes les femmes atteignaient un niveau d’activité physique élevé. d. Combien de cas seraient prévenus si toutes les femmes de 50 ans et plus avaient un niveau élevé d’activité physique? Nombre de femmes de plus de 50 ans = 21% x 8 000 000 = 1 680 000 femmes Nombre de cas prévenus = Nombre de femmes de 50 ans x proportion d’inactives x différence de risque = 1 680 000 x 80% x 5,6 par 100 000 = 75 cas OU = Nombre de femmes de 50 ans x risque populationnel de cancer x fraction attribuable population = 1 680 000 x 15,1 par 100 000 x 29,8% = 75 cas

Answer 124

Concerns about vaccine safety make some parents hesitant about immunization. Health care providers are pivotal in helping parents understand that Canada is a leader in vaccine safety. The present practice point provides an update on the eight components of Canada’s vaccine safety system: (1) an evidence-based pre-license review and approval process; (2) strong regulations for manufacturers; (3) independent evidence-based vaccine use recommendations; (4) immunization competency training and standards for health care providers; (5) pharmacovigilance programs to detect and (6) determine causality of adverse events following immunization (AEFIs); (7) a program for vaccine safety and efficacy signal detection; and (8) the Canadian Immunization Research Network’s special immunization clinics for children who have experienced serious AEFIs.

Answer 125

Steps: (IDEA framework) 1. **P**reliminary step 2. **I**dentify issue and context 3. **D**etermine ethical considerations 4. **E**xplore and assess **o**ptions 5. Select best course of **a**ction 6. **E**valuate Ethical dimensions: **(Justice RBT)** 1. Respect for persons and communities 2. Non-maleficence and beneficence 3. Trust 4. Justice Procedural considerations: **(TRRA-I)** 5. Transparency 3. Responsibility 4. Responsiveness 1. Accountability 2. Inclusiveness

Answer 126

By exposing the teeth to a constant low level of fluoride, it helps reduce the cavity-causing effect of foods and bacteria. _Fluoride molecules create stronger teeth by hardening tooth enamel, contributing to tooth surface re-mineralization and deterring oral bacteria1_. _At the population level, water fluoridation is associated with approximately a 25% to 30% reduction in tooth decay in children and adults_2. The recommended concentration for caries prevention (called the optimal level) is _0.7 milligrams/liter (mg/L)3 4 5 or 0.7 parts per million (ppm)._ Community water fluoridation (CWF) is the process of monitoring and adjusting the fluoride level in drinking water to the optimal level for caries prevention. Water fluoridation has been instrumental in the overall global reduction in dental caries and many communities around the world have access to CWF. The U.S. Centre for Disease Control considers CWF as one of the ten greatest public health achievements of the 20th century6. CWF is the _most cost effective and equitable method to deliver fluoride to the population_. This population-based preventive intervention contributes to o_ral health equity by overcoming common social determinants of health including age, education, income, and access to professional dental care_. CWF yields a _high return on investment that increases according to community population size, with a per capita annual benefit ranging from $5.49 to $93.197 per dollar invested._ _In 2017, there are around 13.9 million Canadians (38.7%) who benefit from CWF._ The _decay-missing-filled (DMF) index or decayed, missing, and filled teeth (DMFT) index is one of the most common methods in oral epidemiology for assessing dental caries prevalence as well as dental treatment needs_ among populations and has been used for about 75 years.[1] This index is based on in-field clinical examination of individuals by using a probe, mirror and cotton rolls, and simply counts the number of decayed, missing (due to caries only) and restored teeth. Another version proposed in 1931 [1] counts each affected surface, yielding a decayed, missing, and filled surfaces (DMFS) index. Statistics are available per populations according to age (e.g., "DMF of 12-year old children"). Because the DMF index is done without X-ray imaging, _it underestimates real caries prevalence and treatment needs._ Other criticisms: _inter-observer bias, no estimates of needs, no indications of number of teeth at risk, does not account for sealants._ * *Improve Oral Health** 1. Improve the _oral health of children and youth_. * *Access to Care** 2. Improve oral health access for _Aboriginal People_. 3. Ensure adequate _access to oral health care_. * *Oral Health Policy** 4. Include oral health as a key part of overall health. 5. Develop Canadian framework about _publicly-financed oral health care._ * *Surveillance** 6. Develop and maintain _information about oral health status_. * *Health Protection, Oral Health Promotion and Disease Prevention** 7. Increase _access to fluoridated water_ to help prevent dental cavities. * *Leadership and Workforce** 8. Promote oral public health leadership. 9. Promote professionals working within their capacity and full scope of practice. 10. Encourage a balanced _supply of dental professionals._

Answer 127

**Pollutants**: PM, CO, VOC, PAH (polycyclic armatic hydrocarbons) **Health risk**: ENT irritation, HA, nausea, dizziness, asthma, breathing problems. For smog (hospital admission, premature deaths) **At risk populations**: children, people with heart + lung problems **Harm reduction**: low emission stove, stove maintenance, clean chimney, burn wisely

Answer 128

**Chromium** *Sources*: Drinking water Hot work (welding fumes) Anticorrosive coatings (chrome plating) *Health effects:* EENT/skin/resp irritation Nasal septum performation, contact dermatitis, skin ulcers Pneumoconiosis, asthma _Lung_ cancer, **IARC 1** (hexavalent) **Mercury** *Sources:* _Metallic_: thermometers, dental amalgam, CFL bulbs _Inorganic_: fungicide, thimerosal, skin lightening cream _Organic (more toxic)_: fish *Health effects:* _Metallic_: erethism (mad hatter, tremor's shakes) _Inorganic_: CNS effects _Organic_: minimata disease (tremors, sensory loss, ataxia), developmental delay, dementia **IARC 2**_B_** (_organic_)**; **3 (inorganic, elemental)** **Lead** (inorganic more toxic) *Sources:* Contaminated food, soil, air Gasoline (pre 1989) Shooting ranges Stained glass Jewelry Paint Imported goods Mining, smelting, batteries Old pipes/solder *Health effects:* Acute abdominal pain CNS changes: Encephalopathy, Developmental neurotoxicity, Intellectual defects, behavioural problems Nephrotoxicity Hemolytic anemia HTN **IARC 2**_A_** (_inorganic_)**; **3 (organic)** **Cadmium** *Sources:* Released by: Metal work, electroplating, mining, waste incineration, fuel combustion Food (molluscs, veg, cereals) Smoking Batteries *Health effects:* Short-term effects: - Toxic pneumonitis, metal fume fever - Itai-itai disease (ouch-ouch in Japanese), severe joint/spine pain - GI side effects Long-term effects: - Progressive palmar fibrosis; - Kidney dysfunction → decreased vit D → osteoporosis; - Cancer (_lung, kidney, prostate, stomach_) (IARC 1) **Arsenic** Released by: fossil fuel combustion, metal production, gold mining, pesticides *Sources:* Drinking water Food (seafood, rice) Wood preservative (copper chromated arsenate, CCA) Smoking *Health effects:* Acute - N/V/abd pain, musular cramps, skin thickening, anemia, motor + sensory neuropathy, death Chronic: (arsenicosis) • thickening and discoloration of the skin; • N/V; • decreased production of blood cells; • arrhythmias; • neuropathy in the hands and feet. Cancer (_skin, bladder, liver, kidney, lung_) IARC 1 **Cobalt** Food, drinking water Additive to beer (in the past) Industry Breathing issues Cardiac issues at high exposure Quebec beer drinker's (cardio)myopathy **Copper** Source: Water distribution pipes Health effect: Cirrhosis **Aluminum** Source: Hot work Health effect: Chronic cough Alzheimer's **Nickel** Source: Smoking Joint prostheses Jewelry - rash Health effect: Lung cancer Nasoseptal perforation Allergic rash **Manganese** Source: Pesticide Health effect: Manganism (like Parkinson's) **Hydrogen sulfide** Source: natural gas, volcanic gas, microbial anaerobic fermentation of organic matter, accidental exposure Health effects Acute: respriatory irritation, SOB, HA, dizziness, stupor, syncope, death

Answer 129

improving healthy eating _information_ (food guide, FOP labelling) improving nutrition _quality of foods_ (decr Na) protecting _vulnerable populations_ (marketing to kids) supporting increased _access to and availability of nutritious foods_ (Nutrition North Canada)

Answer 130

k statistic = observed agreement - expected agreement / (1 - expected agreement) [https://www.statisticshowto.com/cohens-kappa-statistic/](https://www.statisticshowto.com/cohens-kappa-statistic/) See Mayo image.

Answer 131

HEAT heat Fainting heat Rash heat Edema heat Exhaustion Exacerbation of resp/CV illness heat Cramps heat Stroke COLD Windburn Frostnip Frostbite Hypothermia

Answer 132

When it is not possible to get laboratory confirmation of norovirus, health departments can use clinical and epidemiologic criteria to determine if the outbreak was likely caused by norovirus. The original criteria proposed by **Kaplan** et alexternal icon are: _A mean (or median) illness duration of 12 to 60 hours,_ _A mean (or median) incubation period of 24 to 48 hours,_ _More than 50% of people with vomiting, and_ _No enteric bacteria found._ When all four criteria are present, it is very likely that the outbreak was caused by norovirus. However, about 30% of norovirus outbreaks do not meet these criteria. If the criteria are not met, it does not mean that the outbreak was not caused by norovirus. Recently, an alternate set of clinical criteria proposed by **Lively** et alexternal icon have been identified that are more sensitive for norovirus and more often available during outbreak investigations than the Kaplan criteria. These are: _A greater proportion of cases with vomiting than with fever,_ _Bloody diarrhea in less than 10% of cases, and_ _Vomiting in greater than 25% of cases._

Answer 133

**Correct:** _Real increase_ due to change in **virulence/pathogenicity/spread**, change in **prevalence of risk factors**, **population at risk**, change in **treatment/intervention** _Random chance_ **Artefactual:** **Patient factors**: increased demand or access **Provider factor**: Increased testing, misdiagnosis **System**: Change in case definition, change in reporting **Test**: change in SE/SP, change in threshold **Population**: change in denominator, population structure

Answer 134

From 2017 CPHO report It is possible to improve or worsen the health of populations by changing our physical world. Conditions and chronic diseases linked to unhealthy living are increasing in Canada. For example, over 7.8 million Canadians 18 years and older were living with obesity in 2015, which is more than a quarter of this population. Obesity increases the risk for premature death and chronic diseases, such as cardiovascular disease, cancer and diabetes. The relationship between the built environment, healthy living, people’s behaviour and health status is complex. Even so, cities and communities can be designed and built to set people up for success so that healthy choices are the easier choices. _The majority of Canadians – about 80% – live in urban or suburban areas_. While there are trends, the health of a population varies within the same geographic area. The _rise of urban sprawl is a concern as it has been linked to sedentary lifestyles, easy access to unhealthy food, more time spent driving, less physical activity and higher rates of obesity._ While we know that changing the built environment can be a cost-effective way to increase physical activity, less is known about how to improve healthy diets and mental wellness through neighbourhood design as these are newer fields of study. Improving the opportunity to cycle, walk or take public transit to work or school by changing the built environment is a growing area of research. Changing the built environment could significantly influence people’s daily physical activity. **Community design features**, such as _connected streets_, a _mix of residential, commercial, educational and employment areas_, _bike paths_, and _good public transit_ can support being *active to get to work or other places*; whereas _green spaces_, _waterways_, _walking paths_, _trails and recreation facilities_ can promote *recreational physical activity*. Neighbourhoods with easy access to healthier food options appear to be linked to better diets and better health. Those with a higher ratio of unhealthy to healthy food options appear to be linked to poor diets and worse health. However, there are significant gaps in our knowledge and other factors, such as affordability, may have a bigger influence on diet than the built environment. Neighbourhoods may not be set up to address social isolation and loneliness. _Communities with houses that have front yards or that are close to the street, have destinations to walk to and have places for people to gather could encourage social interaction_. Studies suggest that _green spaces are linked to a variety of health benefits including lower risk for premature death_. Ties to the land, water, family, community and identity, as well as a holistic, interconnected view of health and well-being are important components of Indigenous culture that can provide insight into healthy neighbourhood design. Going forward, decision-makers and planners at all levels should take a multi-sectoral, collaborative approach and consider health as an important outcome, as appropriate, when making infrastructure planning decisions. More targeted and hypothesis-driven research, standardized data collection and systematic evaluations of the health impact of community design features are needed. With the diversity of communities and cities across Canada, considering context and engaging citizens are important for ensuring that a community’s unique needs are met when designing for healthy living.

Answer 135

Financial Operational Organizational Privacy Security Technology Equity Governance Environmental Legal

Answer 136

Canadian roles and responsibilities **Federal** National case definition Border security Quarantine at border Liaison with WHO and other national governments National guidance on response NML Stockpile for key drugs Travel advisories **Province** Guidance documents Provincial regulations to make disease reportable Provincial level surveillance Designate hospitals for treatment **Local (vary by province)** Local surveillance Case and contact management Provision of guidance and communications

Answer 137

For women aged _40 to 49 year_s, we recommend NOT screening with mammography; the decision to undergo screening is conditional on the relative value a woman places on possible benefits and harms from screening. (**Conditional recommendation**; **low-certainty evidence**) For women aged _50 to 69 years,_ we recommend screening with mammography _every two to three years;_ the decision to undergo screening is conditional on the relative value that a woman places on possible benefits and harms from screening. (**Conditional recommendation**; **very low-certainty evidence**) For women aged _70 to 74 years_, we recommend screening with mammography *every two to three years*; the decision to undergo screening is conditional on the relative value that a woman places on possible benefits and harms from screening. (**Conditional recommendation**; **very low-certainty evidence**) Recommendations on other screening modalities, apart from mammography, for breast cancer screening: We recommend N_OT using magnetic resonance imaging (MRI), tomosynthesis or ultrasound to screen for breast cancer in women not at increased risk._ (**Strong recommendation**; no evidence) We recommend _NOT performing clinical breast examinations to screen for breast cancer_. (**Conditional recommendation; no evidence**) We recommend _NOT advising women to practice breast self-examination_ to screen for breast cancer. (**Conditional recommendation; low-certainty evidence**)

Answer 138

***mnemonic (second letters) C-D-2M-3N-V*** E**c**onomic incentives E**d**ucation E**m**ergency response E**m**powerment E**n**forcement E**n**gineering E**n**vironment/administrative E**v**aluation

Answer 139

Prevention recommendations apply to healthy weight children and youth 0–17 years of age (i.e.maintain a healthy BMI trajectory according to the WHO Growth Charts for Canada ). They do not apply to children and youth with eating disorders, or who are underweight, overweight, or obese. Management recommendations apply to children and youth 2–17 years of age who are overweight or obese. Children and youth with health conditions where weight loss is inappropriate are excluded. **Growth monitoring** Applies to all children and youth aged 0–17: _we recommend growth monitoring at all appropriate primary care visitsi using the WHO Growth Charts for Canada._ Strong recommendation **Structured behavioural interventions** _Applies to children and youth of HEALTHY weight aged 0–17: we recommend that primary care practitioners NOT routinely offer structured behavioural interventionsii (SBI) aimed at preventing overweight and obesity in healthy children._ Weak recommendation _Applies to OVERWEIGHT or OBESE children and youth aged 2–17: we recommend that primary care practitioners offer or refer children and youth to structured behavioural interventions aimed at healthy weight management._ Weak recommendation **Pharmacological interventions** Applies to children and youth aged _2–11 years_: we recommend that primary care practitioners _NOT offer Orlistat aimed at healthy weight management_. Strong recommendation Applies to children and youth aged _12–17 years_: we recommend that primary care practitioners _NOT offer Orlistat aimed at healthy weight management._ Weak recommendation **Surgical interventions** Applies to _overweight or obese_ children and youth aged 2–17: we recommend that _primary care practitioners NOT routinely refer for surgical interventions_. Strong recommendation

Answer 140

**Attributable risk** - risk difference - portion of incidence in exposed group that is due to exposure - risk in exposed - risk in unexposed **Attributable risk percent** Represents the excess risk in the exposed population that can be attributed to the risk factor (RR-1)/RR x 100% or (Re-Ru)/Re x 100% **Population attributable risk** Amount of absolute risk of a health-related state or event in a population that can be attributed to the exposure Assumes that the exposure causes the outcome Risk in population - risk in unexposed **Population attributable fraction** Proportion of disease which can be attributed to an exposure of interest (Rp-Ru)/Rp x 100% Levin's formula: Prevalence(RR-1)/1+prevalence(RR-1)

