Key PHPM Concepts to Review Flashcards

Question

What is the Pan Canadian STBBI Framework for Action?

Answer 1

Goals -Reduce the incidence of STBBI in Canada -Improve access to testing, treatment, and ongoing care and support -Reduce stigma and discrimination that create vulnerabilities to STBBI Core pillars support an enabling environment -Prevention -Testing -Initiation of care and treatment -Ongoing care and support -ALL UNDERSCORED BY AN ENABLING ENVIRONMENT Guiding Principles -Meaningful engagement of people living with HIV and viral hepatitis and key populations -Moving towards truth and reconciliation -Integrated approach -Cultural relevance -Human rights -Health equity -Multi-sectoral approach -Evidence-based policy and programs

Answer 2

Globalization - Travel and tourism: more movement of people -Global trade: more movement of goods -Migration: immigrants, asylum seekers can be more vulnerable to disease in new country setting Environment -Climate change: changing distribution of vectors, waterborne/foodborne diseases -Urbanization/built environment: Changes to physical landscape change distribution of vectors Sociodemographic -Vulnerable groups: Children, premature infants, pregnant women, elderly persons, men who have sex with men, immunocompromised persons. Can be more susceptible to disease, or have more difficulty accessing care -Demographic: Population composition with regards to age, income, education can be associated with greater health vulnerabilities -Social inequality: Uneven distribution of resources in society, including income, wealth, rights, privileges, social power, education. Disadvantaged groups can suffer disproportionately from infectious diseases. -Lifestyle: High-risk behavior, such as intravenous drug use or unprotected sex with multiple partners can increase exposure and infection rates -Occupational: Lapses in infection control practices can put healthcare workers, veterinarians, butchers, etc. at risk -Prevention: Childhood vaccination programs, appropriate prescription practices -Terrorism: Intentional release or dissemination of biologic agents Public Health System Failures Food and water quality: Contamination of drinking and irrigation water sources, water distribution systems, foodstuff can result in both localized and community outbreaks Animal Health: High animal densities can promote infectious disease transmission. Infected animals close to human settlements can increase the risk for zoonotic epidemics Surveillance and reporting failure: Lapses in surveillance can impede a rapid response to infectious disease outbreaks Healthcare system: Healthcare systems contribute to nosocomial infections

Answer 3

Vaccines prevent CASES C - Cost A - Administration (ease) (oral/intranasal preferred to injection, minimum doses) S - Safety (common side effects mild, severe side effects rare) E - Effective (immunogenicity (produces immune response), efficacy (reduces disease in clinical trials), effectiveness (reduces disease in real world), duration of protection S - Stability (minimal/no need for cold chain, long shelf-life)

Answer 4

o Vaccine type: live attenuated induces greater response than inactivated vaccines o Presence of adjuvants: added to inactivated vaccines to enhance the immune response and extend duration of B and T cell activations o Conjugating proteins: conjugating (linking) a polysaccharide with a carrier protein (protein that is easily recognized by the immune system) leads to a significantly higher immune response o Antigen dose: higher the dose of inactivated antigen (to a threshold) elicits higher antibody responses o Timing between doses: adhering to recommended interval between doses allows development of successive waves of antigen-specific immune system responses and maturation of memory cells o Recipient age: vaccines given early in life when the immune system is immature may result in limited immune response. Vaccines given in older age can result in a reduction in the strength and persistence of antibody responses o Immune system status: immunocompromised individuals will have restricted vaccine response o Host factors: age, sex, pre-existing conditions o Other factors: route

Answer 5

Considerations for vaccine programs 1. Disease characteristics: burden 2. Vaccine characteristics: CASES 3. Program characteristics: immunization strategy, acceptability, feasibility, ability to evaluate, research questions, cost-effectiveness, conformity (SAFER-CC) 4. Contextual factors: PESTLE, Equity, Ethical

Answer 6

Preclinical: Animal and lab studies looking at feasibility and toxicity Phase 1: Immunogenicity and toxicity Phase 2: Safety Phase 3: Vaccine efficacy, rare adverse events Phase 4: Real world effectiveness, post-licensing surveillance

Answer 7

1-Incidence Rate Ratio (IRR) = 1-(incidence in vaccinated/incidence in unvaccinated) OR (incidence in unvaccinated - incidence in vaccinated)/incidence in unvaccinated Individuals who are vaccinated have a (x%) lower risk that those who are not.

Answer 8

HCP -> Local PHU -> Provincial PHA -> PHAC CAEFISS (Canada Adverse Events Following Immunization Surveillance System) Manufacturer -> Health Canada CVP (Canada Vigilance Program) -> CAEFISS IMPACT (Immunization Monitoring Program ACTive, pediatric hospital-based) -> CAEFISS Concerns re: causality: CAEFISS -> ACCA (Advisory Committee on Causality Assessment)

Answer 9

95-100%: Rubella, measles, rabies, Hib, hepatitis B, tetanus, diphtheria, HPV, hepatitis A 90-95%: Rotavirus 75-90%: Pertussis, typhoid <75: Tb

Answer 10

Level of immunity in the population that protects the whole population because the disease can no longer spread Calculation = 1 - 1/R0

Answer 11

Definition: delay in acceptance or refusal of vaccines despite availability of vaccine services Factors contributing to vaccine hesitancy (4Cs) -Complacency: Lack of perceived need or value for vaccine, lack of experience with vaccine-preventable diseases -Convenience: Lack of access (e.g. geographic barriers, cost barriers), cost barriers -Confidence: Lack of trust in vaccine, provider, or the process, past adverse experiences, perceived risk/benefit, actual risk/benefit (technical concerns over probability of side effects) -Culture: Religious beliefs, social context, distrust of the medical system or pharmaceutical industry

Answer 12

Can be used to discuss interventions to a public health issue (e.g. vaccine hesitancy) or hazard (e.g. lead in drinking water) Economic: Create financial incentives Engineering: New electronic systems Education: Increase health care provider awareness Environment: Increase access through school based programs Enforcement/ legislation: Mandatory vaccine legislation Empowerment/ encouragement: Engaging religious or other influential leaders

Answer 13

Study of distribution and determinants of health-related states or events in specified populations, and application of this study to the control of health problems.

Answer 14

Study design * Randomization: selection method decides who is exposed and who is unexposed (e.g. random number generator) * Restriction: limit enrollment based on known cofounders (e.g., do not include alcohol drinkers) * Matching: based on potential confounders (e.g., match cohort based on age) Analysis * Stratification: by a particular variable (e.g. age, sex) * Standardization: such as standardizing for age * Multivariate analysis: control for multiple confounders using regression models

Answer 15

Real relationship between the exposure and the outcome and a third variable modifies the direction or magnitude of that effect Example 1: Individuals exposed to radon who smoke cigarettes have a much higher risk of lung cancer than individuals exposed to radon who do not smoke cigarettes Other examples: Smoking, alcohol drinking, and head and neck cancer -Smoking, asbestos, and mesothelioma -Smoking, uranium mining (or radon exposure), and lung cancer -Smoking, slow acetylator (due to variation in genes encoding detoxification enzymes), and bladder cancer -Aflatoxin, hepatitis infection, and liver cancer -Obesity, menopause status, and breast cancer -Smoking, oral contraceptives, and blood clots

Answer 16

o Method used to determine whether or not the relationship between an exposure and an outcome is due to a confounder or impacted by an effect modifier o Stratify the exposure and outcome by the potential confounder/effect modifier o If the relationship is not due to the confounder, then the incidence of the outcome will be higher in the exposed than in the unexposed in every stratum and the strength of the association will be similar in every stratum o If the relationship is impacted by an effect modifier, then the strength of the association will be different in every stratum o If the relationship is impacted by an confounder, then the pooled RR, or adjusted RR, will be different form the crude RR

Answer 17

Necessary cause mean that without the cause, the effect cannot occur, however, sometimes the causes can occur without the effect. For example, a pathogen, causing a disease. Sufficient cause means the effect must always occur when the cause is present. For example, decapitation causing death. Causation can be described as necessary and sufficient (X -> Y); necessary, but not sufficient (X+Z->Y); sufficient, but not necessary (X->Y, Z->Y), or neither sufficient nor necessary (X+Z->Y, Z+K->Y).

Answer 18

1. Is the microorganism found in all diseased organisms, and not found in all healthy organisms? 2. Can the microorganism be isolated and grown in culture from the diseased organism? 3. Can the cultured microorganism lead to disease when introduced into a healthy organism? 4. Can the same microorganism be isolated and cultured from the inoculated diseased organism?

Answer 19

SSPACCE-TB Strength: Large effect size Specificity: Single risk factor leads to single effect Plausibility: Biologically plausible Analogy: Similarities with other observed associations Coherence: New data agrees with existing evidence Consistency: Association is reproducible in different populations and settings Experimental: Association is demonstrated in experimental evidence Temporality: Exposure must always precede the outcome Biological gradient: Dose-response relationship,

Answer 20

2 x 2 table Outcome? Yes No Exposed 300 1200 1500 Unexposed 680 7820 8500 Total 980 9020 10000 Absolute risk in exposed: a/a+b = 300/1500 = 0.2 Smokers have a 20% risk of bowel cancer Absolute risk in unexposed: c/c+d = 680/8500 = 0.08 Non-smokers have a 8% risk of bowel cancer Relative risk: (a/a+b)/(c/c+d) = 0.2/0.08 = 2.5 Smokers are 2.5 times more likely to get bowel cancer compared to nonsmokers Risk difference: Incidence(exposed)-Incidence(unexposed) = 0.2-0.08 = 0.12 = 120 per 1000 cases Among smokers, 120 per 1000 cases of bowel cancer in the study are attributable to smoking. Among smokers 120 per 1000 cases of bowel cancer in the study could be prevented if smoking was eliminated. Among smokers, there was an additional 120 cases of bowel cancers per 1000 people compared to non-smokers. Attributable risk percent: [I(exposed)-I(unexposed)]/I(exposed) = 0.12/0.2 = 0.6 Among smokers, 60% of bowel cancer cases in the study were attributable to smoking. Among smokers 60% of bowel cancer cases could be prevented if smoking was eliminated. Population attributable risk: I(total)-I(unexposed) = (980/10000)-(680/8500) = 0.098-0.08 = 0.018 18 per 1000 cases of bowel cancer in the population are attributable to smoking. 18 per 1000 cases of bowel cancer in the population could be prevented if smoking was eliminated. Population attributable fraction: [I(total)-I(unexposed)]/I(total) = 0.018/0.098 = 0.18 Alternate population attributable fraction: [Pexposed*(RRexposed -1)] / [Pexposed *(RRexposed -1) + 1)] = [0.15 * (2.5-1)] / [0.15 * (2.5-1) + 1] = 0.225/1.225 = 0.18 18% of bowel cancer cases in the population were attributable to smoking 18% of bowel cancer cases in the population could be prevented if smoking was eliminated. NNT: 1/ARR (attributable risk) = 1/0.12 = 8.33 = 9 (always need to round up to the nearest whole number for NNT) 9 people would need to eliminate smoking in order to prevent 1 case of bowel cancer.

Answer 21

Odds ratio (OR): Probability of an event occurring relative to it not occurring. In case-control studies, the incidence of the disease in the exposed or unexposed is unknown (because the study starts by identifying cases). Calculation: Odds of disease in exposed (among cases)/Odds of disease in unexposed (among controls) = (a/b) / (c/d) = ad/bc Rare disease assumption: the OR approximates the RR when the outcome is rare. Summary: Relative Risk (RR): Use in cohort studies, RCTs, or when risks can be directly calculated. Preferred for intuitive interpretation, especially when the outcome is common. Odds Ratio (OR): Use in case-control studies, logistic regression, or when the outcome is rare. Also used when risks cannot be directly calculated.