Answer 141

**Smoking summary:** Cig smoking prevalence 15% (M 17%, F 13%) in 2017, up from 13% in 2015, 15-19yo = 8% (M 10%, F 6%) 20-24yo = 16% (M 20%, F 11%) E-cig, ever tried 15%, 15-19yo = 23%, 20-24yo = 29% Cannabis prevalence, 15% (up from 12% in 2015), M 19%, F 11%. At least one of 6 drugs = 15% Current Cigarette Smoking T_he prevalence of current cigarette smoking in 2017 was **15%** (4.6 million smokers), an increase from 13% (3.9 million smokers) in 2015. A higher percentage of **males (17%** or 2.5 million) than **females (13%** or 2.1 million) were current smokers_. Eleven percent (11% or 3.3 million) of Canadians reported smoking daily and 4% (1.3 million) reported smoking occasionally. Daily smokers smoked an average of 13.7 cigarettes per day, unchanged from 2015 (13.8). Male daily smokers smoked an average of 14.9 cigarettes per day compared to 12.1 cigarettes per day for female daily smokers. Youth Cigarette Smoking (Aged 15-19 Years) In 2017, _the prevalence of current cigarette **smoking among youth aged 15 to 19 was 8%** (159,000), unchanged from 2015 (10%)_. The prevalence of current smoking for _**male youth was 10%**, higher than for f**emale youth at 6%**_. Three percent (3%) of youth reported smoking daily while 5% reported smoking occasionally. Youth who reported smoking daily smoked an average of 9.4 cigarettes per day, unchanged from 2015. There was no difference in the average number of cigarettes smoked per day by male and female youth daily smokers. Young Adult Cigarette Smoking (Aged 20-24 Years) _The prevalence of current cigarette smoking among y**oung adults aged 20 to 24 was 16%** (387,000) in 2017, unchanged from 2015 (18%)_. The prevalence of current smoking for **_young adult males was 20%**_, higher than for _**females in this age group at 11%_**. The prevalence of daily smoking among young adults was 9%, while 7% smoked occasionally. Daily smoking among males (11%) was higher than among females (7%). Young adults who reported smoking daily smoked an average of 10.7 cigarettes per day, unchanged from 2015. Young adult males who reported smoking daily smoked an average of 12.1 cigarettes per day, higher than for young adult females (8.2). Adult Cigarette Smoking (Aged 25 Years and Older) The prevalence of current cigarette smoking among Canadian adults aged 25 years and older was 16% (4.0 million), an increase from 13% (3.2 million) reported in 2015. There was no difference in the prevalence of current smoking between males (17%) and females (14%). There was an increase in the prevalence of daily smoking among adults to 12% (3.0 million) in 2017, from 10% in 2015, while occasional smoking was unchanged at 4%. There was no difference in the prevalence of daily smoking between adult males (13%) and adult females (11%). The prevalence of daily smoking among adult males (13%) was unchanged from 2015 (11%), there was an increase among adult females (11%) from 2015 (8%). Adults who reported smoking daily smoked an average of 13.9 cigarettes per day, unchanged from 2015. Adult males who reported smoking daily smoked an average of 15.3 cigarettes per day, higher than adult females (12.4). Use of Any Tobacco Product _The survey asked about past-30-day use of a number of tobacco products including: cigarettes (including menthol), cigars, little cigars or cigarillos, smokeless tobacco, water-pipe and pipes._ _In 2017, 18% (5.3 million) of Canadians aged 15 years and older reported using at least one tobacco product in the past 30 days, higher than the 15% (4.6 million) reported in 2015_. The prevalence of past-30-day use of at least one tobacco product was 9% (185,000) among youth aged 15 to 19, a decrease from 13% in 2015. Twenty-one percent (21% or 497,000) of young adults aged 20 to 24 reported use of at least one tobacco product in the past 30 days, unchanged from 2015 (24%). Among adults aged 25 years and older, the prevalence of past-30-day use of at least one tobacco product was 18% (4.6 million), an increase from 15% in 2015. Past-30-day use of at least one tobacco product was higher among males (21% or 3.1 million) than females (14% or 2.2 million). Menthol CigarettesFootnote1 Among Canadians aged 15 years and older, 1% (434,000) reported smoking menthol cigarettes in the past 30 days, unchanged from 2015 (2% or 476,000). Also unchanged from 2015 were past-30-day use of menthol cigarettes among youth aged 15 to 19 (1% or 18,000) and adults 25 years and older (1% or 375,000). Prevalence of past-30-day use of menthol cigarettes decreased to 2% (41,000) among young adults aged 20 to 24, from 4% in 2015. There was no difference in the prevalence of past-30-day use of menthol cigarettes between males and females. Among Canadians aged 15 years and older who reported smoking menthol cigarettes in the past 30 days, almost one-third (29% or 126,000) reported that their usual brand of cigarettes was menthol. Cigars In 2017, 2% (577,000) of Canadians aged 15 years and older reported smoking any type of cigar Footnote 22 in the past 30 days, unchanged from 2015 (2%). The prevalence of past-30-day use of any type of cigar was 3% (55,000) among youth aged 15 to 19, 5% (119,000) among young adults aged 20 to 24 and 2% (403,000) among adults aged 25 years and older; all unchanged from 2015. In 2017, 1% (414,000) of Canadians aged 15 years and older reported smoking little cigars or cigarillos in the past 30 days, unchanged from 2015 (2%). Two percent (2% or 45,000) of Canadian youth aged 15 to 19, 4% (89,000) of young adults aged 20 to 24 and 1% (280,000) of adults aged 25 years and older reported smoking a little cigar or cigarillo in the past 30 days; all unchanged from 2015. Among youth aged 15 to 19 who smoked little cigars or cigarillos in the past 30 days, 61% (26,000) reported smoking a flavoured little cigar or cigarillo. Water-pipe Tobacco Past-30-day use of a water-pipe to smoke tobacco was reported by 1% (208,000) of Canadians aged 15 years and older, unchanged from 2015. One percent (1% or 30,000) of youth aged 15 to 19, and 3% (75,000) of young adults aged 20 to 24, reported using a water-pipe to smoke tobacco in the past 30 days, unchanged from 2015. The prevalence of past-30-day use of a water-pipe to smoke tobacco among adults aged 25 years and older was not reportable due to small sample size. Smokeless Tobacco In 2017, the prevalence of past-30-day smokeless tobacco use was 1% (225,000) for Canadians aged 15 years and older. Two percent (2%) of youth aged 15 to 19 and 1% of young adults aged 20 to 24 reported past-30-day use of smokeless tobacco. These results were unchanged from 2015. The prevalence of past-30-day use of smokeless tobacco among adults aged 25 years and older was not reportable due to small sample size. Cigarette Sources In 2017, current smokers were asked where they usually get their cigarettes. The majority (71%) reported buying them at a small grocery or corner store, unchanged from 2015. Fourteen percent (14%) of current smokers bought their cigarettes at a supermarket or at another kind of store, 7% were given their cigarettes by family, friends or others, 3% purchased their cigarettes on or from a First Nations Reserve and 1% bought them from friends or someone else they know; all unchanged from 2015. Among youth who were too young to legally be sold cigarettes in their province of residence, 50% reported usually obtaining their cigarettes from a regular retail outlet, while 44% usually got them from a social source such as for free from a family member; both unchanged from 2015. Nine percent (9% or 401,000) of current smokers aged 15 years and older reported purchasing cigarettes on a First Nations reserve in the past 6 months, unchanged from 2015. Eleven percent (11%) of youth smokers aged 15 to 19, 10% of young adult smokers aged 20 to 24 and 9% of adult smokers aged 25 years and older reported making such purchases. Smoking Cessation _In 2017, 26% (7.8 million) of Canadians aged 15 years and older reported being former smokers._ Six percent (6% or 462,000) of former smokers had quit less than one year ago (short-term quitters), while the remaining 94% (7.3 million) had quit for one year or more (long-term quitters); both unchanged from 2015. _Among daily cigarette smokers aged 15 years and older, 44% (1.4 million) had made at least one quit attempt lasting 24 hours in the past year, unchanged from 2015. More than 1 in 4 daily smokers (28%) tried to quit on two or more separate occasions, also unchanged from 2015._ _Daily smokers were asked if they were considering quitting, and 57% (1.8 million) reported they were considering quitting in the next 6 months_, unchanged from 2015. Among this group, 35% (597,000) were considering quitting in the next 30 days, also unchanged from 2015. Electronic Cigarettes _In 2017, **15%** (4.6 million) of Canadians aged 15 years and older had ever tried an e-cigarette, an increase from 13% (3.9 million) in 2015_. _Twenty-three percent (**23%** or 460,000) of youth aged 15 to 19, and **29%** (704,000) of young adults aged 20 to 24, had ever tried an e-cigarette, both unchanged from 2015_. Thirteen percent (13% or 3.5 million) of adults aged 25 years and older had ever tried an e-cigarette, an increase from 2015 (11%). Nineteen percent (19% or 2.2 million) of males had ever tried an e-cigarette, which was higher than females (12% or 1.8 million). Past-30-day use of e-cigarettes was reported by 3% (863,000) of Canadians aged 15 years and older, unchanged from 2015. Six percent (6% or 127,000) of youth aged 15 to 19, 6% (145,000) of young adults aged 20 to 24 and 2% (590,000) of adults aged 25 years and older had used an e-cigarette in the past 30 days; all unchanged from 2015. Among past-30-day e-cigarette users, 65% (557,000) were current smokers, 20% (173,000) were former smokers and 15% (133,000) were never smokers. Of these never smokers, 58% (77,000) were youth aged 15 to 19 and 33% (45,000) were young adults aged 20 to 24. The prevalence of past-30-day e-cigarette use among adult never smokers aged 25 years and older was not reportable due to small sample size. Among Canadians aged 15 years and older who had used an e-cigarette in the past 30 days, 43% reported using a fruit flavour the last time they used an e-cigarette, 22% tobacco flavour and 14% candy/dessert. Most youth aged 15 to 19 (69%) and young adults aged 20 to 24 (62%) reported using a fruit flavour, while among adults aged 25 years and older, 33% reported using a fruit flavour and 29% reported using tobacco flavour. Among Canadians who had ever tried an e-cigarette, 64% (3.0 million) reported that the last e-cigarette they used contained nicotine, 24% (1.1 million) reported using an e-cigarette that did not contain nicotine, and 12% (546,000) were uncertain. Thirty-two percent (32% or 1.1 million) of current or former smokers reported using e-cigarettes as a cessation aid in the past two years. CTADS did not include questions about the success of smoking cessation attempts using e-cigarettes. E-cigarette Sources and Reasons for Use Almost half (49% or 2.2 million) of those who ever tried an e-cigarette reported that they borrowed, shared or bought them from a friend or relative. Twenty-three percent (23% or 1.0 million) bought them from a vape shop or vapour lounge and 12% (546,000) from a convenience store or gas station. Among past-30-day e-cigarette users, the most commonly reported reasons for using e-cigarettes were because e-cigarettes help people to quit smoking cigarettes (69%), e-cigarettes might be less harmful than smoking cigarettes (58%) and e-cigarettes may be less harmful than cigarettes to people around them (56%). Respondents could provide more than one answer. Perceived Risk of Harm of Cigarettes and E-cigarettes Canadians were asked how much they think people risk harming themselves when they smoke cigarettes or use an e-cigarette. ``` Smoking cigarettes once in a while was perceived to be a “moderate risk” or “great risk” by most Canadians (64%). The majority (85%) thought there was “great risk” of harm from smoking cigarettes on a regular basis. Almost half (48%) of Canadians perceived using an e-cigarette once in a while to be a “moderate risk” or “great risk”. Using an e-cigarette on a regular basis was thought to pose “moderate risk” or “great risk” of harm by 65% of Canadians. Almost one in four Canadians were unaware how much a person risked harming themselves by using an e-cigarette once in a while (23%), or on a regular basis (24%). ``` Provinces Provincial prevalence of current smoking for those aged 15 years and older ranged from a low of 12% in Prince Edward Island to a high of 20% in Newfoundland and Labrador. Average cigarettes smoked per day among daily smokers ranged from a low of 12.7 cigarettes per day in Ontario to a high of 18.6 in Newfoundland and Labrador. Past-30-day use of at least one tobacco product (cigarettes, cigars, little cigars or cigarillos, smokeless tobacco, water-pipe and pipe) ranged from a low of 16% in Ontario and Prince Edward Island to a high of 22% in Newfoundland and Labrador and Saskatchewan. Past-30-day use of e-cigarettes ranged from a low of 2% in Newfoundland and Labrador and Ontario to a high of 6% in New Brunswick. Drug Use T_he survey asked about past-year use of illegal drugs including cannabis, cocaine or crack, ecstasy, speed or methamphetamines, hallucinogens and heroin._ _The prevalence of past-year use of at least one of six illegal drugs was **15%** (4.5 million), an increase from 13% (3.7 million) in 2015_. This increase was due to an increase in use of cannabis and cocaine between the two survey cycles. Overall, the prevalence of past-year illegal drug use was higher among males (19% or 2.8 million) than females (11% or 1.7 million). Past-year use of at least one of these six illegal drugs was also higher among youth aged 15 to 19 (20% or 396,000) and young adults aged 20 to 24 (35% or 816,000) than among adults aged 25 years and older (13% or 3.3 million). Cannabis Use _Cannabis was the most prevalently used illegal drug._ In 2017, the prevalence of past-year cannabis use was **15%** (4.4 million), an increase compared to 2015 (12% or 3.6 million), and compared to 2013 (3.1 million). In 2017, past-year cannabis use was more prevalent among males (19% or 2.7 million) than females (11% or 1.7 million), which is consistent with previous cycles. The prevalence of past-year cannabis use among males increased from 2015 (15%), whereas for past-year cannabis use there was no change among females. Past-year use of cannabis was more prevalent among youth aged 15 to 19 (19% or 390,000) and young adults aged 20 to 24 (33% or 780,000) than among adults aged 25 years and older (13% or 3.2 million). Past-year use of cannabis among adults aged 25 years and older increased from 2015 (10%), whereas there was no change among youth aged 15 to 19 and young adults aged 20 to 24. The mean age of initiating use of cannabis was 18 years old for males, unchanged from 2015; and 19 years old for females, up from 18 years old in 2015. Among people who have used cannabis in the past year, 37% (or 1.6 million) reported using it for medical purposes, an increase from 24% (831,000) in 2015. The survey does not collect information on how people obtained the cannabis for medical purposes. Of the methods used to consume cannabis in the past 12 months, smoking was the most common. Ninety-one percent (91% or 4 million) of those who used cannabis in the past year smoked cannabis. Other common methods of consumption include mixing cannabis with tobacco (22% or 942,000), chasing (smoking a tobacco product right after smoking cannabis – 34% or 1.5 million), consuming cannabis in edibles (brownies, etc. – 38% or 1.6 million), and vaporizing (29% or 1.3 million). Those who reported using cannabis may have tried more than one method over the past 12 months. The majority (75% or 3.3 million) of those who reported using cannabis in the past year reported using cannabis in the past 3 months, an increase from 2015 (72% or 2.6 million). Of those who had used cannabis in the past 3 months, many reported consuming cannabis on a daily or almost daily basis (32% or 1 million, unchanged from 33% or 840,000 in 2015). Provincial prevalence of past-year cannabis use ranged from 11% (750,000) in Quebec to 23% (940,000) in British Columbia. Other Illegal Drug Use Respondents were asked about past-year use of illegal drugs including cocaine or crack, ecstasy, speed or methamphetamines, hallucinogens and heroin. This section excludes cannabis. Past-year use of at least one of five illegal drugs was 3% (987,000), an increase from 2% (678,000) compared to 2015, and 2% (458,000) compared to 2013. _This increase is associated with an increase in the use of cocaine, compared to 2015 and 2013._ Overall, prevalence of past-year use of these illegal drugs was higher among males (5% or 719,000) than females (2% or 268,000). There was an increase in past-year use of illegal drugs for both males and females, compared to 2015 (5% vs. 3% and 2% vs. 1% respectively). Past-year use of at least one of five illegal drugs was higher among youth aged 15 to 19 (4% or 81,000) and young adults aged 20 to 24 (10% or 241,000) than among adults aged 25 and older (3% or 665,000). While past-year illegal drug use remained low, there was an increase in the prevalence of use of cocaine; 2% (730,000) of Canadians reported using cocaine, an increase from 1% (353,000) compared to 2015, and 1% (259,000) compared to 2013. Cocaine use among adults aged 25 and older was 2% in 2017, an increase from 1% in 2015, and 1% in 2013. There was no change in the prevalence of use of hallucinogens (1% or 443,000), or ecstasy (1% or 271,000). The prevalence of heroin, speed/methamphetamine or salvia use was not reportable due to small sample size. Past-year use was more prevalent among males than females for cocaine (4% males vs. 1% females) and hallucinogens (2% males vs. 1% females). Use and Problematic Use of Psychoactive Pharmaceutical Drugs CTADS includes questions relating to the use and problematic use of three classes of psychoactive pharmaceutical drugs: opioid pain relievers, stimulants (such as medication prescribed for Attention Deficit Hyperactivity Disorder), and tranquillizers and sedatives. While these drugs are prescribed for therapeutic purposes, they have the potential to be used in a problematic manner due to their psychoactive properties. Among respondents who had reported using psychoactive pharmaceuticals, further questions were asked to determine whether the drugs were used for reasons other than for prescribed therapeutic purposes including use for the experience, for the feeling they caused, to get high, to feel better (improve mood) or to cope with stress or problems. In the text below, such non-therapeutic use will be referred to as problematic use. The overall prevalence of psychoactive pharmaceutical use among Canadians aged 15 years and older was 22% (6.5 million), unchanged from 2015 (22% or 6.2 million). The prevalence of past-year psychoactive pharmaceutical use in 2017 was higher among females (24% or 3.6 million) than males (20% or 2.9 million). The prevalence of use was lower among youth aged 15 to 19 (17% or 332,000) than young adults aged 20 to 24 (21% or 492,000) and adults aged 25 years and older (23% or 5.7 million). The prevalence of psychoactive pharmaceutical use for males and females was unchanged from 2015 (18% or 2.6 million males and 25% or 3.6 million females). The prevalence of use for each age category was unchanged from 2015: 15% (311,000) of youth aged 15 to 19; 19% (455,000) of young adults aged 20 to 24; and 22% (5.5 million) of adults aged 25 and older. In 2017, of those who reported having used psychoactive pharmaceuticals in the past year, 5% (302,000) engaged in problematic use of such a drug (i.e., used it for the experience, for the feeling it caused, to get high or for “other” reasons). The prevalence of past-year problematic use among those who used psychoactive pharmaceuticals in 2017 was not reportable for females and adults aged 25 years and older due to small sample size. One percent (1% or 336,000) of the population aged 15 and older engaged in problematic use of psychoactive pharmaceuticals in the past year, an increase from 2015 (0.6% or 173,000)Footnote3. Opioid Pain Relievers O_f the three classes of psychoactive pharmaceuticals, opioid pain relievers were the most used with **12%** (3.5 million) of Canadians aged 15 years and older reporting having used such a drug in the past year, unchanged from 2015 (13% or 3.8 million)_. There was no difference in the prevalence of past-year opioid pain reliever use between females (12% or 1.8 million) and males (11% or 1.6 million) and both were unchanged from 2015 (14% or 2 million and 12% or 1.7 million, respectively). Among the 12% of Canadians who used opioid pain relievers in the past year, 3% (100,000) reported problematic use of them. Among all Canadians aged 15 and older, the prevalence of problematic use of opioids was not reportable due to small sample size. The prevalence of problematic use of opioids was also not reportable for females, for young adults aged 20 to 24 and for adults aged 25 years and older in the overall population due to small sample size. Stimulants Stimulants are defined as products that can be obtained from a doctor such as Ritalin, Concerta, Adderall, Dexedrine or others, and that are prescribed by doctors to help people who have attention or concentration problems (such as ADHD). In 2017, 2% (714,000) of Canadians aged 15 years and older reported having used a stimulant in the past year, an increase from 2015 (1% or 338,000), and from 1% (256,000) in 2013. There was no difference between males and females (3% or 418,000 and 2% or 296,000, respectively). Past-year use of stimulants was higher among youth aged 15 to 19 (5% or 108,000) and young adults aged 20 to 24 (6% or 128,000) than among adults aged 25 years and older (2% or 478,000). Of those who reported past-year stimulant use, 19% (103,000) reported problematic use of such a drug, representing less than one percent (0.3%) of Canadians aged 15 years and older. Problematic use of stimulants among males was higher than females (0.6% or 81,000 vs. 0.1% or 21,000 respectively)Footnote4. The prevalence of problematic use of stimulants among those who used stimulants in the past year was 18% (19,000) for youth aged 15 to 19 and 41% (43,000) for young adults aged 20 to 24. These are unchanged from 2015 for youth aged 15 to 19 (22% or 20,000) and young adults aged 20 to 24 (41% or 37,000). The prevalence for adults aged 25 and older was not reportable due to small sample size. Sedatives In 2017, 12% (3.5 million) of Canadians aged 15 years and older reported past-year use of sedatives, unchanged from 2015 (11% or 3.1 million). The prevalence of such reported use by females (14% or 2.1 million) was higher than that of males (9% or 1.3 million) and both were unchanged from 2015 (14% or 2 million and 7% or 176,000, respectively). Past-year use of sedatives was higher among adults aged 25 years and older (13% or 3.2 million) than youth aged 15 to 19 (5% or 101,000) and young adults aged 20 to 24 (8% or 176,000). In 2017, of those who reported past-year use of sedatives, 1% (49,000) reported using sedatives to get high. This is less than one percent (0.2%) of the population aged 15 and older and unchanged from 2015 (0.3%). The prevalence of reported having used sedatives to get high among females and adults aged 25 years and older was not reportable due to small sample size. Among those who reported having used sedatives, youth aged 15 to 19 reported the highest prevalence of sedative use to get high (15% or 15,000), followed by young adults aged 20 to 24 (11% or 19,000). Harms Related to Illegal Drug Use Respondents were asked if there ever was a time that they felt their illegal drug use had a harmful effect on one of eight factors: physical health, friendships and social life, financial position, home life or marriage, work, studies, or employment opportunities, legal problems, difficulty learning or housing problems. Overall, 4% (820,000) of Canadians aged 15 years and older reported experiencing at least one harm in the past year due to their illegal drug use, an increase from 2015 (3% or 819,000). The prevalence of reported harm as a result of one's own illegal drug use was higher among males (6% or 518,000) than females (3% or 302,000), both higher than 2015 (4% or 540,000 and 2% or 278,000, respectively). A higher proportion of youth aged 15 to 19 (5% or 100,000) and young adults aged 20 to 24 (10% or 192,000) reported harm due to their own illegal drug use than adults aged 25 years and older (3% or 527,000). The prevalence among adults aged 25 years and older was an increase from 2015 (2% or 498,000). The prevalence of reported harm was higher among individuals who reported both the use of an illegal drug and the problematic use of a psychoactive pharmaceutical. Eighteen percent (18% or 820,000) of those who used illegal drugs in the past year and who reported problematic use of psychoactive pharmaceuticals in the past year reported having experienced some harm in the past year due to their drug use. There was increase in the prevalence of reported past-year harm among females who had used illegal drugs and had engaged in problematic use of psychoactive pharmaceuticals in the past year (18% or 302,000 in 2017 vs. 11% or 164,000 in 2015). Alcohol The survey asked about alcohol use, including questions examining the quantity of alcohol consumed. _Prevalence of Alcohol Use_ In 2017, 78% (23.3 million) of Canadians reported consuming an alcoholic beverage in the past year, unchanged from 2015 (77% or 22.7 million). There was no difference in the prevalence of past-year alcohol use between males and females (79% or 11.6 million and 77% or 11.6 million, respectively). There was an increase in past-year alcohol use among females compared to 2015 (73% or 10.9 million). The prevalence of alcohol use among young adults aged 20 to 24 (83%) was higher than among youth aged 15 to 19 (57%) and adults aged 25 years and older (79%). The prevalence of alcohol use for each age category (i.e., youth aged 15 to 19, young adults aged 20 to 24, and adults 25 years and older) was unchanged from 2015. Provincial prevalence of alcohol use in the past year ranged from 68% (85,000) in Prince Edward Island to 84% (5.8 million) in Quebec. For all provinces, the prevalence of alcohol use remains unchanged compared to 2015. Low-Risk Alcohol Use Canada's Low-Risk Alcohol Drinking GuidelinesFootnote 55 (LRDG) consists of five guidelines and a series of tips. Guidelines 1 and 2, and acute and chronic effects are explained in the definitions. People who drank within the low-risk alcohol drinking guidelines consume no more than the recommended quantity of alcohol within the number of days specified, whereas those who exceed the guidelines consume more alcohol than recommended within the stated timeframe. The basis of the LRDG is reported alcohol consumption in the 7 days prior to the survey. A_mong Canadians who consumed alcohol in the past year, **21%** (representing 16% of the population aged 15 years and older or 4.7 million) exceeded guideline 1 for chronic effects and **15%** (representing 11% of the population aged 15 years and older or 3.3 million) exceeded guideline 2 for acute effects._ A higher percentage of males than females drank in patterns that exceeded both guidelines. The chronic-risk guideline was exceeded by 22% (2.5 million) of males who drank and 19% (2.1 million) of females who drank, while the acute-risk guideline was exceeded by 17% (1.9 million) of males who drank and 13% (or 1.5 million) of females who drank. Y_oung adults aged 20 to 24 had riskier patterns of alcohol consumption, compared to youth aged 15 to 19 and adults aged 25 years and older. Twenty-nine percent (29% or 552,000) of young adults who drank exceeded the guideline for chronic risk._ In comparison, 18% (203,000) of youth who drank and 20% (3.9 million) of adults who drank exceeded this guideline. The acute-risk guideline was exceeded by 24% (450,000) of young adults who drank compared to 12% (130,000) of youth who drank and 14% (2.7 million) of adults who drank. The prevalences for risky alcohol consumption are unchanged from 2015.

Answer 142

**BCG**: If ++ exposed to sig TB without protective measures and case finding/tx not available (e.g. _long term traveller to low-resource, high prevalence country)_ **Haemophilus influenzae type b (Hib)**: _adults with increased risk of invasive Hib disease_ - 1 dose regardless of prior history of Hib vaccination and at least 1 year after any previous dose. At risk conditions: Following HSCT, adults w primary immunodeficiencies, malignant heme disorders, HIV, hypo/asplenia, solid organ transplant recipients, cochlear implant recipients. **Inactivated polio**: _1 booster dose for adults at increased risk of exposure to polio._ Increased risk: Travelling to areas where it is known/suspected to be circulating HCW who have close contact w ind who may be excreting virus Members of communities w disease caused by polio People in close contact w those who may be excreting - eg working w refugees, military personnel, on humanitarian missions Lab workers that could handle specimens Family or close contacts of adopted infants that may have been/will be vaccinated with OPV Primary series if prev unimm, one lifetime booster if prev imm **Measles-mumps-rubella (MMR)**: adults born in or after 1970 - 1 dose, except - _travellers, health care workers, students in post-secondary educational settings, and military personnel_ - 2 doses, at least 4 weeks apart. Adults born before 1970 can be assumed to have acquired natural immunity to measles and mumps and do not need MMR vaccination except - non-immune military personnel or health care workers (2 doses, at least 4 weeks apart), non-immune travellers (1 dose), non-immune students in post-secondary educational settings (consider 1 dose). Rubella-susceptible adults, regardless of age - 1 dose. **Pneumococcal vaccination in general:** infants and children immunization of _children who missed routine schedule_ immunization of residents of _long-term care facilities_ immunization of adults who are at high risk of IPD due to lifestyle factors: _smokers_, persons with _alcoholism_, persons who are _homeless_ immunization of all adults _65 years of age and olde_r Pneumococcal vaccine should be considered for adults who use _illicit drugs_ **Pneumococcal conjugate 13-valent (Pneu-C-13)**: _adults with HIV or immunocompromising conditions (except hematopoietic stem cell transplant recipients [HSCT])_ - 1 dose of Pneu-C-13 vaccine followed 8 weeks later by 1 dose of pneumococcal polysaccharide 23-valent (Pneu-P-23) vaccine. Administer Pneu-C-13 vaccine dose at least 1 year after any previous dose of Pneu-P-23 vaccine. Immunocompromising conditions: Asplenia, sickle cell disease, conj immunodeficiencies, HIV infection, immunosuppressive therapy, cancer, solid organ or islet cell transplant, nephrotic syndrome, after HSCT **Pneumococcal polysaccharide 23-valent**: _adults at high risk of invasive pneumococcal disease (IPD), including adults with alcoholism, smokers, and persons who are homeless_ - 1 dose. _One dose should be considered for adults who use illicit drugs_. _Adults at highest risk of IPD, including those with functional or anatomic asplenia or sickle cell disease; hepatic cirrhosis; chronic renal failure; nephrotic syndrome; HIV infection; and immunosuppression related to disease or therapy - 1 booster dose at least 5 years_ from first vaccination with Pneu-P-23 vaccine. **Meningococcal conjugate quadrivalent**: in previously unimmunized adults at high risk of invasive meningococcal disease (IMD) - 2 doses, 8 weeks apart. In previously immunized adults -booster dose every 3 to 5 years if last vaccinated at 6 years of age and younger and every 5 years for those last vaccinated at 7 years of age and older. **Multicomponent meningococcal (4CMenB)**: adults at high risk of IMD should be considered for immunization - 2 doses of 4CMenB vaccine, at least 4 weeks apart. Adults at risk: _Travellers to sub-Saharan Africa and Hajj or hyperendemic area w known serovar_ _Occ risk for exposure - lab workers, military_ _Close contacts of case_ w serovar protected _Hypo/asplenism, primary ab deficiencies, eculizumab use, HIV_ **Hepatitis A**: adults in high risk groups - 2 doses, 6-36 months apart (depending on product used). High risk groups: T_ravel to endemic areas_, _immigrants from endemic areas_, _close contacts of children adopted from endemic area_, populations at risk of outbreaks or where HepA is highly endemic, _close contacts of cases,_ _occ/lifestyle risk of exposure_, _chronic liver disease, receiving plasma-derived replacement clotting factors_ **Hepatitis B (HB)**: adults in high risk groups - 3 or 4 dose schedule (depending on product used). Higher dose of monovalent HB vaccine recommended for those with certain immunocompromising conditions, chronic renal failure and dialysis. At risk groups: _Susceptible to HB and immigrated from a country w high prevalence_, _household/sexual contacts for cases and carriers_, _occ/lifestyle risk of exposure_, _travelling to endemic areas_, populations at risk of outbreaks or where HB is highly endemic, _residents of group homes for people w DD, inmates_, _chronic liver disease, chronic renal disease, hemophiliacs, undergone HSCT, awaiting solid organ transplant, congenital immunodeficiencies, HIV_ **Hepatitis A-hepatitis B**: adults without chronic renal failure and immunocompromising conditions: combined vaccine preferred if both hepatitis A and standard dosage hepatitis B vaccines are recommended - 3 or 4 dose schedule. **Influenza**: recommended for all adults, with focus on adults at high risk of influenza-related complications - 1 dose annually. **Typhoid**: _adults with ongoing or intimate exposure to a chronic carrier of Salmonella typhi_ - 1 dose injectable typhoid vaccine or 4 doses oral typhoid vaccine; re-immunization recommended if at continuing risk. **Rabies**: _adults at high risk of close contact with rabid animals_ - 3 doses for pre-exposure immunization. Periodic serologic testing and booster doses (if required) for those at continuing high risk. **Varicella**: _adults 18 to less than 50 years of age without history of VZV infection_ (self-reported or diagnosed by a health care provider), documented evidence of immunization with 2 doses of a varicella-containing vaccine or laboratory evidence of immunity - 2 doses. Self-reported history or health care provider diagnosis is not considered a reliable correlate of immunity for pregnant women with significant exposure to varicella zoster virus, immunocompromised individuals and health care workers who are newly hired into the Canadian health care system.

Answer 143

_Behavior creates exposure risk_: Hand-to-mouth behavior, closer to the ground, unable to screen consumption _High metabolic absortion_: High respiratory rate, high gut absorption _During neurodevelopmentally sensitive period_

Answer 144

Prevention, treatment, harm reduction, enforcement

Answer 145

These carcinogens are: arsenic, asbestos, benzene, chromium (VI) compounds, diesel engine exhaust, second-hand smoke, nickel compounds, polycyclic aromatic hydrocarbons (PAHs), radon, night shift work, silica (crystalline), solar ultraviolet radiation, and welding fumes. policy action that could be taken to reduce workplace exposure to these carcinogens and include the following: _strengthening occupational exposure **limits** across all Canadian jurisdictions so they are upto- date, rigorous, and evidence-based_; _**reducing or eliminating** the use of cancer causing substances with workplace_specific toxic use reduction policies; and, creating **_registries_** of workplace exposures to occupational carcinogens that will facilitate the tracking of exposures over time. In addition, the report proposes specific policies that target some of the individual carcinogens.

Answer 146

Canadian Student Tobacco, Alcohol and Drugs Survey This is a survey of Canadian students between grades 7 and 12 (secondary I to secondary V in Quebec). It asks about their use of: vaping products tobacco alcohol drugs The survey is done every 2 years. The most recent survey was done in 2018-19. It showed that: _34% of students in grades 7-12 had ever tried a vaping product (referred to as an e-cigarette in the survey) and 20% reported using them within the last 30 days._ _Specifically, 28% had ever tried an e-cigarette with nicotine and 29% had ever tried an e-cigarette without nicotine._ 18% of students have used an e-cigarette with nicotine and 11% had used an e-cigarette without nicotine in the past 30 days. _Most students who had tried a vaping product (such as e-cigarettes) had also tried a cigarette._ _54% of all students thought it would be "fairly easy" or "very easy" to get an e-cigarette with nicotine if they wanted one, and 58% thought it would be “fairly easy” or “very easy” to get an e-cigarette without nicotine if they wanted one._

Answer 147

**Adolescent mothers have higher rates of:** **Physical:** maternal anemia, eclampsia, repeat pregnancy, domestic violence, STI, smoking **Mental:** mental health disorders, depression, substance use, DV, lower self-esteem **Social**: low socio-economic status, income, educational attainment, social support, poverty, less prenatal care, less breastfeeding **Children of adolescents** are at increased risk for: **Infanthood**: prenatal death, premature birth and low birth weight **Childhood**: growth and development issues, particularly cognitive and speech and language delays, accidental injury and neglect, challenges with behaviour and in school. **Adolescent**: higher risk for substance use, early sexual activity, academic struggles, low vocational options, poverty * *Risk factors for unprotected intercourse in teens** include: - experiencing social and family difficulties; - whose mothers were adolescent mothers; - undergoing early puberty; - who have been sexually abused; - with frequent school absenteeism or lacking vocational goals; - with siblings who were pregnant during adolescence; - who use tobacco, alcohol and other substances; and - who live in group homes, detention centres or are street-involved * *Public health interventions** - healthy sexuality **education** and counseling - the provision of **low cost birth control** supplies - confidential and free sexual health **clinic** services - building **community partnerships** with schools, hospitals, and community-based organizations to deliver healthy sexuality and reproductive health programs and service Adolescent pregnancy rate = Number of pregnancies (live births, stillbirths, therapeutic abortions) per 1,000 females age 15-19 years Adolescent pregnancy rate has been declining in Canada over the last 25 years. Over 50% of adolescent pregnancies end in abortion 1.8% of live births in 2018 8.4 births among females aged 15 to 19 years per 1,000 females 2016 3% adolescent pregnancy rate 15-19y (live births + abortions)

Answer 148

**Canadian Criteria And Guidelines for considering diseases reportable** 1. National/international regulatory and prevention programs 2. Incidence in Canada 3. Severity 4. Communicability/potential spread to the general population 5. Potential for outbreaks 6. Socioeconomic burden 7. Preventability 8. Risk perception 9. Necessity for public health response 10. Appearing to increase in incidence or change patterns over the past 5 years **WHO criteria to set priorities for communicable disease surveillance** Burden of disease CFR/severity Epidemic potential Potential threat/changing pattern Health gain opportunity Social and economic impact International regulations or programmes Public perception

Answer 149

_Rabies is transmitted only when the virus is introduced into a bite wound, open cuts in skin, or onto mucous membranes such as the mouth or eyes_. Three broad categories of exposure are recognized as warranting PEP: bite, non-bite and bat exposures. **Bite exposures**: Transmission of rabies occurs most commonly through bites. A bite is defined as any penetration of the skin by teeth. **Non-bite exposures**: This category includes contamination of scratches, abrasions or cuts of the skin or mucous membranes by saliva or other potentially infectious material, such as the brain tissue of a rabid animal. Non-bite exposures, other than organ or tissue transplants, have almost never been proven to cause rabies, and PEP is not indicated unless the non-bite exposure involves saliva or neural tissue being introduced into fresh, open cuts or scratches in skin or onto mucous membranes. These exposures require a risk assessment that considers the likelihood of salivary contamination. Petting a rabid animal or handling its blood, urine or feces is not considered to be an exposure; however, such contact should be avoided. Being sprayed by a skunk is also not considered an exposure. These incidents do not warrant PEP. Post-exposure prophylaxis is recommended in rare instances of non-bite exposure, such as inhalation of aerosolized virus by spelunkers exploring caves inhabited by infected bats or by laboratory technicians homogenizing tissues infected with rabies virus without appropriate precautions; however, the efficacy of prophylaxis after such exposures is unknown. Exposures incurred in the course of caring for humans with rabies could theoretically transmit the infection. No case of rabies acquired in this way has been documented, but PEP should be considered for exposed individuals. _**Bat exposures**: Post-exposure rabies prophylaxis following bat contact is recommended when both the following conditions apply: • There has been direct contact with a bat; AND • A bite, scratch, or saliva exposure into a wound or mucous membrane cannot be ruled out._ Direct contact with a bat is defined as the bat touching or landing on a person. When there is no direct contact with a bat, the risk of rabies is extremely rare and rabies PEP is not recommended. In an adult, a bat landing on clothing would be considered reason for PEP administration only if a bite, scratch, or saliva exposure into a wound or mucous membrane could not be ruled out. Therefore, if a bat lands on the clothing of a person who can be sure that a bite or scratch did not occur and that the bat’s saliva did not contact an open wound or mucous membranes, then PEP is not required. In a child, any direct contact with a bat (i.e., the bat landing on or touching the child, including contact through clothes) could be considered a reason for PEP administration, as a history to rule out a bite, scratch or mucous membrane exposure may not be reliable. When a bat is found in the room with a child or adult who is unable to give a reliable history, assessment of direct contact can be difficult. Factors indicating that direct contact may have occurred in these situations include the individual waking up crying or upset while the bat was in the room, or observation of an obvious bite or scratch mark.