Answer 22

2 x 2 table Disease? Yes No Test + a b Test - c d Sensitivity: Ability of a test to identify correctly those who have the disease when disease is present. Good to rule snOUT disease. Low false negatives. Will rarely miss people with the disease. a/a+c Specificity: Ability of a test to correctly identify those without a disease when disease is absent. Good to rule spIN disease. Low false positives. Will rarely misclassify people as having the disease. d/b+d False Negative Rate: c/c+d False Positive Rate: b/a+b Positive Predictive Value: Probability that an individual with a positive test actually has the disease. PPV increases as prevalence increases. a/a+b Negative Predictive Value: Probability that an individual with a negative test does not have a disease. NPV decreases as prevalence increases. d/c+d Likelihood Ratio: Combines sensitivity and specificity into a single figure that indicates by how much having a test result will reduce the uncertainty of making a given diagnosis. Positive likelihood ratio (LR+): Indicates how much more likely a person with the disease is to have a positive test result than a person without the disease. It expresses how much a positive test result increases the odds that a patient has the disease Calculation: sensitivity / (1 – specificity) Negative likelihood ratio (LR-): Indicates how much more likely a person without the disease is to have a negative test result compared to a person with the disease. It expresses how much a negative test decreases the odds of having it. Calculation: (1 – sensitivity) / specificity

Answer 23

Application of statistics to a wide range of topics including biology, medicine, and public health, where statistics is concerned with the collection, description and analysis of data.

Answer 24

Summarizing data, describe basic features of a sample

Answer 25

Bias is systematic difference between sample and population of interest due to study design, can be reduced by random sampling. Error is differences between sample and population of interest due to sampling variability, can be reduced by increasing sample size.

Answer 26

o Categorical -Non-numeric data -Describe using frequency tables, pie charts, bar graphs  Nominal: categories without any numerical ranking (e.g. country of residence, gender, blood type)  Ordinal: categories that can be ranked/ordered but are not necessarily evenly spaced (e.g., Likert scale, cancer staging) o Numerical variables -Describe using distribution, central tendency, and variability  Discrete: countable sets with meaningful distances between numbers (e.g., number of smokers)  Continuous: continuously varying quantities * Continuous 1: Interval: measured on a scale of equally spaced units, but without a true zero point (e.g. date of birth) * Continuous 2: Ratio: measured on a scale of equally spaced units and has a true zero point (e.g. height in centimetres)

Answer 27

The mean is not appropriate in cases of skewed data, outliers, ordinal/nominal data, or small sample sizes. The median is a robust measure of central tendency, especially for skewed data or data with outliers. However, it is not be appropriate for small sample sizes or nominal data. The mode is useful for identifying the most frequent value in a dataset, especially for categorical or discrete data. However, it is not appropriate for continuous data or small sample sizes.

Answer 28

1. Mean = median = mode 2. Shaped like a bell 3. 68% of values within 1 standard deviation, 95% of values within 2 standard deviations, 99.7% of values within 3 standard deviations 4. Perfectly symmetrical 5. Total area under the curve is 1

Answer 29

Type I error (α) AKA false positive: Error of rejecting the null when it is true. Once the significance level of the hypothesis testing is set, this is equivalent to the significance level Type II error (β) AKA false negative: Error of not rejecting the null when the null is false. Can prevent against this by sufficiently powering the study. Power = 1-β

Answer 30

Probability that difference between result and null hypothesis is due to chance. If the p-value is less than the set significance level (α), then we reject the null hypothesis.

Answer 31

Range that would contain the true population mean for 95% of the random samples obtained. AKA For every 100 samples drawn randomly from the population, we would expect 5% to produce point estimates outside of the CI by chance alone. If a confidence interval crosses 1.0, then it is not statistically significant.

Answer 32

o Simple random sample: each individual in population has an equal chance of being selected o Stratified sample: population first divided into strata, then simple random sampling is performed within each strata o Cluster sampling: each group has an equal chance of being selected; examine all units within the chosen cluster (done because it’s easier and simpler) o Multi-stage sampling: each group has an equal chance of being selected, then each individual within the selected group has an equal chance of being selected

Answer 33

Variance (random error) is that the impact on difference between observed and true values is unpredictable. Bias (systematic error) is where there is consistent deviation of results or inferences that impact on the difference between the observed value and true value in predictable manner (i.e. always occurs in the same direction). It is attributable to a specific cause

Answer 34

Validity is the degree of systematic error in a study (i.e., how closely do the results of a measurement correspond to the true value?) - Internal validity: degree to which the results of a study are not due to bias or confounding - External validity: degree to which the results of the study are relevant for populations other than the target population Reliability refers to consistency of a measurement or the amount of random error that occurs in making a measurement.

Answer 35

T-test: Used to compare 2 means -Paired T-test: comparing two normal populations using dependent samples (e.g. before/after, twins). -Independent T-test: comparing two normal populations using independent samples (e.g. placebo vs treatment, non-exposed vs exposed, control vs case) ANOVA test: Used to compare more than 2 means Chi Square test: Used to assess correlation for categorical variables, to compare whether the observed counts match the expected counts Kappa statistic (ϰ): Used to assess interrator reliability. ϰ > .75 denotes excellent reproducibility ϰ between 0.4 and 0.75 denotes good reproducibility ϰ < .4 denotes marginal reproducibility Pearson correlation: quantify association between two normal variables Spearman correlation: quantify association between two ordinal variables

Answer 36

Linear regression models the relationship between a continuous dependent variable (y) and one or more explanatory variables (x). Allows prediction of a dependent/outcome variable (y) from one or more independent variable(s) (x) - Simple linear regression: one predictor variable (x) - Multiple linear regression: multiple predictor variables (x1, x2, x3, …) Calculation: Y = β0+β1(X) + ε β0= intercept β1= slope of the line ε= random error Assumptions for linear regression:  Normality: for any fixed value of X, Y has a normal distribution around its mean  Constant variance: variance of Y is the same for any value of X  Independence: error values are statistically independent of another  Linearity: Y is a linear function of X (except for ANOVA)

Answer 37

Logistic regression models the relationship between a binary dependent variable and one or more explanatory variables -Used for discrete outcomes (usually nominal, binary, or dichotomous outcomes) -Output is odds ratio -Easy to interpret compared to slopes from linear regression! -Particularly useful for case-control studies -OR are always more extreme than RR, but if outcome rare than OR will be very similar to corresponding RR

Answer 38

Interaction is where the magnitude of the effect of one independent variable (X) on a dependent variable (Y) varies as a function of a second independent variable. Related to effect modification, interaction may be additive or multiplicative.

Answer 39

Addresses all the physical, chemical, and biological factors external to a person, and all the related factors impacting behaviours. It encompasses the assessment and control of those environmental factors that can potentially affect health. It is targeted towards preventing disease and creating health-supportive environments. It is a branch of public health that is concerned with all aspects of the natural and built environment that may affect human health.

Answer 40

Environmental epidemiology: study of effect on human health of exposure to physical, biologic, and chemical agents in the external environment and the related social, economic, and cultural factors o Limitations in detecting disease: -Long and variable latency periods -Etiologic non-specificity of disease clinical features -Small population size and low disease frequency -Observer bias in reporting illness -Interpretation of significance can be difficult, i.e., just because a specific toxic agent is present in the body does not mean that it contributes to any changes in structure/function o Limitations in measuring exposure: -Dependence on indirect measures (e.g., measurements from ambient environment rather than individual) -Surrogate estimates of exposure and dose -Uncertainty about pathways of exposure -Complexity when accounting for synergistic or antagonistic relationships of multiple chemicals -Probable low dose levels in most settings

Answer 41

Exposure: amount of substance encountered in environment over time Routes: inhalation, ingestion, skin, or by injection Duration: Acute vs. chronic

Answer 42

ADME Absorption: ability to pass into the body Distribution: transport throughout the body Metabolism: activation vs. detoxication Excretion: elimination from the body

Answer 43

Susceptibility: Ability of a living thing to be harmed by an agent. Influenced by genotype, age, gender, environmental factors (e.g., nutrition), and underlying state of health (e.g., immune status) Bioavailability: ability of a substance that enters the body to be liberated from its environmental matrix (air, water, soil, food); refers to properties of the matrix Bioaccumulation: progressive increase in the amount or concentration of a chemical in an organism or in an organ or tissue when the rate of uptake exceeds the rate of excretion or metabolism * Biomagnification: sequence of processes in an ecosystem by which higher concentrations are attained in organisms at higher levels in the food chain Biotransformation (intermediary metabolism): biochemical changes a chemical undergoes when it reaches cells of the body; metabolism may lessen toxicity (detoxification) or enhance it (activation)

Answer 44

Dose-response curve determines the relationship between dose and incidence of effects in humans. Dose: amount of agent deposited within the body following an exposure. Depends on the concentration of the chemical and the duration of exposure. Response: biological response to an agent Dose-response curve: dose along the x-axis, response (either as severity of response or % of individuals responding) along the y-axis S-shaped: most dose-response curves are S-shaped with a threshold value U-shaped: risk of adverse health outcomes with both low and high doses of the substance (e.g., iodine or other vitamins and minerals) Linear: no threshold dose (e.g., lead) Terminology - No-observed effect level (NOEL): highest dose at which there was no effect, experimentally derived. NOEL can be used to describe beneficial or harmful effects of a substance - No-observed adverse effect level (NOAEL): highest dose at which there is no observed toxic or adverse effect, experimentally derived - Lowest observed effect level (LOEL): lowest dose at which there was an effect. LOEL can be used to describe beneficial or harmful effects of a substance - Lowest observed adverse effect level (LOAEL): lowest dose at which there is a toxic or adverse effect - Threshold effect area: area between NOAEL and LOAEL - Effective Dose 50 (ED50) - Estimated dose at which substance has an effect for 50% of population. The specified “effect” can be harmful (tumour incidence) or beneficial (analgesia) - Lethal Dose 50 (LD50) - Estimated dose at which mortality would be expected to occur in 50% of population - Benchmark dose (BMD): Dose of a substance associated with a specified low incidence of risk of a health effect (generally range of 1% to 10%). Alternative to the NOAEL - Reference dose (RfD): Estimate of daily exposure to a human population that is unlikely to result in adverse health effects during a lifetime. Expressed in mg/kg/day for oral exposure and mg/m3 for inhalation - Estimated daily intake (EDI): Estimated total daily exposure to a substance from all exposure pathways; if EDI > RfD, individual is at risk of adverse health outcomes o Estimating Intake = (C x CR x CF x EF) / BW, where:  C = concentration of substance  CR = contact rate for exposure medium  CF = conversion factor (for units of measurement, if applicable)  EF = exposure factor (no units)  EF= (FxED)/AT  F= frequency of exposure (days/year); ED= exposure duration (years); AT= averaging time (ED x 365 days/year)  BW = body weight - Tolerable daily intake (TDI): Estimated total daily exposure to a substance that will not result in adverse health outcomes. Like an RfD for things you are not supposed to eat (e.g., phthalates) - Hazard quotient (HQ): Ratio of an exposure level (e.g., EDI) to a toxicity value (e.g., LOAEL, NOAEL) o <1, likely to be no appreciable risk of adverse health effect o >1, potential risk for adverse health effect - Toxicological reference value (TRV): Concentrations at which specific non-cancer adverse effects would not be expected for a defined period of exposure. Based on the threshold determined from toxicity experiments and usually incorporates an Uncertainty Factor (UF) or Safety Factor (SF) to account for uncertainties. UF/SF is a margin of safety to allow for inter and intraspecies variability.