Answer 150

1. Keep survey as short as possible 2. Clear layout and careful design of questionnaire 3. Pilot the questionnaire first to identify any issues with usability or comprehension 4. Use appropriately timed follow-up reminders to complete the survey 5. Use simple language, short sentences etc. 6. Personalised covering letter/email conveying the reasons for the survey and its value 7. Clear statements of confidentiality 8. Consider use of telephone and web based administration of survey – but may introduce biases 9. Ensure that written materials are available in appropriate languages 10. Offer help to specific groups (e.g. elderly, blind, poor literacy skills) 11. Offer incentives, $ or chance to win

Answer 151

**In summary:** 1. **Intro**: Acknowledge situation, make approach, establish rules of engagement 2. **Info**: Gather information on the problem, its source, underlying needs, emotions and perspectives 3. **Solutions**: Request and assess potential solutions, look for win-win + common areas of agreement 4. **Agreement**: Get buy-in on negotiated solutions, next steps for M&E, escalation prn 5. **I+M&E**: Implement plan then monitor and evaluate **R**ule of engagement **I**nformation gathering Identify the **p**roblem Identify underlying **n**eeds of each party Assess/request potential **s**olutions **N**egotiate one or more solutions with parties/Get agreement **I**mplement **E**valuate and debrief 1. Making the approach 2. Sharing perspectives 3. Building understanding 4. Agreeing on solutions American management conflict: Step 1: Define the source of the conflict. The more information you have about the cause of the problem, the more easily you can help to resolve it. To get the information you need, use a series of questions to identify the cause, like, “When did you feel upset?” “Do you see a relationship between that and this incident?” “How did this incident begin?” As a manager or supervisor, you need to give both parties the chance to share their side of the story. It will give you a better understanding of the situation, as well as demonstrate your impartiality. As you listen to each disputant, say, “I see” or “uh huh” to acknowledge the information and encourage them to continue to open up to you. Step 2: Look beyond the incident. Often, it is not the situation but the point of view of the situation that causes anger to fester and ultimately leads to a shouting match or other visible and disruptive result. The source of the conflict might be a minor issue that occurred months before, but the level of stress has grown to the point where the two parties have begun attacking each other personally instead of addressing the real problem. In the calm of your office, you can get them to look beyond the triggering incident to see the real cause. Once again, probing questions will help, like, “What do you think happened here?” or “When do you think the problem between you first arose? Step 3: Request solutions. After getting each party’s viewpoint, the next step is to get them to identify how the situation could be changed. Again, question the parties to solicit their ideas: “How can you make things better between you?”As mediator, you have to be an active listener, aware of every verbal nuance, as well as a good reader of body language. You want to get the disputants to stop fighting and start cooperating, and that means steering the discussion away from finger pointing and toward ways of resolving the conflict. Step 4: Identify solutions both disputants can support. You are listening for the most acceptable course of action. Point out the merits of various ideas, not only from each other’s perspective, but in terms of the benefits to the organization. For instance, you might suggest the need for greater cooperation and collaboration to effectively address team issues and departmental problems. Step 5: Agreement. The mediator needs to get the two parties to shake hands and accept one of the alternatives identified in Step 4. The goal is to reach a negotiated agreement. Some mediators go as far as to write up a contract in which actions and time frames are specified. However, it might be sufficient to meet with the individuals and have them answer these questions: “What action plans will you both put in place to prevent conflicts from arising in the future?” and “What will you do if problems arise in the future? This mediation process works between groups as well as individuals.

Answer 152

Steps for managing a potential exposure to blood borne pathogens **1. Provide Immediate Care to the Exposure Site** Allow injury to bleed freely Remove clothing that is contaminated with body fluids Thoroughly flush exposed area with water or saline Clean area with soap and water and then dry **2. Notify supervisor or delegate**, if applicable **3. Conduct a Risk Assessment of the Exposure** Assess type of exposure (i.e. percutaneous injury, mucous membrane or non-intact skin exposure) Assess type of fluid (i.e. blood, visibly bloody fluid, other potentially infectious fluid or tissue) Assess length of time since fluids left Source's body Determine if an exposure has occurred: If no exposure has occurred, notify the Exposed and counsel/reinforce infection prevention and control practices If an exposure has occurred, serologic testing should be performed **4. Serologic Testing for HBV, HCV and HIV** Obtain consent from the Exposed to do baseline and follow-up serologic testing for HBV, HCV and HIV Baseline includes antibody to HBV (anti-HBs, anti-HBc) and antigen (HBsAg), HCV and HIV Repeat HBV at 6 months Repeat HCV at 3 months and 6 months Repeat HIV serology at 6 weeks, 3 months and 6 months (if negative on previous testing) **4. Counsel the Exposed** Consider PEP for HIV +/- HBV Encourage the Exposed to be immunized for hepatitis B if not previously received While waiting for serology results, the Exposed should: Abstain from sexual intercourse or use a latex condom Not donate blood, plasma, organs, tissue or sperm Not share toothbrushes, razors or needles that may be contaminated with blood or body fluids Not become pregnant Post-Exposure Prophylaxis (PEP) Treatment to prevent infection following an exposure to blood or body fluids is called PEP. PEP is available for HIV and HBV but not HCV and is only provided in hospital emergency departments. If an exposure has occurred, the Exposed must be referred to a hospital emergency department as the decision to recommend PEP is based on the assessment of the attending emergency physician. If the Exposed is started on PEP, a referral should be made to The Ottawa Hospital, General Campus Infectious Diseases Clinic to obtain serology testing results and ensure comprehensive follow-up. _PEP for HIV usually consists of treatment with 2 to 3 antiretroviral drugs for four weeks_. PEP should begin as soon as possible after the exposure, preferably within hours after the exposure. Treatment may be considered at later intervals because of the potential benefits of early treatment of HIV infection should seroconversion occur. If the _Source HIV test result is negative, PEP is discontinued immediately_. _PEP for HBV consists of treatment with hepatitis B immune globulin (HBIG) and hepatitis B vaccine_, depending on the exposed person's susceptibility or immunity to HBV infection. HBIG should be administered within 24 hours. **Risk of Transmission of HBV, HCV and HIV** Several factors influence the risk of infection from a single significant exposure, including: The virus involved (HBV & HCV are more infectious than HIV) The type of exposure (a deep injury is more risky than a splash to the eyes) The amount of blood involved in the exposure (more blood is associated with more risk) The amount of virus in the Source's blood at the time of exposure (more virus is associated with more risk) Hepatitis B Virus (HBV) _For persons who have received Hepatitis B vaccine and have developed immunity to the virus there is virtually no risk for infection. The risk of transmission of HBV following a needle stick or cut exposure (from an infected source) is 6-30%_. In the case of human bites where the skin is broken, the risk of transmission (to the person who is bitten) is unknown but is likely to be quite low since the concentration of HBV is 1000 times lower in saliva than in blood. The management of persons with possible exposures to HBV is outlined in the Canadian Immunization Guide, 7th edition (2006), page 193-196. Hepatitis C Virus (HCV) _The risk of acquiring HCV following a needle stick or cut exposure to an infected source is approximately 1.8%._ The risk of infection from an exposure to mucous membranes or non-intact skin is unknown, but is believed to be very small. There is no vaccine against HCV and no treatment available after an exposure that will prevent infection. Immune globulin and antiretroviral drugs are NOT recommended after exposure. Human Immunodeficiency Virus (HIV) _The risk of acquiring HIV following a needle stick or cut exposure to an infected source is currently estimated at 0.3% (1 in 300)_. _The risk after exposure of the eye, nose, or mouth or non-intact skin to blood infected with HIV is estimated to be approximately 0.1% (1 in 1,000)_. A small amount of blood on intact skin likely poses no risk at all. Preventing injuries is the most effective way to protect workers. A **comprehensive sharps injury prevention program** would include: _Recommended guidelines._ _Improved equipment design._ _Effective disposal systems._ _Employee training._ _Safe recapping procedures, where necessary._ _Surveillance programs._ **Hierarchy of controls** **_Elimination_** - find ways to eliminate or reduce needle use during procedures, medication delivery, and specimen collection. **_Engineering controls_** - remove or isolate the hazard by using _sharps disposal containers_ or other devices that have an integrated injury prevention feature. Safety devices must be chosen with care as no one device or strategy will work in every situation. **_Work-practice controls_** - Steps that can be taken to reduce injuries include _using instruments to grasps needles or load/unload scalpels_, _avoiding hand-to-hand passage of sharps_, _separating sharps from other waste_, _not carry garbage or linen bags close to the body_, etc. **_Personal Protective Equipment (PPE)_** - PPE should be used as the last control approach, where appropriate.

Answer 153

Trihalomethanes - increased risk of cancer; liver, kidney, or CNS problems (formed with chlorine/chloramine and organic/inorganic matter) * Haloacetic acid - increased risk of cancer (formed with chlorine/chloramine and organic/inorganic matter) * Bromate - increased risk of cancer (formed with bromide and ozone) * Chlorite - CNS effects, anemia (formed when chlorine dioxide breaks down)

Answer 154

The goals of comprehensive sexual health education are to equip people with the **information, motivation, and behavioural skills** _to 1) enhance sexual health and well-being_ (e.g., having respectful and satisfying interpersonal relationships, increased self-acceptance, increased capacity to access sexual and reproductive health services) and to 2) _prevent outcomes that can have a negative impact on sexual health and well-being_ (e.g., acquisition and transmission of sexually transmitted infections [STIs], unintended pregnancies, sexual coercion/trauma/abuse/harassment, relationship problems). SPECIFIC COMPONENTS OF SEXUAL HEALTH EDUCATION USING THE IMB MODEL 1. **Information/Knowledge** • Should be relevant to the individual’s personal sexual health and well-being • Can be used to make informed, autonomous decisions • Can be translated into relevant behaviour change 2. **Motivation** • Impact of social norms and peer pressure • Perceived vulnerability to negative outcomes • Perceived opportunity for positive outcomes • Emotional motivation: a person’s level of comfort or discomfort with sexuality (e.g., feelings of self-acceptance and self-worth related to sexuality) • Personal motivation: beliefs and attitudes towards specific sexual health prevention or promotion acts • Social motivation: perceived social support or opposition for an individual’s enactment of a sexual health prevention or promotion behaviour 3. **Behavioural Skills** • Translating information/knowledge and motivation/attitudes into intentions, confidence (i.e., self-efficacy), and behaviour conducive to sexual health and well-being (e.g., using condoms, dental dams, other barriers [e.g., gloves],and/or birth control) • Communication through ongoing conversation (e.g., discussing consent, setting sexual limits, expressing sexual preferences; understanding and expressing nonverbal communication) • Accessing resources/health services 4. **Environmental Factors** (Understanding and engagement) • Awareness of the ways that social, cultural, economic, political contexts can negatively/positively affect sexual health and well-being • Strengthening capacity for self and group advocacy related to sexual health and well-being • Strengthening access to user-friendly, stigma-free sexual and reproductive health services PRINCIPLES OF COMPREHENSIVE SEXUAL HEALTH EDUCATION: -IS _ACCESSIBLE TO ALL PEOPLE INCLUSIVE_ OF AGE, RACE, SEX, GENDER IDENTITY, SEXUAL ORIENTATION, STI STATUS, GEOGRAPHIC LOCATION, SOCIO-ECONOMIC STATUS, CULTURAL, OR RELIGIOUS BACKGROUND, ABILITY, OR HOUSING STATUS (E.G., THOSE WHO ARE INCARCERATED, HOMELESS, OR LIVING IN CARE FACILITIES). - PROMOTES _HUMAN RIGHTS INCLUDING AUTONOMOUS DECISION-MAKING AND RESPECT FOR THE RIGHTS OF OTHERS_. - IS _SCIENTIFICALLY ACCURATE_ AND USES EVIDENCE-BASED TEACHING METHODS. - IS BROADLY-BASED IN SCOPE AND DEPTH AND ADDRESSES A RANGE OF TOPICS RELEVANT TO SEXUAL HEALTH AND WELL-BEING. - IS _INCLUSIVE OF THE IDENTITIES AND LIVED EXPERIENCES_ OF LESBIAN, GAY, BISEXUAL, TRANSGENDER, QUEER, INTERSEX, TWO-SPIRIT, NONBINARY, AND ASEXUAL PEOPLE (LGBTQI2S+), AND OTHER EMERGING IDENTITIES. - PROMOTES _GENDER EQUALITY_ AND THE PREVENTION OF SEXUAL AND GENDER-BASED VIOLENCE. - INCORPORATES A _BALANCED APPROACH_ TO SEXUAL HEALTH PROMOTION THAT INCLUDES THE POSITIVE ASPECTS OF SEXUALITY AND RELATIONSHIPS AS WELL AS THE PREVENTION OF OUTCOMES THAT CAN HAVE A NEGATIVE IMPACT ON SEXUAL HEALTH AND WELL-BEING. - IS RESPONSIVE TO AND INCORPORATES EMERGING ISSUES RELATED TO SEXUAL HEALTH AND WELL-BEING. - IS _PROVIDED BY EDUCATORS WHO HAVE THE KNOWLEDGE AND SKILLS TO DELIVER COMPREHENSIVE SEXUAL HEALTH EDUCATION_ AND WHO RECEIVE ADMINISTRATIVE SUPPORT TO UNDERTAKE THIS WORK. OBJECTIVES of comprehensive sexual health education : 1) _increasing the use of condoms_, dental dams, or other types of barriers, (less unintended pregnancies) 2) _increasing STI testing_, 3) _accessing the human papillomavirus (HPV) vaccine_, 4) _increasing awareness and use of PrEP and post-exposure prophylaxis (PEP) for HIV prevention_, 5) _obtaining/discussing consent for sexual activity with partners_, 6) _building capacity for educators_ to teach a comprehensive sexual health education curriculum, and 7) _increasing capacity for seeking support following sexual assault_.

Answer 155

1. Gather data into a centralized database and create a variance report with differences in what was spent and budgeted to spend 2. Evaluate and identify variances for further investigation Check accuracy of data Percentage variance Magnitude of variance 3. Investigate and identify reasons for variances 4. Compile an explanation of the variances and recommendations for senior management 5. Develop and implement plan to address/remedy variances and incorporate into future budget planning

Answer 156

Pathways for racism to effect health: * (1) economic and social deprivation; * (2) toxic substances and hazardous conditions; * (3)discrimination and other forms of socially inflicted trauma (mental physical, and sexual, directly experienced or witnessed, from verbal threats to violent acts; * (4) targeted marketing of harmful commodities (e.g., “junk” food and psychoactive substances such as , tobacco, alcohol and other licit and illicit drugs); and * (5) inadequate or degrading medical care; and, * (6) degradation of ecosystems, including as linked to systematic alienation of Indigenous populations from their lands and corresponding traditional economies Epistemic racism Positioning the knowledge of one racialized group as superior to another Systemic racism Imbalance of power and resources maintained through inequitable in treatment in law, policies, rules, and regulations Interpersonal racism Belief that an individual possesses certain characteristics based on their race alone Racism Unjust or unfair systems of power or privilege advantaging a group based on race Intersectionality The interconnected nature of social categorizations creating overlapping and interdependent systems of discrimination or disadvantage

Answer 157

Levin's formula PAF (from cohort) = Prevalence of exposure\*(RR-1) / [1 + Prevalence of exposure\*(RR-1)] PAF (from case-control) = Proportion of cases that have the exposure\*(OR-1)/OR EAF = (RR-1)/RR or (OR-1)/OR

Answer 158

_Chronic disease continues to be the biggest cause of disease burden in Canada._Close to half of Canadian adults over the age of 20 years report that they are living with at least one of ten common chronic diseases or conditions (Figure 3).7 On a positive note, recent data suggest _declining incidence rates for a number of chronic diseases in Canada_ (Figure 4).7 A report analyzing national data over the period of 1999 to 2012 from the Canadian _Chronic Disease Surveillance System (CCDSS) identified decreasing overall incidence trends for diagnosed asthma, chronic obstructive pulmonary disease, hypertension, ischemic heart disease, and stroke._

Answer 159

- 1 SD of the mean = 68.3% - 2 SD of the mean = 95.4% - 3 SD of the mean = 99. 7% 95% = 1.96 SD

Answer 160

**Maxwell's dimensions** of health care quality \* Access to services \* Relevance to need (for the whole community) \* Effectiveness (for individual patients) \* Equity (fairness) \* Social acceptability \* Efficiency and economy The **Donabedian model** is a conceptual model that provides a framework for examining health services and evaluating quality of health care.[1] According to the model, information about quality of care can be drawn from three categories: _“structure,” “process,” and “outcomes."_

Answer 161

We recommend _screening pregnant women once during the first trimester with urine culture for asymptomatic bacteriuria_ (**weak** recommendation; **very low-quality** evidence).

Answer 162

Agent: Characteristics include, **Infectiousness** (I): Ability of an organism to establish itself in a susceptible host; I = infected / exposed **Pathogenicity:** Probability of an organism to cause disease (e.g., TB is not very pathogenic) **Virulence**: Severity of disease caused by organism (e.g., Zika is low-virulence; TB is highly virulent)

Answer 163

We recommend AGAINST screening\*1 for developmental delay using standardized tools in children aged 1 to 4 years with no apparent signs of developmental delay and whose parents and clinicians have no concerns about development. (**Strong recommendation; low quality evidence**)

Answer 164

Sender Message Medium Receiver Interpretation Outcome

Answer 165

Psittacosis Histoplasmosis Aspergillosis Cryptococcus MAC Salmonella, campy, cryptosporidiosis, wnv avian influenza

Answer 166

Mnemonic **Person _consents_ to _collection_ of _accurate_ data for _use/disclosure/retention limited_ to an _identified purpose_** **_Accountable_/_challengeable_ organization _safeguards_ those _accessible_ data _openly_** Principle 1 - **Accountability** An organization is responsible for personal information under its control. It must appoint someone to be accountable for its compliance with these fair information principles. Principle 2 - **Identifying Purposes** The purposes for which the personal information is being collected must be identified by the organization before or at the time of collection. Principle 3 - **Consent** The knowledge and consent of the individual are required for the collection, use, or disclosure of personal information, except where inappropriate. Principle 4 - **Limiting Collection** The collection of personal information must be limited to that which is needed for the purposes identified by the organization. Information must be collected by fair and lawful means. Principle 5 - **Limiting Use, Disclosure, and Retention** Unless the individual consents otherwise or it is required by law, personal information can only be used or disclosed for the purposes for which it was collected. Personal information must only be kept as long as required to serve those purposes. Principle 6 - **Accuracy** Personal information must be as accurate, complete, and up-to-date as possible in order to properly satisfy the purposes for which it is to be used. Principle 7 - **Safeguards** Personal information must be protected by appropriate security relative to the sensitivity of the information. Principle 8 - **Openness** An organization must make detailed information about its policies and practices relating to the management of personal information publicly and readily available. Principle 9 - **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. An individual shall be able to challenge the accuracy and completeness of the information and have it amended as appropriate. Principle 10 - **Challenging Compliance** An individual shall be able to challenge an organization’s compliance with the above principles. Their challenge should be addressed to the person accountable for the organization’s compliance with PIPEDA, usually their Chief Privacy Officer.

Answer 167

No poverty Zero hunger Good health and well-being Quality education Gender equality Clean water and sanitation Affordable and clean energy Decent work and economic growth Industry, innovation, and infrastructure Reduced inequalities Sustainable cities and communities Responsible consumption and producction Climate action Life below water Life on land Peace, justice and strong institutions Partnerships for the goals

Answer 168

**Substantive values:** Harm principle Liberty of individuals Proportionality Duty to provide care Reciprocity Solidarity Privacy Equity Trust Stewardship **Procedural values:** Inclusive Reasonable Open and transparent Accountable Responsive

Answer 169

**Steps:** - Topic selection - Scoping - Benefits and harms identified (patient input) - Protocol development - Conduct systematic evidence review - Draft recommendations (patient input, equity, feasibility, acceptability, cost) - Draft guideline - Feedback from clinical experts, peer reviewers, stakeholders - Knowledge translation create tool for primary care and patients (patient input) - Publication of protocol, guideline, systematic review - Dissemination to clinicians, patients, policy makers, public - Clinical Practice - Evaluation QUALITY OF EVIDENCE (Grading of Recommendations Assessment, Development and Evaluation system (GRADE)) **High quality evidence:** - there is a _wide **range of studies**_ included in the analyses - with **_no major limitations_**, - there is _**little variation** between studies_, - and the _summary estimate has a **narrow confidence interval**_ - Moderate quality evidence: there are only a few studies and some have limitations but not major flaws, there is some variation between studies, or the confidence interval of the summary estimate is wide. - Low or very-low quality evidence: the studies have major flaws, there is important variation between studies, or the confidence interval of the summary estimate is very wide. **- Reasons for downgrading:** Risk of bias Imprecision Inconsistency Indirectness Publication bias **- Reasons for upgrading** Large magnitude of effect Dose-response gradient All residual confounding would decrease magnitude of effect (in situations with an effect) **STRENGTH OF RECOMMENDATIONS** Based on: _Quality of evidence_ + * The balance between _desirable and undesirable effects_; * The variability or uncertainty in _values and preferences of citizens_; * Whether or not the intervention represents a wise _use of resources_. _Strong recommendations_ are those for which we are confident that the desirable effects of an intervention outweigh its undesirable effects (strong recommendation for an intervention) or that the undesirable effects of an intervention outweigh its desirable effects (strong recommendation against an intervention). _Conditional\* recommendations_ are those for which the desirable effects probably outweigh the undesirable effects (conditional recommendation for an intervention) or undesirable effects probably outweigh the desirable effects (conditional recommendation against an intervention) but uncertainty exists. The _balance between desirable and undesirable effects is small_, the _quality of evidence is lower,_ and there is _more variability in the values and preferences of individuals_.

Answer 170

SDoH: The economic and social conditions that influence the health of individuals, communities and countries. SDOH are underpinned by structural factors, such as race, sexual orientation, and the history of colonization among FN communities. \*SDOH can be modified, structural determinants cannot. Roles of public health in health inequity: Assess/report Modify/orient PH interventions Partner with other services Lead/participate in policy

Answer 171

Global distillation or the grasshopper effect is the _geochemical process by which certain chemicals, most notably persistent organic pollutants (POPs), are transported from warmer to colder regions of the Earth, particularly the poles and mountain tops_. Global distillation explains why relatively high concentrations of POPs have been found in the Arctic environment and in the bodies of animals and people who live there, even though most of the chemicals have not been used in the region in appreciable amounts.