Answer 45

National survey that collects general health information from Canadians. Most comprehensive, direct health measures survey conducted in Canada. Uses personal interviews and collects physical measurements. Provides baseline data on indicators of environmental exposures, chronic diseases, infectious diseases, fitness, and nutritional status, as well as risk factors and protective characteristics related to these areas - Physical measurements include such factors as height and weight, blood pressure, physical fitness and lung function measures - Many measures based on blood and urine samples including chemicals - Chemicals are selected based on one or more of the following considerations:  Known or suspected health effects  Level of public concern  Evidence of exposure in the Canadian population  New or existing requirements for public health action  Ability to detect and measure chemical in humans  Similarity to chemicals monitored in other national and international programs to allow for meaningful comparisons  Costs of performing the analysis

Answer 46

Provides a wide range of tools to manage toxic substances (e.g. limiting research, development, manufacture, use, storage, transport, disposal, and recycling) o Ensures the most harmful substances are phased out or not released into the environment in any measurable quantity o Environment Canada regulates toxic substances under CEPA o Guiding principles: - Pollution prevention: shift of focus away from managing pollution - Precautionary principle: "where there are threats of serious or irreversible damage, lack of full scientific certainty shall not be used as a reason for postponing cost-effective measures to prevent environmental degradation" - Virtual elimination: reduction to level below which release cannot be accurately measured - Sustainable (economic) development: clean, healthy environment and a strong, healthy economy that meets the needs of the present generation without compromising the ability of future generations to meet their own needs - Ecosystem approach: interrelationships between land, air, water, wildlife and human activities - Polluter Pays principle: users and producers of pollutants and wastes should bear responsibilities for their actions - Science-based decision-making - National standards - Intergovernmental cooperation

Answer 47

Health hazard: chemical, physical or biological factors in our environment that can have negative impacts on health Risk assessment: Systematic evaluation to determine if exposure to a hazardous agent may cause harm to human health. Not to recommend any particular decision, but to inform decision making Risk management: Evaluation of health, economic, technical, social & political context for management options, prescriptive (this is what you should do) Risk communication: Risk communication is the real-time exchange of information, advice and opinions between experts or officials and people who face a hazard or threat to their survival, health, or economic or social wellbeing We use a HIRA to assess health hazards.

Answer 48

HIRA = Hazard Identification and Risk Assessment Objectives: - Balance risks and benefits - Set target levels of risk - Set program priorities (e.g. public health, regulatory agencies) - Estimate residual risk after steps are taken Approach: - Collaborative, involving interested and affected parties - Flexible, incorporating new evidence as it emerges - Broad, considering all of the relevant perspectives (SDOH, social, political, economic, environment) Limitations: - Not helpful for determining individual risk Four steps: HI DR. EARC Hazard identification: Identifying whether the agent is responsible for the health problem, its adverse effects, the target population, and the conditions of exposure - Sources of data: biochemistry, in vitro tests, animal studies, epidemiologic data, environmental surveillance (air pollution monitoring, population-level blood levels, etc.) Dose-response relationship: Examine relationship between exposure and health effects to determine the lowest exposure level for a significant adverse effect to occur - Use thresholds (deterministic, NOAEL, LOAEL, BMD) for non-cancer events, and non-thresholds (stochastic, slope factor or unit risk) for cancer events and lead Exposure assessment: Estimating human exposure to a hazard along the exposure pathway (source of contamination, environmental media, location, target population, route, magnitude, duration of exposure)  Source of contamination: point, disperse  Environmental media: air, water, food, soil, product  Location: home, work, recreation  Target/vulnerable population  Route: ingestion, inhalation, dermal contact, IV  Magnitude and duration of exposure Risk characterization: Summary statement on extra risk of adverse health problems in the exposed, including major assumptions and level of uncertainty. - Can be quantitative (e.g., excess cancer risk of 3 in 100 million) or qualitative (e.g. high, medium, low) - Should describe the risk pathway (pathway from hazard to outcome in question)

Answer 49

TAGOPIE: T - Assemble Team: Establish roles and responsibilities, involve stakeholders, initiate risk communication A - Assessment: Identify the issue and the context (PESTLE), assess risks and benefits G + O - Goal and Objectives: Generate and compare options 1. Primary prevention: minimize exposure, prevent outcome (hierarchy of controls) 2. Secondary prevention: early detection of outcome (e.g., screening) 3. Tertiary prevention: mitigate effects of outcome (e.g., appropriate medical management, chelation) P - Plan: Select a strategy (6 E's, Hierarchy of Controls, Host Agent Environment) I - Implement E - Evaluate

Answer 50

Complete evidence of a potential risk is not required before action is taken to mitigate the effects of the potential risks. Actions should be consistent, accountable, proportionate, targeted, and transparent (CAPTT). Elements - Reasonable suspicion of harm - Scientific uncertainty about cause and effect - Duty to take action to prevent potential harm

Answer 51

Low hazard, high outrage = crisis communication High hazard, low outrage = precaution advocacy High hazard, high outrage = crisis communication Safe (non-outrage factors) - VICTOR: -Voluntary -Individually controlled -Certainty -Trustworthy -Old and familiar -Responsive Outrage factors - MUSIC: -Morally relevant + Memorable - Unfair - Scary/dreaded - Industrial - Catastrophic (as opposed to chronic)

Answer 52

International Agency for Research in Cancer Classification. Identifies environmental factors that can increase the risk of human cancer. Group 1 = carcinogenic to humans, adequate evidence in humans, sufficient evidence in animals. Examples: arsenic, cadmium, asbestos, ethanol, tobacco, radon, sun light, ionizing radiation, HPV, HBV, H Pylori, aflatoxin, iodine Group 2A = probably carcinogenic to humans, limited evidence in humans, sufficient evidence in animals. Examples: bitumens, DDT, inorganic lead, nitrates, night shift work Group 2B = possibly carcinogenic to humans, limited evidence in humans, limited evidence in animals. Examples: chloroform, gasoline, radiofrequency electromagnetic fields Group 3 = not classifiable as to its carcinogenicity to humans, inadequate evidence in humans, inadequate or limited evidence in animals. Examples: drinking water fluoride, crude oil, tannins

Answer 53

Cancer cluster: greater than expected number of cancer cases that occurs within a group of people in geographic area over a defined time period Cancer Cluster Investigation: TAGOP T - Assemble Team: epidemiologists, toxicologists, communications, provincial/federal environment ministry, engage community and stakeholders. Make initial contact and response: -Who, what, where, when, how -Reasons to stop investigation here: cases genetically linked, different cancers that are not related, cases did not live in the same geographic location during time of latency A - Assessment: Determine whether the suspected cancer cluster is a statistically significant excess. Calculate Standardized Incidence Ratio (SIR) and 95% confidence interval. - SIR > 1.0 and statistically significant -> continue investigation G+O - Goals and Objectives: Determine feasibility of conducting an epidemiologic study to look at association between cluster and particular environmental contaminant - Review scientific literature for plausible environmental exposures, identify appropriate comparison group, determine whether sufficient resources are available P - Plan: Conduct etiological investigation through epidemiologic study. Causation cannot be proved through study alone, use Bradford-Hill criteria. Or ISAFE I - Info gathering, initial investigation S - Standardized incidence ratio A - Assessment, review literature F - Feasibility study E - Etiologic investigation

Answer 54

1. Be first, be right, be credible, express empathy, promote action, show respect 2. Here's what we know, here's what we don't know, here's what we are doing about it, here's what you can do about it 3. Be open, honest, and transparent 4. Acknowledge uncertainty 5. Listen to the audience 6. Speak clearly and with compassion

Answer 55

For exam: Know 2 acute effects, 2 chronic effects, and whether there is cancer risk Heavy metals are chemicals typically found in the environment, coming from Earth's crust. Their presence in the environment has been increased through manmade activities like mining, fossil fuels. They are typically toxic at low doses. Arsenic: Odourless and tasteless. Acute health effects = nausea, vomiting, diarrhea, cardiotoxicity, encephalopathy, death. Chronic health effects = neurotoxicity, diabetes, IARC 1 for lung cancer. SCC Comes from groundwater, fossil fuels, agriculture. Exposure through ingesting food mainly, also drinking water, inhaling in industry. Can mitigate risk through food regulation. Cadmium: Soft silvery metal. Acute health effects = GI irritation, joint pain, kidney failure, death. Chronic health effects = nephrotoxicity, IARC 1 for lung cancer. Comes from forest fires, mining. Exposure through ingesting food and drinking water, inhaling in industry. Can mitigate risk through elimination, recycling instead of mining. Lead: Organic and inorganic forms. Acute health effects = nausea, vomiting, abdominal pain, encephalopathy, death. Chronic health effects = neurotoxicity (cognitive deficits), microcytic anemia, IARC 2A for inorganic lead. Comes from soil, mining. Exposure through ingesting food mainly, also drinking water with lead pipes, inhaling dust in environment. Can mitigate risk through replacing lead pipes, restricting lead in consumer products. Current blood lead intervention level is 10 ug/dL, but adverse effects can occur as low as 1-2 ug/dL. Drinking water limit is 5 ug/L (0.005 mg/L). Mercury: Organic and inorganic forms. Acute health effects = neurotoxicity. Chronic health effects = Mad Hatter's disease (personality changes), developmental issues with fetal exposure. IARC 2B for methylmercury. Comes from volcanic activity, fossil fuels. Exposure through ingesting predatory fish, inhaling in industry. Can mitigate risk through decreasing fossil fuels, limiting consumption of predatory fish to 150 g/week, 150 g/month if pregnant (shark, swordfish, tuna)

Answer 56

Volatile Organic Compounds are chemicals that readily evaporate into the atmosphere. They are precursors to ozone. Found in fires, animals, vehicle exhaust, building materials. Also found in burning chemically-treated wood. They cause eye, nose and throat irritation, as well as headaches and dizziness. Two examples are trichloroethylene (found in dry cleaning fluids, causes drowsiness, headaches, nephrotoxicity and kidney cancer) and benzene (found in crude oil, causes drowsiness, headaches, neurotoxicity and leukemia), both of which are IARC Group 1.

Answer 57

Endocrine disruptors are substances that interfere with the normal endocrine system in humans and animals. Examples include BPA (used to be in baby bottles), phthalates (in some children's toys, used to soften PVCs), DDT (also a POP), and PCBs (also a POP).

Answer 58

Persistent organic pollutants are synthetic substances that were common in industrial booms, that persist in the environment for long periods of time. They biomagnify in ecosystem. PFAS are a type of POP. Examples include PCBs, DDT, dioxins (also endocrine disruptors) and furans (also endocrine disruptors).