Answer 172

Theoretical saturation (also known as thematic saturation) Population selection: Purposive sampling Benchmarks used by qualitative researchers to assess the quality and validity of qualitative research: Triangulation Clear documentation of the research process Supporting theory with quotes from the transcript Limitation - process of testing how well the findings of the research fit the data, establishing limits of the theory by identifying and discussing deviant and negative cases. Falsification - process of modifying the theory to incorporate a case that does not fit with the theory Member checking - process of testing the interpretive findings with participants Name 5 qualitative data collection methodologies: Semi-structured interviews Narrative interviews In-depth interviews Focus groups Action research Participant observation Document review List 2 raw data sources in qualitative methods: Transcripts of what was said in interviews and focus groups Field notes on what was observed by the researcher during observation List 4 steps in the iterative process of qualitative data analysis: Some form of _review of all the information_ to gain an initial sense of the data, these ideas might then be fed back to the informants for verification purposes. The process of _organising the data into some manageable form_. This is often described as 'reducing the data', and usually involves developing codes or categories. However, as will be argued below, this process can be potentially problematic if the desire of the researcher is to maintain the unique richness of qualitative forms of data. I_nterpreting the data_ _Presenting_ it in some form, e.g. tables, prose, or diagrams. Name 1 guideline for best practice in reporting qualitative research: Consolidated Criteria for Reporting Qualitative Research (COREQ)

Answer 173

15 Steps of the Hiring Process 1. **Identify the hiring need** The hiring process begins by identifying a need within your organization. This need could vary from filling a vacated position, better managing a team’s workload, or expanding the reach of organizational tasks. Positions are, in other words, either newly formed or recently vacated. 2. **Devise A Recruitment Plan** Once an organization identifies a hiring need, it should begin recruitment. In the case of newly formed positions, organizations should clearly identify how the new role aligns with its goals and business plan. Organizations should also keep relevant internal teams and employees apprised of the new position at each stage of the hiring process. It’s important that all those involved in the hiring decision agree to the hiring process, steps, and appropriate communication channels. Recruitment also includes strategizing how to publicize the new position, both internally and externally; criteria for initial candidate screening; what the interview process will look like; and who will conduct interviews. 3. **Write a job description** The hiring staff should start by generating a job description that includes a prioritized _list of job requirements, special qualifications, desired characteristics, and requisite experience_. The job description should also include _information regarding salary and benefits_. 4. **Advertise the Position** Identifying highly-qualified potential candidates begins _internally_. Start, therefore, by notifying current employees of the opening. Advertising the job may stop there, if you are determined to fill the position internally. If, however, you are interested in external candidates, you should include this information when you notify internally. _External publicity will likely consist of utilizing a combination of the company’s website and social media platforms, job posting sites like LinkedIn, job fairs, industry publications and events, local newspaper advertisements, and word-of-mouth recruitment_. Publicity will likely consist of utilizing a combination of the company’s website and social media platforms and job posting sites like LinkedIn, industry publications, and local newspaper advertisements. 5. **Recruit the Position** Beyond simple job posts, the hiring staff should reach out directly to desirable candidates via LinkedIn, social media, and job fairs. _Active recruitment_ will help generate applications from potential candidates who are not actively searching for new jobs but may be perfect for the available position. 6. **Review Applications** Your organization likely already has a mechanism in place to receive applications--via email, an applicant tracking system (ATS), etc. In many cases, the review process begins with _Human Resource representatives who review the applications and eliminate any candidate who does not meet the minimum requirements for the position_ or the company more generally. In other instances, the hiring team or hiring manager may prefer to review each application. Once a batch of qualified applications are assembled, the hiring staff should review the remaining candidates and identify those they want to interview. 7. **Phone Interview/Initial Screening** Initial interviews typically begin with phone calls with HR representatives. Phone interviews determine if applicants possess the _requisite qualifications to fill the position and align with an organization’s culture and values_. Phone interviews enable organizations to further pare down the list of candidates while expending company resources efficiently. 8. **Interviews** Depending on the size of the organization and hiring committee, one or several interviews are scheduled for those remaining candidates. Interviews include: _Early interviews are typically one-on-one, in-person interviews between the applicants and the hiring manager. Early interviews conversations typically focus on applicants’ experience, skills, work history, and availability._ Additional interviews with management, staff, executives, and other members of the organization can be either one-on-one or _group interviews with the hiring committee_. They may be formal or casual; on-site, off-site, or online via Skype, Google Hangouts, etc. Additional interviews are more in-depth; for example, in interviews between a candidate and multiple members of the hiring team interviewer, each member of the hiring team focuses on a specific topic or aspect of the job to avoid redundancy and ensure an in-depth conversation about the role and the candidates qualifications and experience. Note: at this stage, you should also inform the candidates you elect not to request an interview that the search has moved forward and they are no longer under consideration. Final interviews often include conversations with the company’s senior leadership or a more in-depth discussion with an interviewer from an earlier stage in the hiring process. Final interviews are typically extended only to a very small pool of top candidates. 9. **Applicant Assessment** Once the interviews are completed, or during their completion, company’s often assign applicants one or more standardized tests. These exams measure a wide range of variables, including personality traits, problem-solving ability, reasoning, reading comprehension, emotional intelligence, and more. 10. **Background Check** Your initial job posting should indicate that all candidates are subject to a background check. Background checks review candidates’ _criminal record, verify employment history and eligibility,_ and run credit checks. Some organizations also check social media accounts (Facebook, Twitter, etc.) to make sure potential employees are likely to represent the company in a professional manner. Drug testing may also be warranted, depending on the position. 11. **Decision** After conducting background and reference checks, the hiring staff identifies their top choice. The hiring staff should also select a backup candidate, in case the top choice declines the offer or negotiations fail to produce a signed offer letter. In the event that no candidates meet the hiring criteria, the hiring staff should determine whether or not to start the hiring process over. If so, the hiring staff should discuss whether or not to adjust or alter the hiring process in order to yield more favorable candidates. 12. **Reference Check** Reference checks should verify any pertinent information shared by the candidate about previous employment--job performance, experience, responsibilities, workplace conduct, etc. A typical question to ask references is “Would you rehire this person?” 13. **Job offer** Once a top candidate is identified, the organization should extend an initial offer. The offer letter should i_nclude the position’s salary, benefits, paid time off, start date, potential severance pay, working remotely policy, included company equipment and other terms and conditions of employment._ Negotiations are likely to follow. Therefore, the hiring staff should determine internally which elements of the offer letter are negotiable, and which are not. It is typical for terms like salary, flexible work schedule, and working remotely to be negotiable. 14. **Hiring** After negotiations, once the candidate accepts the job offer they are hired. An accepted offer letter begins a process of filling out and filing paperwork related to employment. Forms and paperwork might include: Form W-4 Form I-9 and E-Verify State Withholding and Registrations A checklist with all required paperwork to be completed by new employees An organization’s employee handbook 15. **Onboarding** Hiring a new employee does not conclude the hiring process. Onboarding your new worker in a welcoming and professional way will help integrate them in a manner that lays the groundwork for a long-term productive relationship between them and your company. A _welcome letter i_s strongly advised. From there, relevant management should reach out to the employee before their start date to welcome them to the organization. Their work space should be prepared, cleaned, and equipped with the necessary credentials and equipment before their first day. If an orientation is part of the onboarding process, make sure your employee has a clear understanding of the expectations and scheduling of those events. Lastly, consider assigning your new employee a _mentor,_ which will help them settle in to their new position and organization, and set them up for long term growth and success.

Answer 174

* Health determinants and status; * Community engagement; * Resources and services; and, * Integration and responsiveness.

Answer 175

1. Is there sufficient evidence to support a reasonable suspicion that the exposure of interest causes the proposed harm? (_Apply the Bradford-Hill criteria_) a) Do studies consistently show an effect? b) Has a strong association been demonstrated? c) Is this a specific outcome associated with a specific exposure? d) Has a dose-response (biological gradient) been observed? e) Has a temporal relationship been observed? f) Is the relationship biologically plausible? g) Is the proposed relationship coherent with existing theory and knowledge? h) Is there an analogy with a proven cause and effect relationship? i) Does experimental evidence support the relationship? 2. Is the _harm associated with the suspected exposure serious_? 3. Is the suspected _exposure widespread_? 4. Is there an observed increase in the incidence of the suspected harm that is temporally associated with increased exposure? 5. Is the harm associated with the suspected exposure _difficult to treat or reverse_? 6. What are the _economic and non-economic costs and benefits of action and non-action_? 7. Are the _proposed control measures proportional to the level of risk_? Are the economic costs of removing the exposure minimal? Are the health and societal costs of removing the exposure minimal? 8. Are comparable situations being treated similarly according to a _standard of practice_? 9. Is the level of the protective measures consistent with equivalent areas in which scientific data are available? 10. If precautionary measures are adopted, is there any new evidence to reduce the level of uncertainty about harm and benefit?

Answer 176

**Microbiological:** - Enteric protozoa (giardia, crypto) - Enteric viruses - E. Coli - Total coliforms - Turbidity **Chemical and physical:** - Many, among them: ammonia, arsenic, benzene, cadmium, chloramines, chromium, cyanobacterial toxins, lead, nitrate, PFOS/PFOA, pH, vynil chloride **Radiological**

Answer 177

Vaccination for NOT previously immunized, \<7yo: DTaP-IPV: - 4 doses of DTaP-IPV-containing vaccine. - if the fourth dose of DTaP-IPV vaccine was given before the fourth birthday, a booster dose of DTaP-IPV or Tdap-IPV vaccine should be provided at 4-6 years of age. HiB: - If first visit at 12-14 months of age: 1 dose of Hib-containing vaccine at first visit and booster dose at least 2 months after the previous dose. - If first visit at 15 months-less than 60 months of age (5yo): _1 dose_ of Hib-containing vaccine. - If first visit at 60 months of age or older (5yo), _Hib-containing vaccine is not required_. Pneumococcal: - 12-23 months of age - 2 doses, at least 8 weeks apart. - 24-59 months of age - 1 dose. Meningococcal conjugate monovalent: - 12-59 months of age - 1 dose; - 5-11 years of age - consider 1 dose. Measles-mumps-rubella: - 2 doses, at least 4 weeks apart Varicella: - 2doses, at least 3 months apart Hepatitis B - 3 doses - months 0, 1 and 6 (first dose = month 0) with at least 4 weeks between the first and second dose, 2 months between the second and third dose, and 4 months between the first and third dose. Influenza Vaccination for NOT previously immunized, 7-17yo: Tdap-IPV: - 3 doses; 2 doses, 8 weeks apart, third dose 6-12 months after second dose. - Tdap booster 10y after last dose Meningococcal: - Meningococcal conjugate monovalent: 7-11 years of age - consider 1 dose. - Meningococcal conjugate monovalent or quadrivalent: 12-17 years of age - 1 dose, even if meningococcal conjugate vaccine received at a younger age MMR: -2 doses, at least 4 weeks apart. Varicella: - 7-12 years of age - 2 doses, at least 3 months apart. 13 years of age and older - 2 doses, at least 6 weeks apart. Hepatitis B: - 7-17 years of age - 3 doses, months 0, 1 and 6 (first dose = month 0) with at least 4 weeks between the first and second dose, 2 months between the second and third dose, and 4 months between the first and third dose. - 11-15 years of age - two doses; schedule depends on the product used. HPV - recommended for women up to and including 26 years of age, may be given to women 27 years of age and older at ongoing risk of exposure: HPV bivalent (HPV2) vaccine - months 0, 1 and 6 (first dose = month 0), HPV quadrivalent (HPV4) vaccine - months 0, 2 and 6 (first dose = month 0) or nonavalent (HPV9) vaccine- months 0, 2 and 6 (first dose = month 0). - recommended for men up to and including 26 years of age, may be given to men 27 years of age and older at ongoing risk of exposure: HPV4 or HPV9 vaccine - months 0, 2 and 6 (first dose = month 0). Influenza

Answer 178

OA risk factors: age, female Epi trends: prevalence in 20+ = 13.6% (2016-2017) Preventive measures: physical activity, avoir overuse, manage weight

Answer 179

STEP 1: MANAGE THE PLANNING PROCESS Purpose: to develop a _plan to manage stakeholder participation, timelines, resources, and determine methods for data-gathering, interpretation, and decision making._ Plan to engage stakeholders, including clients and staff, in a meaningful way. Establish a clear timeline for creating a work plan. Plan how you will allocate financial, material, and human resources. Consider the data required to make decisions at each step and include adequate time for data collection and interpretation. Establish a clear decision‐making process. (e.g., by consensus, by committee) STEP 2: CONDUCT A SITUATIONAL ASSESSMENT Purpose: to _learn more about the population of interest, trends, and issues that may affect implementation, including the wants, needs, and assets of the community._ This step involves identifying: what is the situation; what is making the situation better and what is making it worse; and what possible actions you can take to address the situation. Use diverse types of data (e.g. _community health status indicators, stories/testimonials; evaluation findings; “best practice” guidelines), sources of data (e.g. polling companies; community/partner organizations; researchers; governments; private sector); and data collection methods (e.g. stakeholder interviews or focus groups; surveys; literature reviews; review of past evaluation findings or stakeholder mandates/policies_). STEP 3: IDENTIFY GOALS, POPULATIONS OF INTEREST, OUTCOMES AND OUTCOME OBJECTIVES Purpose: to use _situational assessment results to determine goals, populations of interest, outcomes and outcome objectives._ Ensure program goals, populations of interest and outcome objectives are aligned with strategic directions of your organization or group:  goal: a broad statement providing overall direction for a program over a long period of time.  population(s) of interest : group or groups that require special attention to achieve your goal  outcome objective: brief statement specifying the desired change caused by the program ``` STEP 4: IDENTIFY STRATEGIES, ACTIVITIES, OUTPUTS, PROCESS OBJECTIVES AND RESOURCES Purpose: to _use the results of the situational assessment to select strategies and activities, feasible with available resources, that will contribute to your goals and outcome objectives._ Brainstorm strategies (e.g. health education, health communication, organizational change, policy development) for achieving objectives using one or more health promotion frameworks such as the Ottawa Charter for Health Promotion or the socioecological model. Prioritize ideas by applying situational assessment results. Identify specific activities for each strategy, including which existing activities to start, stop, and continue. Select outputs and develop process objectives. Consider available financial, human and in‐kind resources. ``` STEP 5: DEVELOP INDICATORS Purpose: to develop a _list of variables that can be tracked to assess the extent to which outcome and process objectives have been met._ For each outcome and process objective consider the intended result and whether: the intended result can be divided into separate components; the intended result can be measured; there is appropriate time for observing a result; required data sources are accessible; and the resources needed to assess the result are available. Define indicators to measure each outcome and process objective and perform a quality check on proposed indicators ensuring they are valid, reliable, and accessible. Indicators are used to determine the extent to which outcomes and process objectives were met. STEP 6: REVIEW THE PROGRAM PLAN Purpose: to _clarify the contribution of each component of the plan to its objectives, identify gaps, ensure adequate resources, and ensure consistency with the situational assessment findings._ A logic model is a graphic depiction of the relationship between all parts of a program (i.e., goals, objectives, populations, strategies, and activities) and is one way in which a program overview can be communicated. Review the plan to determine whether: strategies effectively contribute to goals and objectives; short-term objectives contribute to long-term objectives; the best activities were chosen to advance the strategy; activities are appropriate to the audiences; and the resources are adequate to implement the activities.

Answer 180

1) nutrition standards for competitive foods and beverages (i.e., items sold or served outside the school meal programs); 2) marketing and promotion of foods and beverages at school; 3) access to free drinking water; 4) nutrition education for students; 5) Farm to School programs and school gardens; 6) nutrition-related training for school personnel; and 7) strategies to increase participation in school meals.

Answer 181

Steps of the All Hazards Risk Assessment in emergency management planning from Public Safety Canada 1. **Setting the Context** – The process of articulating an institution’s objectives and defining its external and internal parameters to be taken into consideration when managing risks. 2. **Risk Identification (***Hazard Identification HI***)** – The process of finding, recognizing, and recording risks. 3. **Risk Analysis** – The process of understanding the nature and level of risk, in terms of its impacts and likelihood. (*Risk asessment* *RA - probability x severity*) 4. **Risk Evaluation** – The process of comparing the results of Risk Analysis with risk criteria to determine whether a risk and/or its magnitude is acceptable or tolerable. 5. **Risk Treatment** – The process of identifying and recommending risk control or Risk Treatment options. *+Monitoring and review* **Goals of emergency management:** Save lives, reduce suffering, ensure safety if responders Protect health, infrastructure, economy, environment, property

Answer 182

Recommendation 1: We recommend _one-time screening with ultrasound for abdominal aortic aneurysm for men aged 65 to 80_. (**Weak recommendation**; **moderate quality of evidence**) Recommendation 2: We recommend _NOT screening men older than 80 years of age for abdominal aortic aneurysm_. (**Weak recommendation**; **low quality of evidence**) Recommendation 3: We recommend _NOT screening women for abdominal aortic aneurysm_. (**Strong recommendation**; **very low quality of evidence**)

Answer 183

Colorectal Cancer—Clinician Recommendation Table **Who do these recommendations apply to?** These recommendations apply to _asymptomatic adults aged 50 and older who are NOT at high risk for colorectal cancer (CRC)_. Adults are at high risk if they have at least one of the following: Previous CRC or adenomatous polyps (e.g., tubular or villous) Inflammatory bowel disease (e.g., ulcerative colitis or Crohn’s disease) Signs or symptoms of CRC (e.g., blood in the stool) History of CRC in one or more first-degree relatives Adults with hereditary syndromes predisposing to CRC (e.g., familial adenomatous polyposis or Lynch syndrome) This tool provides guidance for primary care practitioners on different screening tests, screening intervals, and recommended ages to start and stop screening. Resources, test availability, and patient preferences should be considered when choosing which screening test is appropriate. **Other recommendations** _We recommend not using colonoscopy as a primary screening test for CRC_ There is a _lack of direct, high-quality evidence of the efficacy of colonoscopy in comparison to that of other screening tests._ Colonoscopy has _greater potential for harms_ (e.g., minor bleeding, major bleeding, perforation, and death) than the other available tests. Colonoscopy requires _more time and expertise to perform, and using colonoscopy for screening means that this test will not be as readily available for people with symptomatic disease, such as visible blood in the stool._ Implementation considerations An FOBT test is the most convenient, uses the fewest resources, and will likely be the preferred option in most situations. It is important to note that flexible sigmoidoscopy is an option in specific circumstances based on patient values and preferences (e.g., averse to stool testing, prefers less frequent testing) and resource availability. Evidence summary RCT data show that screening those aged 50-74 years for CRC with gFOBT or flexible sigmoidoscopy reduces the incidence of late-stage CRC and CRC mortality. FIT has greater sensitivity than gFOBT and similar specificity. Therefore, the reported mortality benefits of gFOBT for people aged 50-74 years can be extended to FIT. The only direct harms noted for either gFOBT or FIT in the studies reviewed were false positives and false negatives. The harms of flexible sigmoidoscopy are rare but include intestinal perforation, minor bleeding, major bleeding, and death

Answer 184

Who is at risk and how does exposure occur to cyanobacteries? What are cyanobacteria? Cyanobacteria, or ‘blue-green algae,’ are _naturally occurring microscopic organisms found in fresh, brackish, or marine water_. Under conditions such as _warmer water temperatures, high nutrient loads_, and other anthropogenic influences, cyanobacteria can multiply quickly and create blooms, sometimes called harmful algae blooms (HABs), cyanoHABs, or cyanoblooms. Cyanoblooms can occur in Canada at any time of year, but are more common in summer or early fall.1 _Cyanobacteria can produce cyanotoxins, high concentrations of which are harmful to animal and human health, in both drinking and recreational water_ e.g., during a cyanobloom. In rare cases, cyanotoxin exposure has been fatal to humans.2 Not all cyanobacteria species produce toxins, but every bloom should be treated as toxic until known otherwise. There are four main types of cyanotoxin – **MICROCYSTIN (Canadian water MAC is for microcystin 0.0015mg/L), nodularin, saxitoxin, and cylindrospermopsin.** Humans, pets, and farm animals e.g., cattle, can be affected by cyanotoxins. C_hildren tend to become sick more easily and frequently than adults_ because of their lower body weight, and the potential developmental effects of cyanotoxins.5 _Infants fed formula reconstituted from contaminated drinking water are also at greater risk_.6 **Cyanotoxin exposure** can occur by _drinking contaminated water; inhalation and skin contact during swimming, bathing, or showering; consumption of produce irrigated with tainted water;2 and ingesting fish or other foods collected from affected freshwater bodies_. **Acute (short-term) exposure** can cause: _**GI**: vomiting, diarrhoea,_ _**Derm**: skin irritation, rash,_ _**Systemic**: fever, headache, muscle/joint pain,_ _**Neuro**: weakness, pale skin, cold hands/feet, numbness of lips/mouth, incoordination, respiratory, and muscular paralysis_. **Chronic (long-term) exposure** can lead to tumor formation, with microcystin-LR possibly a human carcinogen (Group 2B).7 _Climate change_ is expected to affect bloom timing and cyanobacterial dominance.8 _Any indication of a bloom/microcystin presence warrants an advisory for alternative suitable drinking water to reconstitute formula for bottle-fed infants_. Toxins are not removed by boiling water, thus advisories such as “_do not consume” or ”do not use” are warranted for communities lacking necessary treatment capabilities (e.g., coagulation, flocculation)_ and alternate drinking and bathing water sought.6 _Beaches are often closed during blooms_. The public are encouraged to avoid entering water where blooms are present, and should rinse thoroughly afterwards using uncontaminated water CANADIAN GUIDELINES FOR TOTAL MICROCYSTINS DRINKING WATER 1.5 µg/L RECREATIONAL WATER 20 µg/L **Prevention** Take these simple steps to prevent the growth of blue-green algae: use _phosphate-free detergent_s, personal care and household cleaning products _avoid using fertilizers on lawns_, especially fertilizers that contain phosphorus maintain a _natural shoreline_ on lake and riverfront properties _reduce agricultural runoff_ by planting or maintaining vegetation along waterways and minimizing fertilizer use _check septic systems_ to ensure they do not leak into the water source

Answer 185

``` r = correlation coefficient r² = coefficient of determination (amount of variance in y explained by x) ``` Measures the association between two continuous variables

Answer 186

Decentralization—the transfer of authority and responsibility for public functions from the central government to subordinate or quasi-independent government organizations and/or the private sector. The three major forms of administrative decentralization -- deconcentration, delegation, and devolution -- each have different characteristics. **In summary:** - DeConcentration - from central gov't to lower levels within gov't (e.g. the ministry) - DeLegation - from central gov't to arms-length/public-private orgs (e.g. Ontario Health) - DeVolution - from central gov't to regional gov't (e.g. municipalities) - Divestment - privatization **Deconcentration.** Deconcentration--which is often considered to be the weakest form of decentralization and is used most frequently in unitary states-- redistributes decision making authority and financial and management responsibilities among different levels of the central government. It can merely shift responsibilities from central government officials in the capital city to those working in regions, provinces or districts, or it can create strong field administration or local administrative capacity under the supervision of central government ministries. **Delegation.** Delegation is a more extensive form of decentralization. Through delegation central governments transfer responsibility for decision-making and administration of public functions to semi-autonomous organizations not wholly controlled by the central government, but ultimately accountable to it. Governments delegate responsibilities when they create public enterprises or corporations, housing authorities, transportation authorities, special service districts, semi-autonomous school districts, regional development corporations, or special project implementation units. Usually these organizations have a great deal of discretion in decision-making. They may be exempt from constraints on regular civil service personnel and may be able to charge users directly for services. **Devolution.** A third type of administrative decentralization is devolution. When governments devolve functions, they transfer authority for decision-making, finance, and management to quasi-autonomous units of local government with corporate status. Devolution usually transfers responsibilities for services to municipalities that elect their own mayors and councils, raise their own revenues, and have independent authority to make investment decisions. In a devolved system, local governments have clear and legally recognized geographical boundaries over which they exercise authority and within which they perform public functions. It is this type of administrative decentralization that underlies most political decentralization.

Answer 187

CO2 Methane N2O - nitrous oxide Fluorinated Compounds (Water vapour)

Answer 188

Overcrowding Excessive humidity/mold Inadequate insulation Vermin Inadequate plumbing/water Inadequate maintenance No fire alarms

Answer 189

school environment (social/physical); health education; health services; physical education; counseling, guidance and mental health; school food and nutrition services; worksite health promotion; and integration of school and community health activities Pan-Canadian Joint Consortium on Comprehensive School Health: - Learning and teaching - Physical and social environment - Partnerships - Policies

Answer 190

**Age/cause-specific death rate** = total number of deaths during period by age/cause / mid-year population \*1000 or 100,000 **Proportionate mortality rate** = number of deaths due to specific disease during period / total number of deaths from all causes during period \*100 **Standardized mortality ratio** = number of observed deaths / number of expected deaths \*100 **Case fatality ratio** = number of deaths due to specific disease during period / number of persons receiving diagnosis of disease during period \*100

Answer 191

**In summary:** - Delay to later in life - Lower strength products, CBD \> THC - No synthetics - Don't smoke it - Don't inhale deeply - Occasional use only - Don't drive/operate machinery - Don't mix with alcohol - Don't use if risk factors for psychosis (PHx, FHx), substance use problem or pregnant - Don't combine risky behaviors Remember that every form of cannabis use poses risks to your health. The only way to completely avoid these risks is by choosing not to use cannabis. If you decide to use cannabis, follow these recommendations to lower risks to your health. The earlier in life you begin using cannabis, the higher your risk of serious health problems. Teenagers, particularly those younger than 16, should delay using cannabis for as long as possible. You’ll lower your risk of cannabis-related health problems if you _choose to start using cannabis later in life._ Higher-strength or more powerful cannabis products are worse for your health. If you use products with high tetrahydrocannabinol (THC) content, the main mind-altering ingredient in cannabis, you’re more likely to develop severe problems, such as dependence or mental health problems. Cannabidiol (CBD), another cannabis ingredient, can counteract some of THC’s psychoactive effects. If you use, _choose low-strength products, such as those with a lower THC content or a higher ratio of CBD to THC._ _Don’t use synthetic cannabis products._ Compared with natural cannabis products, most synthetic cannabis products are stronger and more dangerous. K2 and Spice are examples of synthetic cannabis products. Using these can lead to severe health problems, such as seizures, irregular heartbeat, hallucinations and in rare cases, death. Smoking cannabis (for example, smoking a joint) is the most harmful way of using cannabis because it directly affects your lungs. T_here are safer, non-smoking options like vaping or taking edibles that are better for your lungs._Keep in mind that these alternatives aren’t risk-free either. _If you choose to smoke cannabis, avoid inhaling deeply or holding your breath_. These practices increase the amount of toxins absorbed by your lungs and the rest of your body, and can lead to lung problems. The more frequently you use cannabis, the more likely you are to develop health problems, especially if you use on a daily or near-daily basis. _Limiting your cannabis use to occasional use at most,_ such as only using once a week or on weekends, is a good way to reduce your health risks. Try to limit your use as much as possible. _Cannabis use impairs your ability to drive a car or operate other machinery. Don’t engage in these activities after using cannabis, or while you still feel affected by cannabis in any way_. These effects typically last at least six hours, but could be longer, depending on the person and the product used. _Using cannabis and alcohol together further increases your impairment. Avoid this combination before driving or operating machinery._ Some people are more likely to develop problems from cannabis use. Specifically, _people with a personal or family history of psychosis or substance use problems, and pregnant women should not use cannabis at all._ _Avoid combining any of the risky behaviours_ described above. The more risks you take, the greater the chances of harming your health as a result of cannabis use.

Answer 192

Syphilis HIV Rubella immunity Gonorrhea Chlamydia Hepatitis B GBS Asymptomatic bacteriuria

Answer 193

The Pan-Canadian STBBI Framework for Action is composed of four interconnected pillars that span the continuum of STBBI care: _- prevention_, _- testing_, _- initiation of care and treatment_, and _- ongoing care and support_. Strengthening **Prevention**: Opportunities for Action 1. Improve a_ccess to effective prevention interventions, including safer-sex materials, harm reduction, testing, treatment, and targeted vaccination programs_. 2. _Research_, implement, and evaluate innovative biomedical prevention interventions (e.g., new vaccines and PrEP) and continue to expand the reach of existing vaccines (e.g., HBV and HPV). 3. Develop and disseminate holistic, scientifically accurate, culturally- and age-appropriate, and gender-responsive sexual health information, resources, and _curricula in school and community settings_. 4. Implement sustained interventions to facilitate empowerment and _behaviour change_ among individuals who engage in risky behaviours. 5. _Equip health professionals_ and front-line providers with knowledge, skills, and resources to provide equitable access to prevention interventions—including the use of treatment to prevent STBBI transmission—vaccination, testing, treatment, and contact investigation programs. Enhancing **Testing**: Opportunities for Action 1. Provide _health professionals_ and front-line service providers with knowledge, skills and resources to implement person-centred, culturally-relevant, and integrated testing that respects patient privacy and rights. 2. Ensure appropriate _linkages to prevention, treatment, and care resources_ are provided to individuals who have been diagnosed with, or at risk of, a STBBI. 3. _Research_, implement, and evaluate innovative and emerging testing technologies, testing approaches, and sustainable quality assurance systems. 4. _Improve availability of, and access to, evidence-based testing_ technologies and approaches in a variety of settings. 5. _Normalize the offer of STBBI testing_ among healthcare providers while individual rights to confidentiality, pre- and post- test counselling, and informed consent are respected. Ensuring **Access to Care and Treatment**: Opportunities for Action 1. Develop holistic, culturally-appropriate, and gender-affirming information and education resources for people to facilitate early treatment. 2. Identify and eliminate barriers that impede timely and affordable access to STBBI treatment, care and support. 3. Address the health of the whole person by adopting holistic and coordinated approaches, developing multi-disciplinary outreach programs and strengthening electronic patient care systems. 4. Provide health professionals and other front-line workers knowledge, skills, and resources to reach and engage people with appropriate and timely treatment. 5. Expand the application of health-systems tools, including communications technologies and electronic health records management systems, to improve the quality of treatment care for people with STBBI. 6. Enhance laboratory surveillance of drug-resistant STBBI to inform effective treatment, antimicrobial stewardship, and the development of new treatments. Ensuring **Ongoing Care and Support**: Opportunities for Action 1. Implement a person-centred approach to care and improve links to health and social support for people living with chronic STBBI. 2. Empower people living with chronic STBBI to feel engaged in making health decisions by acknowledging and improving their health literacy and knowledge. 3. Develop and implement interventions that retain and re-engage people with chronic STBBI with care and support services. 4. Provide health professionals and other front-line providers with knowledge, skills, and resources to serve the diverse needs of their patients and to improve their ability to offer culturally-relevant and gender-affirming continuous care and treatment adherence. 5. Develop or expand navigation resources, including electronic health records or peer navigators to improve the access of people affected by STBBI to treatment, ongoing care, referrals, support, and to re-engage in care if necessary.

Answer 194

LUNG CANCER Arsenic (smoking) Cadmium (smoking) Nickel (smoking) Lead (possibly) Chromium

Answer 195

**Chlorine-resistant:** (should be removed with filters) - Toxoplasma - Cryptosporidium oocysts **Chlorine tolerant:** - Entamoeba histolytica - Giardia intestinalis

Answer 196

Building blocks: Service delivery Health workforce Information Medical products, vaccines & technologies Financing Leadership/governance

Answer 197

1. Eat a well-balanced diet 7. Reduce stress 2. Exercise regularly 8. Manage chronic medical conditions 3. Cease smoking 9. Identify and treat women at risk of severe morning sickness 4. Avoid alcohol intake 10. Maintain a healthy weight 5. Cease illicit drug use 11. Take multivitamins with folic acid 6. Reduce environmental toxin exposure 12. Get vaccinated

Answer 198

Nutrition Facts Table, list of ingredients, allergen statements date marking information, such as best before dates.

Answer 199

The Sodium Reduction Strategy for Canada is multi-staged and based on a three-pronged approach that includes: _structured voluntary reduction of sodium levels in processed food products and foods sold in food services establishments_; _education and awareness of consumers, industry, health professionals and other key stakeholders_; and _research_. A fourth component, _monitoring and evaluation_, cuts across all three other areas. The Strategy is comprehensive and integrated; the recommendations in the four areas cannot be separated from one another in that a successful outcome depends on all being acted upon. The _current mean intake of sodium by Canadians is about 3,400 mg per day_. The Strategy has an interim sodium intake goal of a population average of 2300 mg of sodium per day to be achieved by 2016. The ultimate goal is to lower sodium intakes to a population mean whereby as many individuals as possible (greater than 95%) have a daily intake below the Tolerable _Upper Intake Level (UL) of 2,300 mg per day_. For practical purposes, achieving this requires moving the population mean daily intake of sodium much closer to the Institute of Medicine of the U.S. National Academies’ (IOM) recommended _Adequate Intake which is_ _1,500 mg per day for persons aged 9 to 50 years, and less for those younger and older than that._ Health Concerns and International Response There is a significant body of evidence _linking high sodium intake to elevated blood pressure_, which is the leading preventable risk factor for death worldwide. High blood pressure is the major cause of _cardiovascular disease and a risk factor for stroke and kidney disease_. There is also evidence to suggest that a diet high in sodium is a _risk factor for osteoporosis, stomach cancer and asthma_. According to the World Health Organization, interventions to reduce _population-wide salt intake have been shown repeatedly to be highly cost-effective_.

Answer 200

Deciding whether to evacuate or to shelter in-place Assuming that both options are feasible, the decision to evacuate or to shelter in-place must be based on a balance of the risks associated with the two options. The primary consideration is the **risk of both the exposure level and the exposure duration.** A secondary consideration relates to the intrinsic **risks of moving large numbers of people.** **Evacuation is the better option when:** * The area is not yet exposed, but will be after a certain time e.g. due to an anticipated shift in wind direction (the time to exposure being longer than the time required for the evacuation). * The likely duration of exposure is such that the protection offered by in-place sheltering may become insufficient. Evacuation may also be the better option if: * The _chemicals are widely dispersed and contamination is extensive and persistent_. * The _chemicals are suspected as being hazardous_, but cannot be identified readily. * The _chemical is highly hazardous_. * The _concentration in the air will be hazardous for a prolonged period_. * There is a _risk of explosion_. * _Number evacuees is relatively small_.

Answer 201

1. Distal (Political/social/economic contexts) Colonialism, history of residential schools Racism Discrimination in healthcare, legal system and education Undermined self-determination Social exclusion, cultural destruction Destruction of natural environment 2. Intermediate Health care system Education system Community infrastructure Cultural continuity 3. Proximal Health behaviours Employment Income, poverty Housing, poor living conditions Food security

Answer 202

Absorption Distribution Metabolism Excretion

Answer 203

Assistive devices and other protective equipment Clinical disease management, including chronic and acute illness (vision, CV, hypotension). Education (Canadian Falls Prevention Curriculum) Environmental modification (occupational therapist) Exercise programs Medication review and modification (psychotropics) Nutrition Vision referral and correction

Answer 204

Acceptability Affordability Availability Awareness

Answer 205

**Pedestrians**: - visibility, - distraction, impairment, - special groups like children/elderly/special needs, - enforcement of pedestrian laws **Drivers**: - vehicle speed, - driver education and training **Roadway design**: - volume dispersion, - sidewalks, - rail-grade crossings for trains, - work zones, - speed reduction, calming measures **Vehicles**: - softer/sloping vehicle fronts, - rear view requirements for backing up, - brake assist system (BAS), - intelligent speed assistance, - adaptive headlights, - pedestrian detection fronts

Answer 206

Promotion - Helping consumers make informed choices for healthy and safe food Prevention - Maintaining strong rules for the food industry Protection - Identifying and addressing food safety risks

Answer 207

Categories of quality in _qualitative r_esearch: (***mnemonic CCDT***) Credibility (can be improved with saturation, triangulation, review with participants) Dependability Confirmability Transferability Categories of quality in _quantitative_ research: (***_mnemonic VOR_***) Internal validity External validity Objectivity Reliability

Answer 208

**MH includes: mood, anxiety, psychosis, suicide / substances / dementia.** **Mental Health Promotion** •Anti-stigma strategies •Public awareness •Education and training •Community-based strategies **Prevention and early Intervention** •Early identification and treatment •Prevention strategies •Hope for recovery **Integrated Service System** •Single access point •Continuum of care •Caregivers as active partners •A range of mental health services including specialized *Planning and Foundational Principles/Values* * Use the Seniors’ Mental Health Policy Lens as a tool to assess **policies, programs, and services**. * Understand the _diversity_ among older adults, _local context, and available resources._ * Integrate _well-being and recovery-oriented approaches_ to care and services. *Implementation Facilitators* * The use of _benchmarks_ to review existing services, staffing, and resource deployment * _Cultural safety_ as an integral part of implementation * _Partnership and collaboration_ to generate integration * The use of _technology_ to facilitate ease of access * _Training, education, and support_ for health-care providers

Answer 209

Salary and wages Materials and supplies Services and rents Reserve contributions Internal charges and overhead

Answer 210

In summary, **prioritization principles**: * **Disease burden:** impact (magnitude, seriousness), # people affected * **Effectiveness**: quality of evidence base, pertinence * **Economical considerations:** efficiency, value, availability of resources, cost-benefit, cost-effectiveness, budgetary impact, economy * **Organizational factors**: Mandate, timing, urgency, appropriateness, accountability, capacity, optimal service delivery, responsiveness, legality * **Practical matters**: Feasibility, acceptability * **Ethical issues**: Equity, access, justice in allocation of resources World Bank: - Value - Appropriateness - Feasibility - Acceptability - Cost-benefit - Timing Cromwell: - effectiveness of program, budgetary impact/affordability, equity, number of people likely to benefit, ability to access program, cost-effectiveness, quality of available evidence Tanios: - Intervention outcomes and benefits, type of health service, disease impact/burden, therapeutic context, economic impact, environmental impact, quality of evidence, implementation complexity, priorities/fairness, overall context EOHU matrix: - efficiency, effectiveness, equity, accountability, responsiveness, economy OPHS foundations: - Need, impact, capacity, partnership and collaboration

Answer 211

Before Meeting (preparation) - Define **purpose** of meeting and who is attending - Create **agenda** and assign meeting roles - **Logistics** (time, place, background) During Meeting (facilitation) - Ensure discussion is clear, concise and respectful - Ensure start and end **time** are respected and meeting agenda met - may review **past minutes** Post Meeting (Summary/ Delegation & evaluation and reporting) - **Summarize and communicate decisions made, action items, and deadlines** - **Evaluate** meeting - Potentially **report** on meeting results to other organizations or levels within own organization

Answer 212

*mnemonic VRACS* Vital statistics Registries Administrative databases Census Surveys

Answer 213

**Strategies:** Regulation National guidelines Education/advice Voluntary compliance Economic (incentives, disincentives) Technological Taking no action when non is required **Underlying Principles**! Maintaining and Improving Health is the Primary Objective ! Involve Interested and Affected Parties ! Communicate in an Effective Way ! Use a Broad Perspective ! Use a Collaborative and Integrated Approach ! Make Effective Use of Sound Science Advice ! Use a “Precautionary” Approach ! Tailor the Process to the Issue and its Context ! Clearly Define Roles, Responsibilities, and Accountabilities ! Strive to Make the Process Transparent

Answer 214

1. Reuse of a single use instrument or piece of equipment 2. Improper re-processing of multi-use instrument - did not mechanically clean instrument lumen before high-level disinfection 3. Improper storage of correctly processed medical equipment 4. Inadequate documentation of processing procedures (i.e. may have correctly following reprocessing but did not record key procedures such as autoclave temperature and pressure or use of biological indicator). 5. Mechanical Failure of sterilizer

Answer 215

Three key actions to improve air quality _1. Carpool, ride your bike, take the bus or walk more often_ Motor vehicles are a major contributor to smog, especially in large urban areas where traffic is heavy. Traffic can contribute to smog year-round, even in the winter. _2. In the winter, ask yourself “Do I really need to use my woodstove or fireplace today?”_ Burning wood for home heating is a leading cause of smog in the wintertime. _3. Save energy_ In Canada, much of the home heating is produced by fossil fuels (coal, gas and oil). Using less energy for home heating and reducing your use of electricity will help clean the air. Support renewable energy where you can.

Answer 216

The 13 organizational factors that impact organizational health, the health of individual employees and the financial bottom line, including the way work is carried out and the context in which work occurs, are: Psychological Support Organizational Culture Clear Leadership & Expectations Civility & Respect Psychological Competencies & Requirements Growth & Development Recognition & Reward Involvement & Influence Workload Management Engagement Balance Psychological Protection Protection of Physical Safety 1. Psychological Support A workplace where co-workers and supervisors are supportive of employees' psychological and mental health concerns, and respond appropriately as needed. For some organizations, the most important aspect of psychological support may be to protect against traumatic stressors at work. Why it is important? Employees that feel they have psychological support have greater job attachment, job commitment, job satisfaction, job involvement, positive work moods, desire to remain with the organization, organizational citizenship behaviours (behaviours of personal choice that benefit the organization), and job performance. What happens when it is lacking? Employee perceptions of a lack of psychological support from their organization can lead to: increased absenteeism withdrawal behaviours conflict strain - which can lead to fatigue, headaches, burnout and anxiety turnover loss of productivity increased costs greater risk of accidents, incidents and injuries 2. Organizational Culture A workplace characterized by trust, honesty and fairness. Organizational culture, in general, are basic assumptions held by a particular group. These assumptions are a mix of values, beliefs, meanings and expectations that group members hold in common and that they use as cues to what is considered acceptable behaviour and how to solve problems. Why it is important? Organizational trust is essential for any positive and productive social processes within any workplace. Trust is a predictor of cooperative behaviour, organizational citizenship behaviours (behaviours of personal choice that benefit the organization), organizational commitment, and employee loyalty. An organization that has a health-focused culture enhances employee well-being, job satisfaction and organizational commitment, which helps to retain and attract employees. A work culture with social support also enhances employee well-being by providing a positive environment for employees who may be experiencing psychological conditions such as depression and anxiety. What happens when it is lacking? Culture sets the tone for an organization – a negative culture can undermine the effectiveness of the best programs, policies and services intended to support the workforce. An unhealthy culture creates more stress, which lowers employee well-being. A culture of profit at all costs and constant chaotic urgency can create an environment in which burnout is the norm. 3. Clear Leadership & Expectations A workplace where there is effective leadership and support that helps employees know what they need to do, how their work contributes to the organization and whether there are impending changes. Why it is important? Effective leadership increases employee morale, resiliency and trust, and decreases employee frustration and conflict. Good leadership results in employees with higher job well-being, reduced sick leave, and reduced early retirements with disability pensions. A leader who demonstrates a commitment to maintaining his or her own physical and psychological health can influence the health of employees (sickness, presenteeism, absenteeism) as well as the health of the organization as a whole (vigour, vitality, productivity). What happens when it is lacking? Leaders who are more instrumental in their approach (focusing on producing outcomes, with little attention paid to the big picture, the psychosocial dynamics within the organization, and the individual employees) are more likely to hear staff health complaints including general feelings of malaise, irritability and nervousness. Similarly, leaders who do not demonstrate visible concern for their own physical and psychological health set a negative example for their staff and can undermine the legitimacy of any organizational program, policy and/or service intended to support employees. Middle managers are at greater risk because they must be leaders and be led simultaneously. This role conflict can lead to feelings of powerlessness and stress. 4. Civility and Respect A workplace where employees are respectful and considerate in their interactions with one another, as well as with customers, clients and the public. Civility and respect are based on showing esteem, care and consideration for others, and acknowledging their dignity. Why it is important? A civil and respectful workplace is related to greater job satisfaction, greater perceptions of fairness, a more positive attitude, improved morale, better teamwork, greater interest in personal development, engagement in problem resolution, enhanced supervisor-staff relationships, and reduction in sick leave and turnover. Organizations characterized by civility and respect create a positive atmosphere marked by high spirits and work satisfaction. This civility allows people to enjoy the environment, whether they are staff, clients or customers. What happens when it is lacking? A workplace that lacks civility and respect can lead to emotional exhaustion amongst staff, greater conflicts, and job withdrawal. A work environment that is uncivil and disrespectful also exposes organizations to the threat of more grievances and legal risks. One example of disrespectful behaviour is bullying. Exposure to workplace bullying is associated with psychological complaints, depression, burnout, anxiety, aggression, psychosomatic complaints and musculoskeletal health complaints. Bullying not only affects those directly involved, but also affects bystanders, as they too experience higher levels of stress. A number of provinces currently have legislation to address such behaviours. 5. Psychological Competencies & Requirements A workplace where there is a good fit between employees' interpersonal and emotional competencies, their job skills and the position they hold. A good fit means that the employees possess the technical skills and knowledge for a particular position as well as the psychological skills and emotional intelligence (self-awareness, impulse control, persistence, self-motivation, empathy and social deftness) to do the job. Note that a subjective job fit (when employees feel they fit their job) can be more important than an objective job fit (when the employee is assessed and matched to the job). Why it is important? A good job fit is associated with: fewer health complaints lower levels of depression greater self-esteem a more positive self-concept enhanced performance job satisfaction employee retention What happens when it is lacking? When there is a poor job fit, employees can experience job strain, which can be expressed as emotional distress and provocation, excessive dwelling on thoughts, defensiveness, energy depletion and lower mood levels. Organizationally, job misfit is linked to fewer applicants in the recruitment and training process, lack of enjoyment and engagement, poor productivity, conflict, and greater voluntary turnover. 6. Growth & Development A workplace where employees receive encouragement and support in the development of their interpersonal, emotional and job skills. This type of workplace provides a range of internal and external opportunities for employees to build their repertoire of competencies. It helps employees with their current jobs as well as prepares them for possible future positions. Why it is important? Employee development increases goal commitment, organizational commitment and job satisfaction. Employees feel that organizations care when the organization supports growth and development. Skill acquisition and career development directly enhance employee well-being. It is important to ensure that opportunities go beyond learning specific technical skills, and also include opportunities to learn personal and interpersonal skills that are critical to successfully caring for oneself and relating to others. What happens when it is lacking? Employees who are not challenged by their work will grow bored, their well-being will suffer, and their performance will drop. When staff do not have opportunities to learn and improve their interpersonal and psychological skills, the result can be conflict, disengagement and distress. 7. Recognition and Reward A workplace where there is appropriate acknowledgement and appreciation of employees' efforts in a fair and timely manner. This element includes appropriate and regular financial compensation as well as employee or team celebrations, recognition of years served, demonstrating/acting according to organizational values, and/or milestones reached. Why it is important? Recognition and reward: motivates employees fuels the desire to excel builds self-esteem encourages employees to exceed expectations enhances team success Employees receiving appropriate recognition and reward have more energy and enthusiasm, a greater sense of pride and participation in their work, and are more likely to treat colleagues and customers with courtesy, respect and understanding. What happens when it is lacking? Lack of recognition and reward undermines employee confidence in their work and trust in the organization. Employees may feel demoralized or they may quit. An imbalance between effort and reward is a significant contributor to burnout and emotional distress leading to a range of psychological and physical disorders. 8. Involvement and Influence A workplace where employees are included in discussions about how their work is done and how important decisions are made. Opportunities for involvement can relate to an employee's specific job, the activities of a team or department, or issues involving the organization as a whole. Why it is important? When employees feel they have meaningful input into their work they are more likely to be engaged, to have higher morale, and to take pride in their organization. This feeling, in turn, increases the willingness to make extra effort when required. Job involvement is associated with increased psychological well-being, enhanced innovation, and organizational commitment. What happens when it is lacking? If employees do not believe they have a voice in the affairs of the organization, they tend to feel a sense of indifference or helplessness. Job alienation or non-involvement is associated with cynicism and distress, greater turnover, and burnout. 9. Workload Management A workplace where tasks and responsibilities can be accomplished successfully within the time available. A large workload is often described by employees as being the biggest workplace stressor (i.e., having too much to do and not enough time to do it). It is not only the amount of work that makes a difference but also the extent to which employees have the resources (time, equipment, support) to do the work well. Why it is important? Most employees willingly work hard and feel a good day's work is fulfilling and rewarding. Workload management is important because there is a unique relationship between job demands, intellectual demands and job satisfaction. Job demands reduce job satisfaction, while intellectual demands or decision-making latitude, increase job satisfaction. Even when there are high demands, if employees also have high decision-making ability, they will be able to thrive. Having high decision-making latitude also allows for positive coping behaviours to be learned and experienced. What happens when it is lacking? Any system subject to excess load without reprieve will break. This is as true for people as it is for equipment. Increased demands, without opportunities for control, result in physical, psychological and emotional fatigue, and increase stress and strain. Emotionally fatigued individuals also have a diminished sense of personal accomplishment and an increased sense of inadequacy. Excessive workload is one of the main reasons employees are negative about their jobs and their employers. 