Answer 59

Radiation - energy that travels through space at the speed of light Non-ionizing radiation = microwaves, radio waves, visible light and UVA (aging) Ionizing radiation = UVB (burning), X-rays, gamma rays Radiation can cause health effects through stochastic and deterministic effects. Deterministic effects have a threshold (beyond which cell DNA is damaged beyond repair) and are dose-dependent. Stochastic effects are random, with varying severity that is independent of the dose, but increased probability of damage that is dependent on the dose. Stochastic effects do not have a threshold. Example 1: UV radiation. IARC Group 1 for SCC, BCC and melanoma. Prevention with sunscreen, avoidance during midday, clothing to cover skin, shade, sunglasses, hat, legislation to prevent youth using tanning beds, no direct sun exposure under 1, no sunscreen under 6 months Example 2: Radiofrequency EMF. IARC Group 2B. Causes localized heating of tissues. Causes electromagnetic hypersensitivity, characterized by nonspecific symptoms such as headache, memory changes, dizziness, sleep disturbances. Ubiquitous in modern day - radio, cell phones, wifi, MRI, bluetooth. Prevention by limiting children's exposure to devices, limiting use of devices, use of handsfree devices. Wi-fi is a non-risk. Example 3: noise (not radiation, but rather sound waves). Health effects above 40 dB include CVD, sleep disturbance, stress, hearing problems. Canadian recommendations <40 dB at night, <55 dB during daytime. Prevention through elimination (legislation), engineering (road barriers, quieter vehicles), PPE (ear plugs)

Answer 60

6 E's Economic: taxes, subsidies Enforcement: restrictions, regulations Education: awareness campaigns Environment: planning of where x can be implemented Engineering: technological advances

Answer 61

Traffic-related Air Pollution (TRAP): mixture of vehicle exhausts, secondary pollutants formed in the atmosphere, evaporative emissions from vehicles, and non-combustion emissions (e.g., road dust, tire wear) Components: carbon monoxide (CO), fine PM, VOCs, nitrogen dioxide (NO2), diesel exhaust, benzene PM and NO2 impair lung function. CO causes fatigue, dizziness, and neurological damage. VOCs cause irritation along the respiratory tract. PM is associated with lung cancer, benzene is associated with leukemia Vulnerable populations: young and elderly, pre-existing cardiac and respiratory diseases (e.g. COPD, asthma)

Answer 62

PM < 100 µm irritate mucus membranes, PM10 reach upper respiratory tract, Fine PM2.5 reach lower respiratory tract, Ultrafine PM0.1 reach alveoli

Answer 63

The Air Quality Health Index (AQHI) is a tool to communicate the excess mortality risk from PM, NO2, and O3. Each unit represents a 1% increase in mortality. 1-3 = Low Risk 4-6 = Moderate Risk (risk populations should consider reducing if having symptoms) 7-10 = High Risk (children and elderly should take it easy, risk populations should reduce time outdoors, general population should consider reducing if having symptoms) 11+ = Very High Risk (risk populations should avoid outdoors, children and elderly should avoid outdoor exertion, general population should reduce time outdoors) Special Air Quality Statement = AQHI 7+ for 1-2 hours Air Quality Health Advisory = AQHI 7+ for 3 or more hours

Answer 64

50% of wildfires are caused by lightning strikes, the other 50% are caused by manmade activity. Contributors: dry conditions, lack of precipitation, warm temperature, strong winds, air density (this last one can increase pollution). Pollution: Mainly from wildfire smoke which contains, PM2.5, NO2, VOCs, O3 Impacts: -Fires damage infrastructure and housing, and lead to soil erosion -Smoke contains many pollutants (above), PM2.5 can be inhaled deeply due to small size -Acute smoke exposure causes irritation of mucous membranes, runny nose, cough. Can also cause dizziness, shortness of breath, asthma attacks -Smoke exposure is associated with asthma exacerbation, COPD exacerbation, and premature death -Wildfires also affect mental health through PTSD, anxiety, depression High-risk populations in wildfires: -Young children and older adults, pregnant, disabled -Indigenous -Smokers -Rural/remote -Homeless/poverty/unemployed/low education -Outdoor workers -Pre-existing health conditions -Newcomers

Answer 65

Indoor air pollutants: mould, fungi, asbestos, dust mites, pollen, ozone, environmental tobacco smoke, radon, lead, bacteria Control through: controlling the source (cleaning, avoiding idling, controlling humidity), ventilation (HVAC, open windows), filtering the air (HEPA filters), policy to regulate air quality (Canadian Ambient Air Quality Standards, Health Canada's Indoor Air Reference Levels for Chronic Exposure to Volatile Organic Compounds), never burn pressure-treated or chemically treated wood.

Answer 66

Radon: Colourless, odourless, radioactive gas produced by the breakdown of uranium in soils and rocks. Undertake remedial measures when average annual concentration > 200 Bq/m³ (Becquerels per cubic metre). IARC group 1 for lung cancer, smokers at higher risk. Asbestos: Sources: cement, plaster, heating systems, building insulation, floor and ceiling tiles. Health effects are pulmonary fibrosis (asbestosis and pneumoconiosis), IARC Group 1 for mesothelioma. No risk if undisturbed. Mould/fungi: Moisture enables growth. Health effects include eye, nose and throat irritation, coughing, asthma, allergy. Aflatoxin is associated with liver cancer. Control by reducing humidity and ensuring no water damage/leakages/visible mould.

Answer 67

Climate change: statistically significant variation in the average state of the climate that persists for an extended period. Greenhouse gases (O3, NO2, CH4 (methane), CO2) are warming the Earth. Health impacts: - Increased food insecurity and malnutrition from reduced crop yields due to hotter temperatures and water shortages - Increased heat-related morbidity and mortality due to extreme temperatures. Also more extreme weather leading to injury and population displacement -Respiratory impacts of increased air pollution, due to many factors including increases in wildfires -Increases in waterborne diseases from flooding and sewage runoff, increase in marine algae blooms from warmer water -Increase in vector-borne diseases from mosquitoes and ticks extending range due to warmer temperatures -Increase in foodborne illness from more frequent warm days -Negative impact on mental health from stress of disasters and displacement -Increase in diseases of sun exposure (sunburn, skin cancer, cataracts) due to depletion of stratospheric ozone layer

Answer 68

Mitigation: Actions that aim to reduce emissions of greenhouse gases. Needed to prevent future anthropogenic interference with the climate system. Ex. carbon pricing to reduce high carbon practices and incentivize the development and use of low carbon technologies (through cap and trade or carbon tax) Adaptation: Actions that reduce impacts of ongoing and expected climate change on human communities. Needed now and can provide immediate and short term benefits. Ex. development of drought-resistant crops, emergency response planning for disasters.