10. Engagement Employees enjoy and feel connected to their work and where they feel motivated to do their job well. Employee engagement can be physical (energy exerted), emotional (positive job outlook and passionate about their work) or cognitive (devote more attention to their work and be absorbed in their job). Engaged employees feel connected to their work because they can relate to, and are committed to, the overall success and mission of their company. Engagement is similar to, but should not be mistaken for job satisfaction, job involvement, organizational commitment, psychological empowerment, and intrinsic motivation. Why it is important? Engagement is important for individual satisfaction and psychological health, and leads to: increased profitability for company greater customer satisfaction enhanced task performance greater morale greater motivation increased organizational citizenship behaviours (behaviours of personal choice that benefit the organization) What happens when it is lacking? Organizations that do not promote engagement can see: negative economic impact in productivity losses psychological and medical consequences have greater employee turnover workplace deviance (in the form of withholding effort) counterproductive behaviour withdrawal behaviours 11. Balance Present in a workplace where there is recognition of the need for balance between the demands of work, family and personal life. This factor reflects the fact that everyone has multiple roles employees, parents, partners, etc. These multiple roles can be enriching and allow for fulfillment of individual strengths and responsibilities, but conflicting responsibilities can lead to role conflict or overload. Greater workplace flexibility enables employees to minimize work-life conflict by allowing them to accomplish the tasks necessary in their daily lives. Work-life balance is a state of well-being that allows a person to effectively manage multiple responsibilities at work, at home and in their community. Work-life balance is different for everyone and it supports physical, emotional, family and community health and does so without grief, stress or negative impact. Why it is important? Recognizing the need for work-life balance: makes employees feel valued and happier both at work and at home reduces stress and the possibility that home issues will spill over into work, or vice versa allows staff to maintain their concentration, confidence, responsibility, and sense of control at work results in enhanced employee well-being, commitment, job satisfaction, organizational citizenship behaviours (behaviours of personal choice that benefit the organization), job performance and reduced stress What happens when it is lacking? When work-family role conflict occurs (that is, roles within the workplace and outside it are overwhelming to a person or interfering with one another), health and well-being are undermined by accumulating home and job stress. This imbalance can lead to: constant tiredness bad temper inability to progress high job stress resulting in dissatisfaction with work and being absent either physically or mentally These effects can then lead to additional stress-related illness, as well as higher cholesterol, depressive symptoms, and overall decreased health. The impact on the organization can include increased costs due to benefit payouts, absenteeism, disability, and turnover. Not all employees will have the same work-life balance issues. Age, cultural, gender, family and marital status, care-giver demands, socioeconomic status and many other factors affect an employee's work-life balance. Organizations will benefit from having flexible arrangements to address this issue. 12. Psychological Protection Workplace psychological safety is demonstrated when employees feel able to put themselves on the line, ask questions, seek feedback, report mistakes and problems, or propose a new idea without fearing negative consequences to themselves, their job or their career. A psychologically safe and healthy workplace actively promotes emotional well-being among employees while taking all reasonable steps to minimize threats to employee mental health. Why it is important? When employees are psychologically protected they demonstrate greater job satisfaction, enhanced team learning behaviour and improved performance. Employees are more likely to speak up and become involved. They show increased morale and engagement and are less likely to experience stress-related illness. Psychologically protected workplaces also experience fewer grievances, conflicts and liability risks. What happens when it is lacking? When employees are not psychologically safe, they experience demoralization, a sense of threat, disengagement, and strain. They perceive workplace conditions as ambiguous and unpredictable. This demoralization can, in turn, undermine shareholder, consumer, and public confidence in the organization. 13. Protection of Physical Safety This factor includes the work environment itself. Steps can be taken by management to protect the physical safety of employees. Examples include policies, training, appropriate response to incidents or situations identified as risks, and a demonstrated concern for employees' physical safety. Why is it important? Employees who work in an environment that is perceived as physically safe will feel more secure and engaged. Higher levels in the confidence of the safety protection at work results in lower rates of psychological distress and mental health issues. Safety is enhanced through minimizing hazards, training, response to incidents, and the opportunity to have meaningful input into the workplace policies and practices. The concept of 'safety climate' is linked to this factor as they both relate to the larger culture or climate of the organization. What happens when it is lacking? Failure to protect physical safety results in workplaces that are likely to be more dangerous. Not only could employees be injured or develop illnesses, those who do not see their workplace as physically safe will feel less secure and less engaged. What are other issues in the workplace that may affect mental health? Along with the 13 PSRs listed above, there several other key issues in the workplace that affect employee mental health. Within each issue are various factors that organizations need to consider in their efforts to create a mentally healthy workplace. The following is adapted from "Workplace Mental Health Promotion, A How-To Guide" from The Health Communication Unit at the Dalla Lana School of Public Health at the University of Toronto, and the Canadian Mental Health Association, Ontario. Stigma and Discrimination – Stigma is a personal attitude and belief that negatively labels a group of people, such as those with mental illness. Stigma creates fear and consequently results in discrimination which discourages individuals and their families from getting the help they need. Stress – Stress refers to potentially negative physical or mental tensions experienced by a person. A stressor is any event or situation that an individual perceives as a threat; precipitates either adaptation or the stress response. Stress can come from both good and bad experiences, so the effects of stress can be positive or negative. Stress is not all bad – without stress, there would be no productivity or engagement. Stress becomes a problem when individuals are not able to handle an event or situation and become overwhelmed. Demand/control and effort/reward relationships – Major causes of job stress come from problems with conflicts in demand vs. control as well as effort vs. reward. When the demand and control an employee has at work changes, stress results if either factor is not increased or decreased proportionately. The same is true for the relationship between effort and reward. Changes to the organization can make for a more mentally healthy workplace, especially when employees feel appropriately rewarded for their effort and in control of their work. Presenteeism – Presenteeism is the action of employees coming to work despite having a sickness that justifies an absence, therefore they are performing their work under sub-optimal conditions. When employees come to work not mentally present due to an illness, extreme family/life pressures or stress, they are not giving themselves adequate time to get better. Presenteeism can occur because employees feel they cannot afford to take the day off there is no back-up plan for tasks the individual is responsible for when they return to work, there would be even more to do committed to personally attending meetings or events concerned about job insecurity related to downsizing or restructuring Job Burnout – Job burnout is a state of physical, emotional and mental exhaustion caused by long-term exposure to demanding work situations. Burnout is the cumulative result of stress. Anyone can experience job burnout. However, professions with high job demands and few supports can increase the prevalence of burnout and reduce engagement. Helping professions, such as jobs in health care, teaching or counseling, often have high rates of burnout. Burnout has three main characteristics: exhaustion (i.e., the depletion or draining of mental resources) cynicism (i.e., indifference or a distant attitude towards one's job) lack of professional efficacy (i.e., the tendency to evaluate one's work performance negatively, resulting in feelings of insufficiency and poor job-related self-esteem) Harassment, Violence, Bullying and Mobbing – Most people think of violence as a physical assault. However, workplace violence is a much broader problem. It is any act in which a person is abused, threatened, intimidated or assaulted in his or her employment. Workplace violence includes: threatening behaviour – such as shaking fists, destroying property or throwing objects verbal or written threats – any expression of an intent to inflict harm harassment – any behaviour that demeans, embarrasses, humiliates, annoys, alarms or verbally abuses a person and that is known or would be expected to be unwelcome. This act includes words, gestures, intimidation, bullying, or other inappropriate activities. verbal abuse – swearing, insults or condescending language physical attacks – hitting, shoving, pushing or kicking bullying – repeated, unreasonable or inappropriate behaviour directed towards an employee (or group of employees) that creates a risk to health and safety mobbing – ongoing, systematic bullying of an individual by his or her co-workers – this includes rudeness and physical intimidation, as well as more subtle and possibly unintentional behaviour involving social ostracism and exclusion Most jurisdictional occupational health and safety acts have been expanded to include harm to psychological well-being. Organizations should not tolerate any violent behaviour including aggression, harassment or threats of violence. Violent or aggressive behaviour hurts the mental health of everyone in the organization and creates a psychologically unsafe work environment filled with fear and anxiety. For more information on workplace violence, see the OSH Answers Violence and Harassment in the Workplace. Substance Use, Misuse and Abuse at Work – Substance use, misuse, abuse and coping strategies can have a significant impact on mental health at work. Addictions and mental health conditions are often coupled (called a concurrent disorder). However, it is often the addiction that first gets noticed, especially in the workplace. Generally, substance use becomes a problem when an individual has lost control over their use and/or continues to use despite experiencing negative consequences. Employers should look for warning signs that indicate an employee may be struggling with substance abuse. Some signs of substance abuse are similar to those caused by increased stress, lack of sleep and physical or mental illness. Don't assume that an employee has a substance abuse problem; however, ignoring warning signs will only make the problem worse if someone is indeed struggling Canada.ca

Answer 217

Direct Standardization: Apply observed rate to standard population, calculate rate ratio, compare. Indirect Standardization: Apply standard rate to observed population, calculate rate ratio (SMR), compare. The requirements for calculating SMR for a cohort are: The number of persons in each age group in the population being studied The age specific death rates of the general population in the same age groups of the study population The observed deaths in the study population

Answer 218

Accessible Actionable Credible and trusted Relevant Timely Understandable

Answer 219

Factors that increase the chance of developing active TB close contact with people living with untreated active TB overcrowded, poorly ventilated homes food insecurity having other illnesses, such as diabetes or HIV smoking

Answer 220

A hospital providing maternity services or a community health facility is designated as BABY-FRIENDLY if it _meets the criteria for achieving the Ten Steps_ AND adheres to the _International Code of Marketing of Breast-milk Substitutes._ 1 WRITTEN BREASTFEEDING POLICY 2 KNOWLEDGE AND SKILLS TO IMPLEMENT BREASTFEEDING POLICIES 3 INFORMING PREGNANT WOMEN AND THEIR FAMILIES ABOUT BREASTFEEDING 4 SKIN-TO-SKIN CONTACT IMMEDIATELY FOLLOWING BIRTH 5 ASSISTING MOTHERS WITH BREASTFEEDING CHALLENGES 6 SUPPLEMENTING ONLY WHEN MEDICALLY INDICATED 7 MOTHER AND INFANT ROOMING-IN 8 CUE-BASED FEEDING 9 SUPPORT NO ARTIFICIAL TEATS AND SOOTHERS 10 SUPPORT TRANSITION TO BREASTFEEDING SUPPORT IN THE COMMUNITY

Answer 221

**Pollutants**: NO, NO2, PM2.5, ultra-fine PM **Risk factors**: - Living less than 100m from a major road or less than 500m from a highway, - people with longer commutes, - pedestrians/cyclist commuters. **Health impacts**: - all-cause and CV mortality, CV disease, - asthma in adults, resp sx in adults, - decreased lung function in all ages, - lung cancer. **Solutions**: - Raise awareness, - include buffer zones in planning land use especially for schools, daycares, LTCF, homes. - Build walking/cycling away from roads. - Avoid spending time near major raods, especially during rush hours or when exercising.

Answer 222

In-person discussion sessions: offers opportunity for dialogue, costly, time consuming, subject to availability of participants Online interactive platform; flexible, engages remote or rural, requires online design and moderation Online questionnaire: flexible, engages remote or rural, participants do not hear perspective of others, needs feedback analysis Request for feedback: cost-effective,,controlled manner, detailed feedback, participants do not hear perspective of others, needs feedback analysis

Answer 223

−Présentation (Moi, l’autre, échange des coordonnées) −Description générale de l’événement (modèle journalistique): −Quoi? Quand? Où (proximité de la pop)? −Description de la triade A-E-H: −Quelle substance? Quantité (ex. nb tonnes entreposées)? −Panache? Cond. météo (vents)? A-t-on pris des mesures env.? Comment (appareil, distance…)? TAGA disponible? −Quels sont les Sx présentés? Combien de personnes sont touchées? Y a-t-il eu des transferts à l’urgence (Si oui, compléter info avec Md)? Parmi pop et trav. −Actions réalisées: Quelles mesures de protection ont été mises en place? −Partenaires… Qui est au courant? Et penser à aviser les autres −Visite des lieux + cellule interne −Évaluation des risques à compléter (Propriétés subst., effets à la santé selon niveau exposition, tx recommandé…) Comparer mesures env. aux normes −Décision + actions suppl. : Mesures de protection (confinement, évacuation, décontamination…) pour pop et trav. −Communication (Md -risques à la santé, tests à faire et tx- pop, médias) −Psychosocial (service de consult. sur les lieux, ligne tél., etc.) −Surveillance

Answer 224

**Food insecurity**: _Inability to access sufficient nutritious food_ (i.e., sufficient quantity and quality) Drawing on data for 103,500 households from _Statistics Canada’s Canadian Community Health Survey conducted in 2017 and 2018, we found that 12.7% of households experienced some level of food insecurity in the previous 12 months_. There were 4_.4 million people, including more than 1.2 million children_ under the age of 18, living in food-insecure households in 2017-18. This is higher than any prior national estimate. Disparities were for households with children (especially lone parent), in Nunavut, Black and Indigenous people. **Among children**, exposure to severe food insecurity (measured as child hunger) has been linked to poorer health status and the subsequent development of a variety of _chronic health conditions, including asthma and depression_. * *Among adults**, associations with _chronic diseases, including mood and anxiety disorders, arthritis, asthma, back problems, and diabetes. And mortality._ Policy strategies to reduce food insecurity (linked to poverty): A _basic income_ (sometimes called a guaranteed annual income) would establish a minimum level of income for all Canadians by topping up the income of anyone who falls below a designated poverty line. The impact of such a basic income would be most significant for people living in extreme levels of food insecurity. Basic income is proven to be an effective solution to food insecurity. For example, _Canadian seniors who receive a basic income through Old Age Security and the Guaranteed Income Supplement cut their risk of food insecurity in hal_f. TO ELIMINATE FOOD INSECURITY, WE NEED TO TACKLE POVERTY The Eat Think Vote campaign calls on the federal government to study the feasibility of establishing a basic income floor to ensure all Canadians can afford sufficient, safe, healthy and culturally appropriate food. Removing the financial obstacles to food security can be accomplished through a number of strategies: Undertaking a feasibility study on the implementation of a basic income to be administered through the tax system and set above the Low Income Measure. _Increasing the National Child Benefit to a level that adequately addresses child poverty and indexing it to the cost of living_. Developing a _national housing strategy, including increased federal investment in affordable housing_. Instituting a _national Pharmacare program to provide affordable access to pharmaceutical drugs and reduce overall Canadian drug spending._ Developing a _publicly funded childcare system that ensures affordable access to child care for low-income parents_. _Increasing the Working Income Tax Benefit_. _Students_ also face food insecurity. Read the document developed by Food Secure Canada's Youth Caucus about Student Hunger and Food Insecurity.

Answer 225

* _Deaths_—from the **Canadian Vital Statistics Death Database (CVS:D)** of Statistics Canada, * **_Hospitalization_**s—from the **Hospital Morbidity Database (HMDB)** and the **Discharge Abstract Database (DAD)** of the Canadian Institute for Health Information (CIHI), * _Emergency department visit_s—from the **National Ambulatory Care Reporting System (NACRS)** (CIHI) and, * _Emergency department visit_s—from the Public Health Agency of Canada’s **electronic Canadian Hospitals Injury Reporting and Prevention Program (eCHIRPP)**. **Concussion recognition tool:** 1. Step 1 - red flags, call an ambulance (double vision, LOC, seizure, vomiting, severe HA, weakness, neck pain, change in conciousness or behavior) 2. Step 2 - Observable signs - check for visual clues (slow to get up, disorientation, balance difficulty, facial injury) 3. Step 3 - Symptoms 4. Step 4 - memory assessment Any child or adult with a suspected concussion should be immediately removed from practice or play and should not return to activity until assessed medicallly, even if the symptoms resolve

Answer 226

hazards perceived as risky are: Coerced vs self-imposed Industrial vs natural Exotic Memorable Dreaded Catastrophic Unknowable, invisible threats Uncontrollable vs perceived controlled Unfair Morally relevant Untrustworthy sources Unresponsive process Affects children Rapid vs slow-progression Personnaly aware/affected vs unaware Novel vs familiar No rewards/benefits/fun associated with risk Specific victims vs strangers After reviewing the research, risk expert David Ropeik identified 14 specific factors that affect perception of danger: **Trust.** When people trust the officials providing information about a particular risk — or the process used to assess risk — they tend to be less afraid than when they don't trust the officials or the process. **Origin.** People are _less concerned about risks they incur themselves than the ones that others impose on them_. This helps explain why people often get angry when they see someone talking on the cell phone while driving — and yet think nothing of doing so themselves. **Control.** _Perceived control over outcomes_ also matters. This helps explain why someone is not afraid of driving a car — even though automobile crashes kill thousands of people each year — but may be afraid of flying in an airplane. **Nature.** Dangers in nature — such as sun exposure — are perceived as relatively benign, whereas _man-made harms — nuclear power accidents or terror attacks — are more menacing._ **Scope.** _Cataclysmic events, capable of killing many people at the same time, are scarier than chronic conditions_ — which may kill just as many people but over a longer period. That helps explain why a tsunami or earthquake feels scarier than heart disease or diabetes. **Awareness.** Saturation media coverage of high-profile disasters raises awareness of particular risks more than others. Likewise, an _event that hits close to home, such as having a friend diagnosed with cancer, heightens risk perception_. **Imagination.** When _threats are invisible or hard to understand,_ people become confused about the nature of the risk, and the event becomes scarier. **Dread.** Events that invoke dread — such as drowning or being eaten alive — scare people more than those that do not. **Age affected.** Risks are more frightening when they affect _children_. Asbestos in a school building, for example, may bother people more than asbestos in a factory. **Uncertainty.** _Events inspire more fear when officials don't communicate what is known — or when the risks are simply unknown._ In the Deepwater Horizon spill, for example, officials could more easily estimate the amount of oil spewing into the ocean than they could predict what effect that would have on wildlife and fisheries. **Familiarity.** _Novel risks are perceived to be more dangerous_ than more familiar threats. That's why West Nile virus may be perceived as more of a risk to health than not testing a smoke detector regularly. **Specificity**. _Victims who are publicly identified_ evoke a greater emotional reaction than those who remain nameless and faceless. **Personal impact.** _Risks that affect people personally_ are more frightening than those that affect strangers. **Fun factor.** Engaging in risky behavior may not seem that way if it involves pleasure. Some examples are _drug taking, unsafe sex, and high-risk sports_

Answer 227

\* _To convert mcmoL/L to mcg/dL, multiply by 20.72_. For example: 0.483 mcmoL/L= 10 mcg/dL * *5 to 14mcg/dL** 1. Review lab results with the child’s family. 2. Perform routine health maintenance, including neurodevelopmental screening, and assess nutrition. 3. Take a careful PEHH to _identify potential sources of exposure_. _Provide preliminary advice about reducing or eliminating exposure source(s)._ 4. Contact local public health authority for guidance. 5. _Re-test venous BLL at 1 to 3 months_ to ensure the child’s lead level is not rising. If it is stable or decreasing, retest in 3 months. 6. Provide _nutritional counselling related to calcium and iron_. Recommend having a fresh fruit with every meal because iron absorption quadruples when taken with vitamin C-containing foods. Encourage the consumption of iron-enriched foods (e.g., cereals, meats). Ensure iron sufficiency with adequate laboratory testing (CBC, ferritin, CRP) andtreatment. Consider starting a multivitamin with iron. 7. Complete a _full neurodevelopmental assessment and follow-up_. Lead’s effects on development may manifest over years. * *15 to 44mcg/dL** 1. Perform steps as described above for BLLs 5 to 14 mcg/dL. 2. Confirm the BLL with repeat _venous sample at 1 to 4 weeks._ 3. Additional, specific evaluation of the child, such as _abdominal x-ray_ should be considered based on the PEHH. Gut decontamination may be considered if ingested foreign objectsare visualized on x-ray. Contact your local Poison Centre for assistance. Chelation is not typically recommended for asymptomatic patients. * *\>44mcg/dL** 1. Follow guidance for BLLs 15 to 44 mcg/dL. 2. Confirm the BLL with **repeat venous testing at 48 hours.** 3. Consider _hospitalization and/or chelation therapy in consultation with your local Poison Control Centre_. Mitigating lead exposures at home, identifying other possible sources,assessing the family’s social situation, and chronicity of the exposure will influence management.

Answer 228

Each year, _45,000 Canadians die from a tobacco-related disease_. Canada’s Tobacco Strategy will help us reach the goal of less than 5% tobacco use by 2035. About Canada’s Tobacco Strategy We have committed $330 million over the next 5 years to: h_elp Canadians who smoke to quit or reduce the harms of their addiction to nicotine_ and _protect the health of young people and non-smokers from the dangers of tobacco use_ This new strategy notes that tobacco use is not equally spread across the population. It is often linked to other health and social inequities. Along with our partners we will reach out to groups of Canadians with higher rates of tobacco use. These include: _LGBTQ+_ _young adults_ _Indigenous Peoples_ This new strategy also notes that giving smokers access to less harmful options than cigarettes will: help reduce their health risks possibly save lives The Tobacco and Vaping Products Act was passed on May 23, 2018. It makes it legal for adults to buy vaping products that contain nicotine, as a less harmful option than smoking. This is part of our broad new vision for dealing with tobacco use. **Themes of Canada’s Tobacco Strategy** The main themes of Canada’s Tobacco Strategy are to: _help Canadians quit tobacco_ _protect youth and non-tobacco users from nicotine addiction_ _work with Indigenous groups to create specific plans for Indigenous people_ _strengthen our science, surveillance and partnerships_ **Help Canadians quit tobacco** This will be achieved by: supporting improved services and resources to help people quit smoking funding programs to explore the most effective ways to help Canadians quit smoking by working with: researchers communities public health groups giving information on and access to less harmful sources of nicotine **Protect youth and non-tobacco users from nicotine addiction** This will be achieved by: teaching youth and young adults about the risks of using vaping and tobacco products _enforcing compliance for retailers and producers of tobacco and vaping products_ creating a research program to understand and strengthen law enforcement to combat Canada’s illicit tobacco market putting increased rules and guidelines in place, such as: regulating vaping products updating health warning messages plain and standardized appearance measures **Work with Indigenous groups to create specific plans for Indigenous people** This will be achieved by: continuing and expanding existing tobacco projects in Indigenous communities working with national and regional Indigenous groups to co-develop distinct strategies to meet the needs of Canada’s Indigenous peoples **Strengthen our science, surveillance and partnerships** This will be achieved by: increasing funding to: study new and unique ways to address tobacco use in Canada understand the health impacts of new nicotine products and how Canadians use them aiding research from health stakeholders by publicly releasing: industry reports research findings surveillance findings maintaining and supporting work done around the world as a part of the World Health Organization’s Framework Convention on Tobacco Control

Answer 229

 **Surveillance**: The establishment of a national medical surveillance program to use data collected by the Public Health Agency of Canada to properly track incidence rates and the associated economic costs of Lyme disease.  **Education and Awareness**: The creation and distribution of standardized educational materials related to Lyme disease, for use by any public health care provider within Canada, designed to increase national awareness about the disease and enhance its prevention, identification, treatment and management.  **Guidelines and Best Practices**: The establishment of guidelines regarding the prevention, identification, treatment and management of Lyme disease, and the sharing of best practices throughout Canada

Answer 230

Peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice and equity.

Answer 231

Staph toxin \<6h (high protein/salt) B. cereus \<6h (rice) C. botulinum \<6h (canned) C. perfringens \<6h (starchy foods - beans, gravy, meats) Norovirus 10-50h (people, shellfish, produce) Salmonella 6-72h - usually 12-36 (chicken) Campylobacter 1-10d - usually 2-5 (chicken, pets) E. coli 2-10d - usually 3-4 (meat, can be contaminated veg) Listeria Up to 72d - usually 2-3w (processed items) Hepatitis A 15-50d (avg 28-30) - usually 28-30 (contaminated berries, travel, food worker) Cyclospora Fruit and veg - 7 days Trichinosis Pork - 5-45 days

Answer 232

The incremental cost-effectiveness ratio (ICER) is a _statistic used in cost-effectiveness analysis to summarise the cost-effectiveness of a health care intervention_. It is defined by the _difference in cost between two possible interventions, divided by the difference in their effect_. It represents the _average incremental cost associated with 1 additional unit of the measure of effect._

Answer 233

A defined and identifiable **target population**; * **Strategies to ensure high coverage**, such as personal invitations with times and places for screening; * **Adequate clinical facilities** for taking Pap tests and **laboratory services** to examine them; * **Quality control programs** for taking and interpreting Pap tests; * Adequate clinical facilities for diagnosis, treatment and follow-up of women with a detected abnormality; * An established **referral system** to help facilitate women through the screening process i.e., a link between the patient, laboratory and clinical facility for providing information about normal Pap test, diagnosis of an abnormal test and/or treatment of any detected abnormality; * Organized **evaluation and monitoring** of the impact of the program with established data quality control programs.

Answer 234

_Actual_ level of income (absolute + relative to needs) _Assurance_ that you will receive it Expectation that it is _adequate for needs now and in the future_

Answer 235

In summary, PH preventive actions for heat: Assess: **heat-health vulnerability resiliency** Promote: **healthy communities/individuals + social capital/networks** Prevent by adrressing: **GHG emissions, transportation policies, urban heat island effect, climate resiliency** Heat Alert and Response System(s) (HARS) core elements: **Community Mobilization and Engagement—** Requires a coordinating agency to prepare the community for the upcoming heat season by identifying community needs, recruiting stakeholders and developing plans to implement a HARS. **Alert Protocol**—Identifies weather conditions that could result in increased morbidity and mortality in the region. The protocol is used to alert the public, as well as government officials and stakeholders, who then take pre-determined actions to protect health. **Community Response Plan**—Facilitates actions by individuals to protect themselves during periods of extreme heat by directing public health interventions aimed at reaching vulnerable individuals who require assistance. **Communication Plan**—Raises awareness about the impacts that heat may have on health, and provides advice through media releases, interviews and websites on how to reduce health risks. **Evaluation Plan**—Assesses HARS activities and facilitates improvements. Aims to evaluate the extent to which implemented measures are timely, relevant, effective, meet local priorities, and contribute to the reduction of health impacts. **PREVENTATIVE ACTIONS** reduce **green-house gas emissions** assess heat-health **vulnerability resiliency** build **climate resiliency** modify **transportation** policies reduce urban **heat island effect** promote **healthy communities and individuals** improve **social capital and social networks** In summary, PH preventive actions are to: Assess: **heat-health vulnerability resiliency** Promote: **healthy communities/individuals + social capital/networks** Prevent by adrressing: **GHG emissions, transportation policies, urban heat island effect, climate resiliency**

Answer 236

**The Five Principles of Trauma-Informed Care** **Collaboration**: Making decisions with the individual and sharing power **Trustworthiness**: Task clarity, consistency, and Interpersonal Boundaries **Choice**: Individual has choice and control **Empowerment**: Prioritizing empowerment and skill building **Safety**: Ensuring physical and emotional safety

Answer 237

The _**payback period** is the length of time an investment reaches a **break-even point**_. **ROI** tries to directly measure the amount of return on a particular investment, relative to the investment’s cost. To calculate ROI, the benefit (or return) of an investment is divided by the cost of the investment. The result is expressed as a percentage or a ratio. _**Net present value (NPV)** is the difference between the present value of cash inflows and the present value of cash outflows over a period of time._ NPV is used in capital budgeting and investment planning to analyze the profitability of a projected investment or project. This concept is the basis for the Net Present Value Rule, which dictates that _only investments with positive NPV values should be considered_. The **internal rate of return** is a metric used in financial analysis to estimate the profitability of potential investments. The internal rate of return is a _discount rate that makes the net present value (NPV) of all cash flows equal to zero in a discounted cash flow analysis_. When comparing investment options whose other characteristics are similar, _the investment with the highest IRR would probably be considered the best._

Answer 238

Measurement of BMI These recommendations apply to apparently healthy adults ≥ 18 years of age who present to primary care. These recommendations do not apply to people with eating disorders, or who are pregnant. _We recommend measuring height, weight and calculating BMI at appropriate primary care visits._ (**Strong** recommendation; very low quality evidence) Prevention of weight gain These recommendations do not apply to people with eating disorders, or who are underweight, pregnant, overweight or obese (Body Mass Index [BMI] ≥ 25). _We recommend that practitioners not offer formal, structured interventions aimed at preventing weight gain in normal weight adults._ (**Weak** recommendation; very low quality evidence) Management of overweight and obesity These recommendations apply to adults ≥ 18 years of age who are overweight or obese (25 ≤ BMI \< 40). Pregnant women and people with health conditions where weight loss is inappropriate are excluded. _These guidelines do not apply to people with BMI ≥ 40, who may benefit from specialized bariatric programs._ F_or adults who are obese (30 ≤ BMI \< 40) and are at high risk of diabetes, we recommend that practitioners offer or refer to structured behavioural interventions aimed at weight loss._ (**Strong** recommendation; moderate quality evidence) For adults who are overweight or obese, we recommend that practitioners offer or refer to structured behavioural interventions aimed at weight loss. (Weak recommendation; moderate quality evidence) _For adults who are overweight or obese, we recommend that practitioners not routinely offer pharmacologic interventions (orlistat or metformin) aimed at weight loss._ (**Weak** recommendation; moderate quality evidence)

Answer 239

CASP **randomized controlled trial** Is the basic **study design valid** for a randomized controlled trial? (Section A) 1. Did the study address a _clearly focused research question_? (PICO) 2. Was the assignment of participants to intervention _randomized_? 3. Were _all participants who entered the study accounted for_ at its conclusion? (loss to follow-up, intention to treat analysis) Was the study **methodologically sound?** (Section B) 1. Were the participants + investigators _blinded_? 2. Were the _study groups similar_ at the start of the RCT? (Table 1) 3. Was each _study groups treated equally_? What are the results? (Section C) 1. Were the effects of intervention reported comprehensively? (power, outcome measurement, missing data, biases, statistical tests, etc) 2. Was the precision of the estimated effect reported? (CI) 3. Do the benefits of the experimental intervention outweigh harms and costs? Will the results help locally? (Section D) 1. Can the results be applied to your local population and context? 2. Would the experimental intervention provide greater value to the people in your care than any of the existing interventions? **CASP SYSTEMATIC REVIEWS** Are the results of the **study valid**? (Section A) 1. Did the review address a _clearly focused question_? 2. Did the authors _look for the right type of papers_? 3. Do you think _all the important, relevant studies were included_? 4. Did the review’s authors do enough to _assess quality of the included studies_? 5. If the results of the review have been combined, was it reasonable to do so? What are the results? (Section B) 1. What are the overall results of the review? 2. How precise are the results? (CI) Will the results help locally? (Section C) 1. Can the results be applied to the local population? 2. Were all important outcomes considered? 3. Are the benefits worth the harms and costs? **CASP QUALITATIVE RESEARCH** Are the results of the **study valid**? (Section A) 1. Was there a _clear statement of the aims of the research_? 2. Is a _qualitative methodology appropriate_? 3. Was the _research design appropriate_ to address the aims of the research? 4. Was the _recruitment strategy_ appropriate to the aims of the research? 5. Was the _data collected in a way that addressed the research issue_? 6. Has the _relationship between researcher and participants been adequately considered_? What are the results? (Section B) 7. Have ethical issues been taken into consideration? 8. Was the _data analysis sufficiently rigorous_? 9. Is there a clear statement of findings? Will the results help locally? (Section C) 1. How valuable is the research?

Answer 240

Verify accuracy of indicator exceedance (retest) - Needs 2 E. Coli + for EBWA or 1 E. Coli +other data like chlorine residual) Gather other data (turbidity, chlorine residuals, other sites) Notify authorities (PHU, ministry of health/env) Corrective action (increase disinfection, flush lines) Decide on advisory, notify public + special populations Rescind advisory (Rescinded by LPHA)

Answer 241

Health (definitions) WHO: A state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. Ottawa Charter: The extent to which an individual or group is able to realize aspirations and satisfy needs, and to change or cope with the environment. Health is a resource for daily life, not the objective of living. Indigenous health model: 4 Directions/Medicine Wheel: Physical, Emotional, Spiritual, Mental Public health (definition) The organized efforts of society to keep people health and prevent injury, illness, and premature death. It is a combination of programs, services, and policies that protect and promote the health of all Canadians and prevent inequities.

Answer 242

Karasek's “job strain” model states that the greatest risk to physical and mental health from stress occurs to workers facing **high psychological workload demands or pressures** combined with **low control or decision latitude** in meeting those demands.

Answer 243

Infectious: HBV, HCV Metabolic: obesity, diabetes, fatty liver/NASH Toxins: etoh, smoking, aflatoxins, vinyl chloride, anabolic steroids Other diseases: PBC, A1AT, Wilson

Answer 244

HTN CVD T2DM OSA Abnormal menstrual cycles Bone and joint problems Reduced balance Low self-esteem Depression Feeling judged Being teased or bullied

Answer 245

Positive Mental Health Capacity to feel, think, act in ways that enhance the ability to enjoy life and deal with challenges (PHAC) Models of Mental Health 3 Factor: Emotional, Social, Psychological well-being 2 Continua: Mental Health, Mental Illness

Answer 246

_**Emergency boil water advisories** should be issued in response to the confirmed detection of Escherichia coli (E. coli) in drinking water._ The detection of E. coli in drinking water is a definite indication of human or animal faecal contamination and the possible presence of pathogenic microorganisms. If the presence of E. coli is confirmed in drinking water, an emergency boil water advisory should be issued immediately There are a number of situations which may prompt the issuance of a **precautionary boil water advisory**. These situations need to be assessed on a case-by-case basis, and require the incident response team to conduct an investigation and site-specific risk assessment. They are outlined below: 1) _Persistent presence of **total coliforms** in the distribution system_, despite remedial measures (such as flushing water mains, increasing chlorine residuals); 2) _Unexpected **changes in source water** quality_ that could overwhelm the treatment system; 3) A _**breach in system integrity** such as a broken water main_ (e.g., pressure loss). 4) _Local **maintenance** or planned repairs in the distribution system_ which may cause a significant pressure drop, a breach in system integrity or potential contamination of drinking water; _5) Minor equipment **malfunction** which may impact treatment efficacy or distribution systems;_ 6) Unexpected and _significant **changes in routine monitoring**_ parameters within the distribution system such as pressure, turbidity and disinfectant residuals; and **Possible negative consequences** of issuing boil water advisories include the risk of _scalding_, especially to young children and elderly people, and consumers _turning to an unsafe alternative source of drinking water_. Boil water advisories can also have significant _economic impacts on local businesses and services_. The decision to issue an advisory will need to weigh the risks mitigated by the advisory with the potential negative impacts of the advisory. In circumstances where an advisory is in place for an extended period of time, it is important to consider the possible impact on the public’s awareness and compliance. A number of studies have shown that the public’s willingness to adhere to boil water advisories decreases the longer an advisory is in place, and that ”_message fatigue_” is a major concern. **Contents of boil water advisory notice** Advisory notices should be clear and understandable to the general public, and include the following elements (CDC, 2013): _ Description of the situation, the reason for the advisory, including faecal contaminant level(s);  When the situation occurred;  Any potential adverse health effects from drinking the water (e.g., diarrhea);  Area(s) and population(s) affected, including subpopulations that may be particularly vulnerable if exposed to the contaminant in their drinking water;  Specific guidance on how to boil water, whether alternate water supplies should be used and, if so, recommended sources;  Other actions consumers should take, including when they should seek medical help, if known;  What the water system authority is doing to correct the situation;  When the water system authority expects to resolve the situation, while indicating that the advisory is in place until the public is notified otherwise;  A central point of contact for additional information and where to seek updates as they become available; and  A statement encouraging the notice recipients to share the notice with other persons, communicate with neighbours and check on isolated or vulnerable individuals, where applicable._ **Conditions for rescinding a boil water advisory** Criteria for rescinding a boil water advisory should include the _resolution of the contamination event that prompted the issuing of the advisory._ Boil water advisories are usually rescinded:  if the advisory was issued on evidence of bacteriological water quality conditions: _as soon as at least two consecutive sets of bacteriological samples, collected a minimum of 24 hours apart, produce negative results_. Additional guidance on actions in response to the presence of E. coli in drinking water, including rescinding boil water advisories, can be found in Part C.  if the advisory was issued on evidence of operational conditions: _when the treatment, distribution, or operational malfunction has been corrected and any remaining corrective actions have been completed_ in order to eliminate any contaminated water, and has been confirmed through bacteriological water quality testing.  _if an advisory was issued on evidence of a waterborne outbreak: after the above conditions have been met and when surveillance indicates that the incidence of the illness in the community has returned to background levels_. Owing to lengthy incubation periods for some pathogens and their secondary spread, new cases of illness may occur after the period of contamination has passed. Conversely, a lack of new cases may indicate that the boil water advisory is being followed and not that the causative situation has been rectified. When an advisory is rescinded, it is important that the communication strategy described in Section A.1 be followed. _Messages noting that the advisory has been rescinded should be conveyed through all the same communication channels used when the advisory was first issued, ensuring that all affected groups are reached._ The notices should highlight any remaining actions required of consumers, as well as where to seek additional information. After rescinding an advisory, the incident response team should review and evaluate their boil water advisory protocol, in order to better understand and improve the process in the future.

Answer 247

RECOMMENDATIONS CPHA calls upon the federal, provincial/territorial and municipal governments, and Indigenous peoples’ governing organizations to provide the tools and approaches necessary to meet the objectives of the legislation, and to develop and implement coordinated, pan-Canadian approaches that address: • **Health promotion - to support healthier and safer behaviours** • _Develop and disseminate clear and consistent information regarding the potential risks and benefits associated with the use of cannabis, while recognizing that a preferred approach is to not consume the product or to delay onset of use to the extent possible_ • _Develop and implement policies and programs that strengthen community capacity and individual skills that promote healthy behaviours_ • **Health protection** - to _ensure that high-quality cannabis-based products free from harmful byproducts are available for consumption_ • Develop and implement _federal regulations concerning the growing, harvesting, processing and packaging of cannabis and cannabiscontaining products for retail sales_ • Develop and implement a retail sales model that expands the system currently in place for the medical cannabis regime (i.e., e-commerce). Should storefront retail sales be approved by any province or territory, such operations should be restricted to government-controlled, not-for-profit monopolies or not-for-profit non-governmental organizations. Under no circumstance should retail sales be co-located with sales of other controlled substances such as alcohol, tobacco and/or pharmaceuticals • _All cannabis containing products should be sold in resealable, childproof packaging_ • A_ll relevant smoke-free bylaws for public spaces, and workplace tobacco and alcohol consumption policies should be adapted to include cannabis_ • **Prevention and harm reduction** - to _prevent or delay the onset of use and to reduce the likelihood of harm from use, problematic use and/ or overdose_ • Establish tax rates for cannabis-containing products based on THC concentrations (i.e., higher tax rates for products with higher THC concentrations) • Establish _limits on product advertising_ • Establish a _common minimum age for consumption across Canada_ • Permit alternative approaches for product consumption, to _reduce the reliance on inhaling cannabis smoke_ • Clarify the effects of second-hand cannabis smoke • Clarify the unique challenges associated with the consumption of edible cannabis-containing products • **Population health assessment** - to understand the extent of cannabis consumption, and measure the potential impact of the interventions, policies and programs on the population • _Monitor statistics such as self-reported daily use, age of initiation, types and potency of products consumed, reasons for consumption, gender and socio-economic status_ • Strengthen individual health surveillance - to understand the effect on society and evaluate the effects of cannabis use • _Monitor statistics such as emergency room admittances for cannabis overdose and cannabisuse related injuries_ • Monitor use disorders • Monitor the effect of smoking cannabis and other consumption vehicles on health • **Evidence-informed services** - to help people who are at risk of developing, or have developed problems with cannabis (and/or other psychoactive substances) • Develop tools to help physicians and other health and social services professionals identify individuals at risk of developing a cannabis use disorder • Where necessary, adapt current substance use treatment programs to include cannabis. These approaches, at all levels of government, must be based on the best available information of what works, what is likely to work and what does not work. As such, CPHA also calls upon governments in Canada to support, develop and implement research programs, including cross-jurisdictional research, that address all aspects of cannabis use, with priorities developed with the Canadian Institutes of Health Research. Similarly, underpinning these initiatives is a requirement for an evaluation plan that provides timely assessment of what works and isn’t working so that adjustments can be made. Furthermore, CPHA calls on all provincial/ territorial governments and Indigenous peoples’ governing organizations to collaborate closely on the development of all cannabis-related legislation, regulations and guidelines to minimize jurisdictional variations in approaches. Finally, CPHA calls on the Minister of Justice and Attorney General of Canada to introduce a moratorium on criminal prosecution related to possession of small quantities of cannabis for personal use, as a means of reducing the stigma associated with court proceedings and a potential criminal record for a product that will soon be legal. An additional consideration, once the legislation is implemented, is the potential effect of criminalization of youth who provide small quantities of cannabis to other youth for personal use. Care should be taken to apply the proposed rules concerning trafficking to reflect the severity of the crime.

Answer 248

_Disease control options_ **control/remove source of pathogen** insecticidal spraying food recall **interrupt transmission (suppress infected, break chain of transmission, protect unexposed)** education or policy to change behaviour isolation modify host response vaccination

Answer 249

We recommend _against screening\* asymptomatic non-pregnant adults aged 18 years and older for thyroid dysfunction in primary care settings_ (**strong recommendation, low-certainty evidence**). This recommendation does not apply to adults who have the following risk factors for thyroid dysfunction: individuals who have had a previously diagnosed thyroid disease or surgery, individuals receiving thyroid medications or medications that may affect thyroid function (i.e., lithium, amiodarone), individuals with previous or ongoing exposure to thyroid radioiodine therapy or head and neck radiotherapy, or individuals with pituitary or hypothalamic diseases. This recommendation only applies to screening asymptomatic non-pregnant adults aged 18 years and older. While the task force recommends against routinely screening for thyroid dysfunction in this population, clinicians should remain alert to signs and symptoms (e.g., unusual fatigue, unexpected weight loss or gain, menstrual irregularities, goiter, etc.) or risk factors (e.g., pituitary or hypothalamic diseases) suggestive of thyroid dysfunction and investigate accordingly.

Answer 250

Foodborne - hep. A, diarrheal diseases (food safety) Waterborne (avoid unsafe water, BWA) +/-Vectorborne depending on climate Respiratory diseases in evacuation shelters (hand/cough hygiene) Wounds, injuries (wound hygiene, tetanus booster) Mold Mental health If power lost - hypothermia, CO-poisoning, cold chain for vaccine

Answer 251

Trends in prostate cancer In Canada, the incidence rate of prostate cancer peaked in 1993 and again in 2001. Each of these peaks was followed by a decline. The decline has been particularly steep since 2011. T_he patterns in prostate cancer incidence largely mirror screening activity using the prostate-specific antigen (PSA) test._ _The death rate for prostate cancer has been declining since 1994_. The decline likely reflects improved treatment. Chances (probability) of developing or dying from prostate cancer It is estimated that about _1 in 9 Canadian men will develop prostate cancer_ during their lifetime and _1 in 29 will die from it._

Answer 252

Built environment Active neighbourhoods Access to healthy foods Supportive environments Consider health of populations Avoid worsening health inequity Evaluate health impacts Strengthen existing approaches Collaborate to collect data/engage citizens Innovate so healthy choices are easy choices

Answer 253

The Centre for Emergency Preparedness and Response is Canada's central coordinating point for public health security issues. Among its many responsibilities, CEPR: develops and maintains _national emergency response plans_ for the Public Health Agency of Canada and Health Canada; _monitors outbreaks_ and global disease events; a_ssesses public health risk_s during emergencies; contributes to keeping Canada's _health and emergency policies in line with threats to public health security_ and general security for Canadians in collaboration with other federal and international health and security agencies; is responsible for the important federal public health rules governing _laboratory safety and security, quarantine_ and similar issues; and is the health authority in the Government of Canada on _bioterrorism, emergency health services and emergency response._ _+stockpiles_

Answer 254

Lead (2019) _MAC = 0.005 mg/L ALARA (=_5 mcg/L ) Common sources: _Leaching from plumbing (lead service lines, lead solder and brass fittings)_ Health basis of MAC: Reduced intelligence in children measured as decreases in IQ is the most sensitive and well established health effect of lead exposure. There is no known safe exposure level to lead. Other: Possible effects include behavioral effects in children. Reduced cognition, increased blood pressure, and renal dysfunction in adults are also possible;.classified as probably carcinogenic to humans Lead levels should be kept as low as reasonably achievable. _Sampling should be done at the tap to reflect average exposure._ The most significant contribution of lead in drinking water is generally from the lead service line that supplies drinking water to the home. _The best approach to minimize exposure to lead from drinking water is to remove the full lead service line_. Drinking water treatment devices are also an effective option.

Answer 255

5 categories of occupational exposures Physical Biological Chemical Ergonomic Psychosocial

Answer 256

How much did we do? (scope, reach ) How well did we do it? (quality, efficiency) Is anyone better off? (effectiveness)

Answer 257

A **nested case-control study** design involves the _selection of several healthy controls for each case, typically from those still under observation in the cohort at the time when the case developed the disease_ [3]. However, nested case-control studies have some limitations: 1) Inefficiency due to the alignment of each selected control subject to its matched case. 2) When there are more than one disease outcomes considered, a strict implementation of the nested case-control design requires the selection of a new set of controls for each distinct disease outcome. **Case-cohort study designs** were proposed as an alternative to the nested case-control study design. _Case-cohort study requires only the selection of a random sample from the overall cohort, named a subcohort, and all cases._ It has been demonstrated that the case-cohort study design, for a single disease outcome, is more efficient than a nested case-control study design; however, the difference is very small [1]. _Compared to the nested case-control studies, a major advantage of the case-cohort design is the ability to study several disease outcomes using the same subcohort._ For example, suppose that researchers are interested in whether smoking is a risk factor for diabetes as well as lung cancer. Under this situation, two control groups need to be sampled under the nested case-control design while a case-cohort design only requires one subcohort which is used to evaluate the effect of smoking for both diabetes and lung cancer. In summary, nested case-control and case-cohort designs are efficient in terms of cost and can be used to evaluate the relationship between the exposure and diseases. Compared to a nested case-control design, the case-cohort design is more efficient and allows an investigator to study several disease outcomes by using the same random sample.

Answer 258

AGAINST Beneficence, non-maleficence - injecting drugs is inherently dangerous Duty to provide care, deontologic consideration - participating and witnessing inherently dangerous clinical process of injecting drugs FOR Utilitarianism - practical approach to save lives Solidarity Respect for autonomy

Answer 259

**Undesirable consequences:** - Bankruptcy, crime - dysfunctional relationships - mental health issues such as depression, anxiety, and suicide - poor work and academic performance **Individual risk factors** (a) experiencing an early big win; (b) having mistaken beliefs about the odds of winning; (c) experiencing financial problems; and (d) having a history of mental health problems **Population risk factors:** _- gambling availability_ _- gambling modality,_ _- hours of operation._ **Healthy public policy seeks to:** - prevent or mitigate gambling‐related harm, - promote healthy choices, and - protect vulnerable or high‐risk populations **Policy interventions:** 1. Ontarians are **not exposed to high‐risk gambling environments and modalities.** Examples of action that results from this principle:  Any planned expansion of gambling in Ontario must be preceded and informed by _community consultation and public health‐based risk assessment_.  Gambling modalities known to have a high potential for harm, such as _EGMs, are controlled and their number limited_, and the most problematic features are not permitted.  Research to identify high‐risk environments and modalities is funded.  _New gambling venues and modalities are rigorously evaluated_, with an emphasis on social and health impacts. 2. Ontarians have the **right to abstain from gambling, and to establish limits on the extent of their participation**. Examples of action that results from this principle:  _Self‐exclusion mechanisms_ are robust, comprehensive, accessible, and culturally competent, and their effectiveness is routinely evaluated.  Patrons have the ability to _pre‐establish spending limits_.  _Opportunities to gain access to cash or credit on‐site are limited_.  Communities are consulted about the level and forms of gambling they feel are appropriate for them. 3. Those who choose to gamble are **informed of the odds of winning, and of the potential consequences and risks**. Examples of action that results from this principle:  _Odds of winning are clearly posted at tables and on machines_.  _Evidence‐based awareness and prevention initiatives_ are supported and evaluated on a routine basis. 4. Ontarians whose lives are most affected by problem gambling have **access to high‐quality, culturally appropriate care**. Examples of actions that result from this principle:  Ontarians have access to services across the province, both in person and online.  Services are built around the needs of clients, including those with co‐occurring disorders such as mental health and substance use problems.  Multicultural, multilingual outreach and services are made available.  Primary care clinicians are supported to provide screening and brief intervention services and are knowledgeable about other available resources/services. 5. Gambling legislation and regulation must establish a **minimum duty of care.** Examples of action that results from this principle:  _Advertising of gambling does not promote false beliefs and is not directly or indirectly aimed at vulnerable populations_.  Government’s mandate to regulate gambling in the public interest is defined to explicitly include the mitigation of health and safety risks.  Gambling is defined in legislation as a public health issue.  The social responsibility mandate of the regulator is broadened and its scope is clearly defined. 6. Government regulation and operation of gambling should have as its primary **focus the protection of populations at greatest risk of developing gambling problems**. Examples of action that results from this principle:  _Strict controls on young people’s access to gambling_, and advertising directed toward young people, are in place.  Appropriate interventions are implemented for those clearly exhibiting evidence of dangerous patterns of gambling (e.g. extended length of session). 7. Government decisions on gambling are **based on best evidence, and research on gambling** is supported. Examples of action that results from this principle:  Policy and regulatory changes – and most importantly, any gambling expansion – are subject to rigorous and transparent evaluation on a routine basis.  Government continues to provide support to _gambling research_, and implementation of research results toward clinical practice guidelines.  Government decisions are informed by best evidence on both public benefits and costs of gambling to individuals, families, communities and society.  A mandatory player card system is introduced and used to prevent and identify gambling problems as well as the proportion of gambling revenues derived from people with gambling problems.

Answer 260

Guidelines for Canadian Drinking Water Quality are established specifically for contaminants that meet all of the following criteria: 1. Exposure to the contaminant _could lead to adverse health effects in humans;_ 2. The contaminant is _frequently detected or could be expected to be found in a large number of drinking water supplies throughout Canada_; and 3. The contaminant is detected, or _could be expected to be detected, in drinking water at a level that is of possible human health significance_.

Answer 261

1. Canada has evidence-based goals for vaccine preventable disease rates and immunization coverage 2. Canada is better able to identify under and un-immunized populations and has an enhanced understanding of the determinants of vaccine acceptance and uptake 3. Canadians have timely and equitable access to immunization 4. Canada has the evidence needed to develop and implement evidence-based interventions, to improve immunization coverage rates 5. Canadians have the information and tools needed to make evidence-based decisions on immunization 6. Canada understands the key barriers to, and best practices in, improving immunization coverage and invests in addressing them

Answer 262

* *HIA Process** (SSARME) - Screening - **Scoping** - Appraising - Reporting * *- Monitoring** - Evaluation * *HEIA Steps** 1. **Scoping** 2. Potential impacts 3. Mitigation 4. **Monitoring** 5. Dissemination

Answer 263

Building partnership with housing/shelter provider Written TB infection control plan Health care liaison Optimize sleeping arrangements (1.2m apart, head-to-toe) Optimize ventilation (6 total air changes per hour, UV germicidal irradiation) Support hygiene measures - (facial tissue, trash cans, disposable masks, hand hygiene) Screen + educate staff + volunteers Non-stigmatizing TB screening at client intake, offer LTBI treatment Administrative measures: TB risk assessment, clear communication pathways, register of facility staff+clients, track bed assignments, implement cough alert protocol, maintain records of training

Answer 264

**Reasons for antimicrobial resistance**: Use in vet medicine and agriculture, over-prescribing, OTC, inadequate IPC, global travel Antimicrobial resistance (AMR) describes the capability of disease-causing microorganisms to withstand antimicrobial treatments such as antibiotics, thereby limiting available treatment options. AMR has been identified by the World Health Organization as one of the ten most significant threats to global health. Globalization, travel, and medical tourism mean that Canada shares this threat.52, 53 If left unchecked, it is estimated that AMR could cause 10 million deaths a year worldwide by 2050.54 Concerning national AMR trends were observed for several infectious diseases. For example, rates of community-acquired methicillin-resistant _Staphylococcus aureus (MRSA) infections increased by 62% between 2012 and 2017; Neisseria gonorrhoeae infections resistant to azithromycin increased by 50% from 2015 to 2016_.53 _While infection rates of some of the most resistant organisms, carbapenemresistant Enterobactericeae (CRE), have been stable, a very worrisome trend can be found in the five-fold increase, between 2014 and 2017, in the number of people who are carriers_ of these bacteria.55 However, some progress has been made in Canada to reduce AMR, primarily in hospital settings. For example, _healthcare-associated Clostridioides difficile and healthcare-associated MRSA infections decreased respectively by 36% and 6% from 2012 to 2017_.55

Answer 265

Checklist for Meta-analysis **Study question** Objectives clearly stated Clinically relevant and focused study question included Effectiveness of intervention not convincingly demonstrated in clinical trials **Literature search** _Comprehensive literature search conducted_ Searched information sources listed (ie, PubMed, Cochrane database) Terms used for electronic literature search provided Reasonable limitations placed on search (ie, English language) Manual search conducted through references of articles, abstracts Attempts made at collecting unpublished data **Data abstraction** _Structured data abstraction form used_ Number of authors (\>2) who abstracted data given Disagreements listed between authors and how they were resolved Characteristics of studies listed (ie, sample size, patient demographics) _Inclusion and exclusion criteria provided for studies_ Number of excluded studies and reasons for exclusion included **Evaluation of results** Studies were combinable _Appropriate statistical methods_ used to combine results Results displayed _Sensitivity analysis conducted_ **Evaluation for publication bias** _Publication bias addressed_ through evaluation methods such as funnel plot or sensitivity analysis **Applicability of results** _Results were generalizable_ **Funding source** Funding source(s) stated _No conflict of interest seen_

Answer 266

Many of the maternal and paternal risk factors for poor birth outcomes, such as lifestyle behaviours, are modifiable in the preconception period [4,5,6]. In fact, research has shown that PCH has positive impacts on many reproductive health outcomes and is _cost effective for specific interventions, such as folic acid supplementation and diabetes care_ [7,8]. While it is not an exhaustive list, PCH can: * prevent preterm births; * improve birth weight; * prevent congenital anomalies, including neural tube defects; * reduce infant mortality; * reduce maternal mortality [1].

Answer 267

The CCDI comprises six domains: Data sources include CCHS, CHMS, CCDSS, DAD, CTADS, CIS, LFS, GSS, CCR. **(1) social and environmental determinants;** _education_: % pop with \< high school (CCHS) _income_: % pop living below LICO (CIS - canadian income survey) _employment_: average annual unemployment rate (LFS - labour force survey) _community belonging_: % pop report very strong/somewhat strong sense of belonging to local community (CCHS) **(2) maternal and child health risk and protective factors;** _Maternal DM/HTN_: rate of pregnant women with diagnosed DM/HTN (DAD) _Preterm birth_: % live births before 37 weeks (DAD) _BF_: % women report BF child for at least first 6 months of life (CCHS) _Second-hand smoke_: % households with children \<15yo with regular child exposure to ETS (CTADS) _Family violence_: %pop report physical or sexual abuse or exposure to violence (GSS - General Social Survey) **(3) behavioural risk and protective factors;** physical activity, sleep, nutrition, stress (CCHS, CHMS) drug/smoking (CTADS) **(4) risk conditions;** obesity, elevated sugar, cholesterol, HTN (CHMS, CCDSS) **(5) disease prevention practices; and** contact with HCP, screening, vaccination (CCHS) **(6) health outcomes/status** general health, morbidity prevalence/incidence (CCDSS, CCHS, CCR)

Answer 268

Total coliforms - Group of bacteria found in digestive tracts and environment - Possible contamination and a risk of waterborne disease Fecal coliforms - Mainly found in digestive tracts and feces - More specific indicator of fecal contamination E. coli - Almost always comes from animal feces - Significant risk to human health Enteric protozoa Enteric virus Turbidity Chlorine residuals

Answer 269

Primary vaccine failure could be defined as the failure to seroconvert or the failure to mount a protective immune response after vaccination despite seroconversion, whereas secondary vaccine failure is the gradual waning of immunity over time.

Answer 270

Pyramid showing escalation of injuries through levels. Level 1: Injuries that do not receive attention in a health institution; Level 2: Injuries resulting in primary care treatment; Level 3: Injuries requiring emergency treatment; Level 4: Injuries requiring hospitalization or that result in disability; Level 5: Fatal injuries.

Answer 271

1. Direct health costs - actual costs of delivering intevention e.g. drugs, nursing staff, lab tests 2. Direct non-health costs - transport, support services, pension payouts, disability benefits, unemployment benefits (EI) 3. Indirect costs - e.g. days lost from work, reduced productivity 4. Intangible costs - e.g. pain, psychological harm, stigma

Answer 272

Partner who drinks heavily Past hx of sexual abuse Mental illness Polysubstance abuse Social isolation and lack of social support

Answer 273

* *Contact investigation has three main objectives.** In order of priority these are as follows: 1. Identify and initiate treatment of secondary cases of active TB disease. 2. Identify and treat the source case who infected the index case, if the index case is under 5 years old. 3. Identify contacts with LTBI in order to offer preventive treatment Only respiratory tuberculosis (TB), with limited exceptions, is infectious; contact follow-up should be carried out for both sputum smear-negative and smear-positive cases. The objective of contact follow-up is to identify and treat any secondary cases, and to identify contacts with latent TB infection (LTBI) in order to offer preventive treatment. _Source-case investigation is recommended for children under 5 years old with a diagnosis of active TB disease._ Interviews with the infectious case to identify contacts should include questions about locations/activities of potential exposure as well as specific named contacts. The discussion of site-based, social network contact investigation as well as the section on contact follow-up in homeless populations has been expanded from the 6th edition of the Standards. _Prioritization of contact follow-up is recommended by the infectiousness of the source case, extent of exposure and immunologic vulnerability of those exposed_. Thus, the most effort is put into contacts who are most at risk of being infected and/or most at risk of developing active TB disease if infected. _The classic concentric-circle approach to contact follow-up is no longer recommended. Rather, the initial follow-up should include non-household contacts from the outset when case infectiousness and contact vulnerability indicate, rather than waiting. Contacts may be grouped as follows_: **High priority** household contacts plus close non-household contacts who are immunologically vulnerable, such as children under 5 years. **Medium priority** close non-household contacts with daily or almost daily exposure, including those at school and work. **Low priority** casual contacts with lower amounts of exposure. _For smear-positive/cavitary/laryngeal TB, it is recommended that the initial contact follow-up include both high- and medium-priority contacts._ _For smear-negative, non-cavitary pulmonary TB, the initial contact follow-up should be for high-priority contacts only_. _In both situations, contact investigation is iterative: it should be expanded if the initial follow-up results indicate that transmission has occurred_. _A single evaluation at least 8 weeks after the end of exposure (with tuberculin skin testing [TST] and symptom assessment) is recommended in most non-household contact settings, in order to maximize participation and minimize overdiagnosis_ of "conversion" related to boosting. _Initial plus 8 week post-exposure TST is recommended for household and other high-priority contacts_. Two-step TST is not recommended in the setting of a contact investigation. TST is no longer recommended as a primary assessment tool in the contact follow-up of elderly residents in long-term care, in whom it is less reliable and for many of whom the risks of treatment of LTBI in old age will outweigh any benefit. The focus for these individuals should be on early detection of secondary cases.

Answer 274

Pre-conception Folic Acid and Multivitamin Supplementation for the Primary and Secondary Prevention of Neural Tube Defects and Other Folic Acid-Sensitive Congenital Anomalies In Canada multivitamin tablets with folic acid are usually available in 3 formats: regular over-the-counter multivitamins with 0.4 to 0.6 mg folic acid, prenatal over-the-counter multivitamins with 1.0 mg folic acid, and prescription multivitamins with 5.0 mg folic acid. (III) Recommendations 1. Women should be advised to maintain a healthy folate-rich diet; however, folic acid/multivitamin supplementation is needed to achieve the red blood cell folate levels associated with maximal protection against neural tube defect. (III-A) 2. All women in the reproductive age group (12–45 years of age) who have preserved fertility (a pregnancy is possible) should be advised about the benefits of folic acid in a multivitamin supplementation during medical wellness visits (birth control renewal, Pap testing, yearly gynaecological examination) whether or not a pregnancy is contemplated. Because so many pregnancies are unplanned, this applies to all women who may become pregnant. (III-A) 3. _Folic acid supplementation is unlikely to mask vitamin B12 deficiency (pernicious anemia)._ Investigations (examination or laboratory) are not required prior to initiating folic acid supplementation for women with a risk for primary or recurrent neural tube or other folic acid-sensitive congenital anomalies who are considering a pregnancy. It is recommended that folic acid be taken in a multivitamin including 2.6 ug/day of vitamin B12 to mitigate even theoretical concerns. (II-2A) 4. Women at HIGH RISK, for whom a folic acid dose greater than 1 mg is indicated, taking a multivitamin tablet containing folic acid, should be advised to follow the product label and not to take more than 1 daily dose of the multivitamin supplement. Additional tablets containing only folic acid should be taken to achieve the desired dose. (II-2A) 5. _Women with a LOW RISK for a neural tube defect_ or other folic acid-sensitive congenital anomaly and a male partner with low risk require a diet of folate-rich foods and a daily oral multivitamin supplement containing _0.4 mg folic acid for at least 2 to 3 months before conception, throughout the pregnancy, and for 4 to 6 weeks postpartum or as long as breast-feeding continues_. (II-2A) 6. Women with a _MODERATE RISK for a neural tube defect or other folic acid-sensitive congenital anomaly or a male partner with moderate risk require a diet of folate-rich foods and daily oral supplementation with a multivitamin containing 1.0 mg folic acid, beginning at least 3 months before conception_. Women should continue this regime until 12 weeks’ gestational age. (1-A) From 12 weeks’ gestational age, continuing through the pregnancy, and for 4 to 6 weeks postpartum or as long as breast-feeding continues, continued daily supplementation should consist of a multivitamin with 0.4 to 1.0 mg folic acid. (II-2A) 7. _Women with an increased or HIGH RISK for a neural tube defect, a male partner with a personal history of neural tube defect, or history of a previous neural tube defect pregnancy in either partner require a diet of folate-rich foods and a daily oral supplement with 4.0 mg folic acid for at least 3 months before conception and until 12 weeks’ gestational age._ From 12 weeks’ gestational age, continuing throughout the pregnancy, and for 4 to 6 weeks postpartum or as long as breast-feeding continues, continued daily supplementation should consist of a multivitamin with 0.4 to 1.0 mg folic acid. (I-A). The same dietary and supplementation regime should be followed if either partner has had a previous pregnancy with a neural tube defect. (II-2A) _LOW risk group_: Women or their male partners with no personal or family history of health risks for folic acidsensitive birth defects. _MODERATE risk group_: Women with the following personal or co-morbidity scenarios (1 to 5) or their male partner with a personal scenario (1 and 2): 1. Personal positive or family history of other folate sensitive congenital anomalies (limited to specific anomalies for cardiac, limb, cleft palate, urinary tract, congenital hydrocephaly) 2. Family history of NTD in a first or second-degree relative 3. Maternal diabetes (type I or II) with secondary fetal teratogenic risk. Measurement of red blood cell folate levels could be part of the pre-conception evaluation to determine the multivitamin and folic acid supplementation dose strategy (1.0 mg with RBC folate \< 906 and 0.4 to 0.6 mg with RBC folate \> 906) with a multivitamin) 4. Teratogenic medications with secondary fetal teratogenic effects by folate inhibition via anticonvulsant medications (carbamazepine, valproic acid, phenytoin, primidone, phenobarbital), metformin, methotrexate, sulfasalazine, triamterene, trimethoprim (as in cotrimoxazole), and cholestyramine 5. Maternal GI malabsorption conditions secondary to co-existing medical or surgical conditions that have been shown to result in decreased RBC folate levels (Crohn’s or active Celiac disease, gastric bypass surgery, advanced liver disease, kidney dialysis, alcohol overuse) _INCREASED/HIGH risk group_: Women or their male partners with a personal NTD history or a previous neural tube defect pregnancy

Answer 275

Health effects of vaping vs smoking If you are a smoker: quitting smoking is the best thing you can do to improve your health. There is support available to help you quit. _completely replacing cigarette smoking with vaping will reduce your exposure to harmful chemicals_.Footnote1 there are short-term general health improvements if you completely switch from smoking cigarettes to vaping products.Footnote1 _Vaping is less harmful than smoking. Many of the toxic and cancer-causing chemicals in tobacco and the tobacco smoke form when tobacco is burned_.Footnote2Footnote3Footnote4 _Vaping products do not:_ _produce smoke_ _contain tobacco_ _involve burning_ Except for nicotine, _vaping products typically contain:_ _a fraction of the 7,000 chemicals found in tobacco smoke_ _lower levels of several of the harmful chemicals found in smoke_ Vaping to help quit smoking Quitting smoking can be difficult, but it is possible. Vaping products and e-cigarettes deliver nicotine in a less harmful way than smoking cigarettes. These products may reduce health risks for smokers who can't or don't want to quit using nicotine: on their own by using counselling services by using medication or approved nicotine replacement therapies like: gums patches lozenges _While evidence is still emerging, some evidence suggests that using e-cigarettes is linked to improved rates of success._ While quitting cigarettes, you may go through a time when you use both cigarettes and vaping products. Switching from tobacco cigarettes to vaping will reduce your exposure to many toxic and cancer causing chemicals.

Answer 276

Interventions “The advice of a health professional is the most important factor in whether a person receives a vaccine” - Dr. Ian Gemmill   **Enhancing access to vaccination: Improve convenience and access to vaccination** Home visits Reduce client out-of-pocket costs Vaccination programs in schools and childcare centres   **Increasing community demand for vaccinations** Engagement of religious or other influential leaders to promote vaccination in the community Social mobilisation and mass media: “Play the issue, not the opponent”; adversarial approaches to anti-vax advocates can create the false impression that vaccination is a contested intervention Employing reminder and follow-up (recall systems) Non-financial incentives Mandating vaccinations / sanctions for non-vaccination 2 Canadian provinces (Ontario, New Brunswick) and all US states require children to be vaccinated prior to attending school, but allow for medical, religious, and philosophical exemptions Some other provinces (e.g., Alberta) do not require immunization, but will exclude a child from school if there is a VPD outbreak WHO has no official stance on mandatory immunization Other approaches: Vaccination is not mandatory in Australia, but it provides nontaxable payments to parents for each child who meets immunization requirements between 18-24 months and again between 4-5 years of age; immunization is mandatory in Latvia, and philosophical or religious exemptions are not permitted **Enhancing provision of vaccines – provider level:** Start early Present vaccination as default approach Be honest about side effects and reassure of robust vaccine safety system Tell stories in addition to providing scientific facts Build trust with patients/parents A qualitative study reported that a mother’s trust is obtained when a provider spends time discussing vaccines, does not deride her concerns, is knowledgeable, and provides satisfactory answers Focus on protection for the child and community Address pain: 5P approach Pharmacologic: Use least-painful brand when possible; if under 12 can use topical anesthetics; if under 2 consider providing sweet-tasting solution Physical: Breastfeeding during vaccination for infants \< 2yrs; \<1mo encourage skin-to-skin contact Positioning: \<3yrs encourage holding during injections or patting/rocking after injection; encourage sitting up instead of supine position Psychological: Distraction techniques, deep breathing Procedural: educate parents of children of all ages about pain management for vaccine injection before or on the day of vaccination; for children under 10, parents should be present; do not aspirate; inject the most painful vaccine last; provide tactile distraction at the time of injection (e.g., Buzzy Helps, Shotblocker) Electronic immunization records Standing orders Provider reminders Communications training for HCW: Focus on building a trusting relationship; “overselling” vaccines increases hesitance; aim to increase patient knowledge and awareness about vaccination (see table below) Religious considerations in immunization God’s will: Some Plain people and practitioners of Dutch or Christian Reform believe that vaccination interferes with God’s will Porcine-derived gelatin is used in Varivax, Zostavax, and MMR as a stabilizer; Islamic scholars posit that “the transformation of pork products into gelatin alters them sufficiently to make it permissible for observant Muslims to receive vaccines containing pork gelatin”; for practitioners of Judaism, non-oral porcine-derived products are acceptable Human cell lines derived from fetal cells from legal abortions that occurred the 1960s are used in the production of MMR, varicella, hep A, rabies, Quadracel, and Tdap; vaccines do not contain human cells; the Vatican has affirmed that “‘In the absence of effective alternatives, individuals may use the morally tainted vaccines,’ and assert that it is necessary to ‘provide for the good of one’s children,’ including the prevention of disease where possible.” Immunoglobulin immunizations are blood products and may be declined by Jehovah’s Witnesses   Epidemiology of vaccine hesitancy in Canada Data from the Childhood National Immunization Coverage Survey, 2013 Prevalence of parents/guardians reporting that their children had never received an immunization: 1.5% Proportion of parents who agree vaccines are safe: 95% Proportion of parents who agree vaccines are effective: 97% Proportion of parents with concerns about vaccine side effects: 70% Proportion of parents who strongly agree that alternative practices (e.g., chiropractic, homeopathy) can replace vaccines: 5% Between 75-90% of two-year-olds are up-to-date on their immunizations, depending on the antigen (highest for MMR and polio, lowest for Var)  

Answer 277

_Strategic Objectives_ **Reduce stigma** and raise public awareness. **Connect Canadians**, information, and resources. Accelerate the use of **research and innovation** in suicide prevention. _Guiding Principles_ Build **hope and resiliency**. **Promote mental health** and wellbeing. Complement current initiatives in suicide prevention. Be **informed by current research and best available evidenc**e. Apply a **public health approach**. Leverage **partnerships**. **Vision** A Canada where suicide is prevented and everyone lives with hope and resilience **Mission** To prevent suicide in Canada, through partnership, collaboration and innovation while respecting the diversity of cultures and communities that are touched by this issue **Purpose** To guide the federal government's efforts in suicide prevention through implementation of An Act respecting a Federal Framework for Suicide Prevention (2012) **Legislated Elements** (Section 2 of the Act) Provide guidelines to improve public awareness and knowledge of suicide. Disseminate information about suicide and its prevention. Make existing statistics about suicide and related risk factors publicly available. Promote collaboration and knowledge exchange across domains, sectors, regions and jurisdictions. Define best practices for suicide prevention. Promote the use of research and evidence-based practices for suicide prevention.

Answer 278

**U.S EPA criteria air pollutants** Particulate matter (PM-10 and PM-2.5) Ozone (O3) Carbon monoxide (CO) Nitrogen dioxide (NO2) Sulfur dioxide (SO2) Lead (Pb) **Particulate matter 2.5 and 10** Particulate matter (PM) consists of airborne particles in solid or liquid form. PM may be classified as primary or secondary, depending on the compounds and processes involved during its formation. Primary PM is emitted at the emissions source in particle form, for example, the _smokestack of an electrical power plant or a recently tilled field subject to wind erosion_. Secondary PM formation results from a series of chemical and physical reactions involving different precursor gases, such as sulphur oxides and nitrogen oxides, and ammonia reacting to form sulphate, nitrate and ammonium particulate matter. The size of PM particles largely determines the extent of environmental and health damage caused. For this reason, Environment Canada identifies different sizes of PM: Total Particulate Matter (TPM) -airborne particulate matter with an upper size limit of approximately 100 micro metre (µm) in aerodynamic equivalent diameter _Particulate Matter \<10 microns (PM10) - airborne particulate matter with a mass median diameter less than 10 µm_ _Particulate Matter \< 2.5 microns (PM2.5) - airborne particulate matter with a mass median diameter less than 2.5 µm_ Numerous studies have linked PM to _aggravated cardiac and respiratory diseases such as asthma, bronchitis and emphysema and to various forms of heart disease_. PM can also have adverse effects on vegetation and structures, and contributes to visibility deterioration and regional haze. Efforts to address particulate matter (PM) levels in the air are important in both the United States and Canada. Canada and the United States have completed a joint transboundary particulate matter science assessment report in support of the _Canada-U.S. Air Quality Agreement._ **Common air pollutants: carbon monoxide** Carbon Monoxide (CO) is a colourless, odourless, tasteless and poisonous gas. It is a product of incomplete _combustion of hydrocarbon-based fuels and is emitted directly from automobile tailpipes_. Other lesser but significant sources are the wood industry, residential wood heating and forest fires. CO can have a significant impact on human health. It enters the bloodstream through the lungs and forms carboxyhemoglobin, a compound that inhibits the blood's capacity to carry oxygen to organs and tissues. Persons with heart disease are especially sensitive to CO poisoning. Infants, elderly persons, and individuals with respiratory diseases are also particularly sensitive. CO can affect healthy individuals, _impairing exercise capacity, visual perception, manual dexterity, learning functions, and ability to perform complex tasks._ **Common air pollutants: volatile organic compounds** Volatile organic compounds (VOCs) are carbon-containing gases and vapors such as _gasoline fumes and solvents_ (but excluding carbon dioxide, carbon monoxide, methane, and chlorofluorocarbons). Although there are many thousands of organic compounds in the natural and polluted troposphere that meet the definition of a VOCs, most measurement programs have concentrated on the 50 to 150 most abundant hydrocarbons. Many individual VOCs are known or suspected of having direct toxic effects on humans, ranging from carcinogenesis to neurotoxicity. A number of individual VOCs (e.g. benzene, dichloromethane) have been assessed to be toxic under the Canadian Environmental Protection Act, 1999 (CEPA 1999). T_he more reactive VOCs combine with nitrogen oxides (NOx) in photochemical reactions in the atmosphere to form ground-level ozone, a major component of smog._ VOCs are also a precursor pollutant to the secondary formation of fine particulate matter (PM2.5). Both ozone and PM2.5 are known to have harmful effects on human health and the environment. **Common air pollutants: sulphur oxides** Sulphur dioxide, or SO2, belongs to a family of sulphur oxide gases (SOx). It is formed from the sulphur contained in raw materials such as _coal, oil and metal-containing ores during combustion and refining processes_. SO2 dissolves in water vapour in the air to form acids, and interacts with other gases and particles in the air to form particles known as sulphates and other products that can be harmful to people and their environment. Both SO2 in its untransformed state, and the acid and sulphate transformation products of SO2, can have adverse effects on human health or the environment. SO2 itself can cause adverse effects on respiratory systems of humans and animals, and damage to vegetation. When dissolved by water vapour to form acids it can again have adverse effects on the respiratory systems of humans and animals, and it can cause damage to vegetation, buildings and materials, and contribute to acidification of aquatic and terrestrial ecosystems. When transformed into sulphate particles that are subsequently deposited on aquatic and terrestrial ecosystems, acidification can result, and when sulphate is combined with other compounds in the atmosphere, such as ammonia, it becomes an important contributor to the secondary formation of respirable particulate matter (PM2.5). PM2.5 is known to have harmful effects on human health and the environment, and contribute to visibility impairment and regional haze. **Common air pollutants: ground-level ozone** Ground-level ozone is a colorless and highly irritating gas that forms just above the earth's surface. It is called a _"secondary" pollutant because it is produced when two primary pollutants react in sunlight and stagnant air_. These two primary pollutants are nitrogen oxides (NOx) and volatile organic compounds (VOCs). NOx and VOCs come from natural sources as well as human activities. About 95 per cent of NOx from human activity come from the _burning of coal, gasoline and oil in motor vehicles, homes, industries and power plants._ VOCs from human activity come mainly from gasoline combustion and marketing, upstream oil and gas production, residential wood combustion, and from the evaporation of liquid fuels and solvents. Significant quantities of VOCs also originate from natural (biogenic) sources such as coniferous forests. Ozone is known to have significant effects on human health. Exposure to ozone has been linked to pre-mature mortality and a range of morbidity health end-points such as hospital admissions and asthma symptom days. In addition to its effects on human health, ozone can significantly impact vegetation and decrease the productivity of some crops. It can also injure flowers and shrubs and may contribute to forest decline in some parts of Canada. Ozone can also damage synthetic materials, cause cracks in rubber, accelerate fading of dyes, and speed deterioration of some paints and coatings. As well, it damages cotton, acetate, nylon, polyester and other textiles. The Ozone Annex was added to the Canada-United States Air Quality Agreement (December 2000) to address the transboundary air pollution leading to high levels of ground-level ozone, a major component of smog. **Common air pollutants: ammonia** Ammonia is a colourless gas with a pungent odor that is noticeable at concentrations above 50 ppm. Most of the NH3 emitted is generated from livestock waste management and fertilizer production. NH3 is poisonous if inhaled in great quantities and is irritating to the eyes, nose, and throat in lesser amounts. It combines in the atmosphere with sulphates and nitrates to form secondary fine particulate matter (PM2.5). PM2.5 is known to have harmful effects on human health and the environment. NH3 can also contribute to the nitrification and eutrophication of aquatic systems. **Common air pollutants: nitrogen oxides** Nitrogen oxides include the gases nitrogen oxide (NO) and nitrogen dioxide (NO2). NOx is formed primarily from the liberation of nitrogen contained in fuel and nitrogen contained in combustion air during combustion processes. NO emitted during combustion quickly oxidizes to NO2 in the atmosphere. NO2 dissolves in water vapour in the air to form acids, and interacts with other gases and particles in the air to form particles known as nitrates and other products that may be harmful to people and their environment. Both NO2 in its untransformed state, and the acid and nitrate transformation products of NO 2 , can have adverse effects on human health or the environment. NO2 itself can cause adverse effects on respiratory systems of humans and animals, and damage to vegetation. When dissolved by water vapour, the acids formed can have adverse effects on the respiratory systems of humans and animals. Nitric acid (HNO3) can cause damage to vegetation, buildings and materials, and contribute to acidification of aquatic and terrestrial ecosystems. When NO2 is transformed into nitrate particles that are subsequently deposited on aquatic and terrestrial ecosystems, acidification can result. When nitrate is combined with other compounds in the atmosphere, such as ammonia, it becomes an important contributor to the secondary formation of respirable particulate matter (PM2.5). NO2 is one of the two primary contributing pollutants, along with volatile organic compounds (VOCs), to the formation of ground-level ozone. Both ozone and PM2.5 is known to have harmful effects on human health and the environment.

Answer 279

Creating and enforcing laws and policies Developing strategies/frameworks/initiatives Increasing knowledge and awareness Creating safe and supportive communities Promoting healthy families and relationships Targeting at-risk populations

Answer 280

A multi-barrier source-to-tap approach for the management of drinking water includes 1) the **_protection of source water_,** 2) the _use of appropriate and consistently effective **drinking water treatment**_, 3) a **_well-maintained distribution system_**, _qualified personne_l, _routine verification of drinking water quality_, 4) and **_communication and public education_**.

Answer 281

**Inequalities in Infant Mortality in Canada** About 3.7 out of 1 000 babies born in Canada will not live past their first birthday. **Leading causes of infant deaths (2018):** #1 Congenital malformations #2 Short gestation and low birth weight #3 Maternal complications **Other:** Severe lack of oxygen, Infection, SIDS **Risk factors of infant death include:** Low maternal education Inadequate housing Lack of access to health care Food insecurity Poverty Unemployment While the infant mortality rate in Canada has improved over the past few decades, this improvement is not equally distributed. Infant mortality is strongly associated with socioeconomic status in Canada: Canadians living in the most materially deprived areas have rates of infant mortality 1.6 times higher than the rates of those living in the least deprived areas. Areas where more Indigenous peoples live have a higher infant mortality rate: Inuit 3.9 times higher First Nations 2.3 times higher Métis 1.9 times higher Inequities experienced by First Nations, Inuit and Métis populations are a direct result of colonial policies and practices that included massive forced relocation, loss of lands, creation of the reserve system, banning of Indigenous languages and cultural practices, and creation of the residential school system. Unaddressed intergenerational trauma adds to the ongoing challenges faced by Indigenous peoples. Many infant deaths are preventable. Addressing inequalities in education, income, and material deprivation may improve conditions that influence the health of both the mother-to-be and the infant.

Answer 282

**Health in all policies + Healthy public policy in summary:** - Non-health sectors, intersectoral - Systematic consideration during planning process - Seeks to have positive impact on health + SDoH, to improve pop health + equity - Avoids harmful effects **Health policy** dictates who should do what to whom, when they should do it, how much is available for doing, where they should do it, and who should pay for it. **Healthy public policy** concerns policies written in _other sectors_ (such as education or transportation), which may have an _important impact on health because they modify known social determinants of health_. The intent is to ensure that this _health impact is positive,_ and that _policy makers include health considerations in their planning._

Answer 283

* PH data sources: * Surveillance data * Vital statistics, mortality data * Census * Surveys * Registries * * * Administrative databases: hospital admission/outpatient, physician billing, prescription database, EMS * EMR data * Laboratory data * * Call lines, service user views * Gov/city partners: police/EMS/fire * NGOs * Community perspective: stories, testimonials, interviews and focus groups Evidence base for interventions: * * Academic research: systematic reviews, meta-analysis, RCT, case-control studies, cohort, qualitative studies, evaluations * Grey literature from community/partner organizations, private sector, best practice guidelines/standards, evaluation findings, environmental scans * Expert consultation **Organization by domains:** 1. Sociodemographic profile - Develop a community profile (age, sex etc, pop #s) that is the focus of the HNA - statistics Canada 2. Epidemiology - Describe epidemiology of mental health of the relevant population - P/T mental health surveys, hospitalisation database, physician billing, prescription database 3. Comparative assessment - compare local provision against national norms - CCDSS 4. Service user views - patient surveys, satisfaction 5. Resources available - description of healthcare and allied health available for mental health (e.g. community psychologists, dedicated psychiatric facilities) 6. Healthcare utilization - emergency department visits, EMS call outs

Answer 284

**Screening program** criteria: **- Condition (4):** 1) burden, 2) latent state, 3) natural history, 4) accepted treatment **- Test (2):** 1) suitable, 2) acceptable **- Program (4):** 1) who pts are, 2) economically balanced for society, 3) continuous process, 4) facilities for dx+tx Erickson De Wals **vaccine program** criteria: Appropriate disease (1) - burden of disease Good vaccine (5) - safety, immunogenicity, effectiveness, cost-effective, ease of administration Good program (10) - feasible, acceptable, delivery strategy, sufficiently researched implementation, can be evaluated, comparable to others, legal/political/ethical/equity considerations

Answer 285

No fault compensation Collective liability Security of paument Exclusive jurisdiction Independent board

Answer 286

**Comparing 2 proportions between 2 groups** Chi-square/Fisher's exact Paired = McNemar **Comparing means between groups** (non-parametric) 2 groups = t-test (Wilcoxon rank sum) 2 Paired groups = Paired t-tests (Wilcoxon signed rank) \>2 groups = ANOVA (Kruskal-Wallis) **Comparing 2 continuous variables** (non-parametric) Correlation: Pearson (Spearman) Linear regression

Answer 287

Trends in lung cancer In Canada, _the incidence rate of lung cancer is higher in men than in women_. _In males, the rate of lung cancer began decreasing in 1990. In females, the lung cancer incidence rate began decreasing in 2011._ The difference in incidence rates and trends between the sexes is likely because of **differences in tobacco use**. More men smoked than females, and men’s smoking rates began to decline earlier than women’s smoking rates. In males, _the death rate from lung cancer began to level off in the late 1980s and has been declining ever since. The death rate for females was increasing until 2006 but is now decreasing._ Men continue to have a higher rate of lung cancer death than women. Chances (probability) of developing or dying from lung cancer It is estimated that about _1 in 14 Canadian men will develop lung cancer during their lifetime and one in 16 will die from it_. It is estimated that about _1 in 15 Canadian women will develop lung cancer during their lifetime and one in 19 will die from it_.

Answer 288

In June 2001, the CDMH approved the development of an NIS, with the following five components: "Go Plan a Safe Procurement Registry" ■ National **_Goals_ and Objectives** ■ **Immunization Program _Planning_** ■ **Vaccine _Safety_** ■ Vaccine **_Procurement_** ■ **Immunization _Registry_** Network In its 2016 Budget, the Government of Canada committed $25M over five years to increase immunization coverage rates. F/P/T partners have worked together to establish a set of short term objectives. Objective #1: Canada has _evidence-based goals for vaccine preventable disease rates and immunization coverage_ Objective #2: Canada is better able to identify under and un-immunized populations and has an enhanced understanding of the _determinants of vaccine acceptance and uptake_ Objective #3: Canadians have _timely and equitable access to immunization_ Objective #4: Canada has the evidence needed to develop and implement _evidence-based interventions, to improve immunization coverage rates_ Objective #5: _Canadians have the information and tools needed to make evidence-based decisions on immunization_ Objective #6: Canada understands the _key barriers to, and best practices in, improving immunization coverage_ and invests in addressing them