Answer 69

One health is an approach to health that recognizes the interacting and synergistic relationships between human health, animal health and ecosystem health, and aims to optimize each of them.

Answer 70

Health: Not only the absence of disease or infirmity, but also the state of physical, mental and social wellbeing Wellness: Physical, mental, social and spiritual wellbeing that enables a person to achieve full potential and live enjoyable life. Illness: A person's subjective experience of feeling unwell Disease: Pathological process that may or may not produce symptoms that result in patient's illness Impairment: Any loss or abnormality of psychological, physiological, or anatomical structure or function Disability: Restriction or lack of ability to perform an activity in a manner or range considered normal for a human being, due to impairment Handicap: Disadvantage that results when a disability or impairment limits/prevents the fulfillment of a role that is normal depending on age, sex, and social/cultural factors for that individual Example: Stephen Hawking who’s motor neuron disease damaged his vocal cords (impairments) removed his ability to speak (disability), but as he is cognitively intact and his disability has not had a serious handicap for his career is as a theoretical physicist.

Answer 71

I EAT HEALTHYR I - Income and Social Status E - Employment and Working Conditions A - Access to Health Services T - Healthy Behaviours (Think "T" for "Take care of yourself") H - Housing + Physical Environments E - Education and Literacy A - Adverse Childhood Experiences L - Social Supports and Coping Skills (Think "L" for "Love and support") T - Biologic and Genetic Traits (Think "T" for "Traits") H - Gender (Think "H" for "He/She") Y - Culture (Think "Y" for "Your background") R - Race/Racism

Answer 72

Poverty: condition of a person who is deprived of the resources, means, choices and power necessary to acquire and maintain a basic level of living standards and to facilitate integration and participation in society. Canada's poverty rate is ~10% 3 measures of poverty: 1. Market Basket Measure - used to determine Canada's official poverty rate.  Based on the cost of buying things that represent basic standard of living, including clothing, transportation, shelter and other expenses 2. Low-income cut off - Income threshold below which families must devote 20% or more of disposable income on necessities (food, shelter, clothing) 3. Low-income measure - household considered low-income if its income is below 50% of median household incomes National Poverty Reduction Strategy (2018): Three pillars - dignity, opportunity and inclusion, resilience and security

Answer 73

Tree model Root determinants: Deeply embedded structural factors, and are considered to have the most profound influence on health. E.g. Colonization, Indian residential schools, Indigenous self-determination, Reserves Core determinants: Intermediate determinants. E.g. Criminal justice system, health care system, community infrastructure and resources Stem determinants: Immediate factors directly linked to health outcomes. E.g. Income, employment, food insecurity, access to safe drinking water Intersections: Social determinants intersect and jointly affect individuals, and there are cumulative effects of disadvantage on health Indigenous Self-Determination: Five principles - freedom, authority, support, responsibility, confirmation Cultural Resurgence: Through ceremony, language, traditional healing

Answer 74

Framework to understand individual health behaviours. 6 components: Perceived susceptibility - whether the person believes they are at risk Perceived severity - whether the person believes the disease is serious Perceived benefits - whether a person believes there are significant positive effects Perceived barriers - whether the person believes there are obstacles to a health action Cues to action - triggers that push an individual towards a a health action Self-efficacy - person's confidence in their ability to perform a health action

Answer 75

Stage Theory of Organizational Change 1. Awareness - Identify the problem and possible solutions 2. Adoption - Decide on a solution, ensure mid-levels are on board 3. Implementation - Organization-wide implementation of the solution 4. Institutionalization - Long-term maintenance of the solution

Answer 76

Stages: Diagnosis, Action-Planning, Implementation, Evaluation Concepts: Organizational climate - The personality and mood or the organization e.g. openness, level of conflict Organizational culture - the values, norms and behaviours of an organization e.g. "we work really hard" Organizational capacity - ability of an organization to function and meet its goals.

Answer 77

Process by which an innovation (policy, program, intervention) is shared and taken up within a system. - Innovators (2.5%): enthusiasts, risk takers. Encouraged by the idea of being “change agents” - Early adopters (13.5%): visionaries, opinion leaders, and trend setters, respected by peers - Early majority (34%): pragmatists, want reliable innovations, respond well to peer recommendations - Late majority (34%): conservatives, influenced by peer pressure, skeptical and cautious - Laggards (16%): skeptics, little contact with opinion leaders, desire to maintain status quo

Answer 78

Community engagement is a process of having community members participate in assessing, planning, implementing, and evaluating solutions to problems that affect them. 5 levels of community engagement (ICICE) I - Inform: Give community information C - Consult: Obtain community feedback on solutions I - Involve: Obtain community input on ideas C - Collaborate: Work together with community to make change E - Empower: Provide tools and resources to help community solve their own problems - Everyone is a stakeholder - Diverse voices contribute to better planning and decision-making - Engage under-served populations by reducing barriers to involvement - Engagement contributes to better health outcomes while building healthier workplaces and communities - Engage partners to find collective solutions that will lead to healthy communities - Engage with transparency and integrity in a way that builds trust with our communities and demonstrates accountability

Answer 79

Definition: approach to health that aims to maintain and improve the health of entire population while reducing inequities in health status among population groups. Key Elements: - Focus on the health of populations - Address the determinants of health and their interactions - Base decisions on evidence - Increase upstream investments - Apply multiple strategies - Collaborate across sectors and levels - Employ mechanisms for public involvement - Demonstrate accountability for health outcomes

Answer 80

LOFT o Legislation: mandated rules or directives that encouraged healthy behaviours or discourage high-risk behaviours o Organizational change: modifying behaviours in an organizational setting such as in a school or workplace o Fiscal measures: use of financial incentives to promote and maintain good health (e.g. Children’s fitness tax credit) o Taxation: levying of a tax on income or products (e.g. tobacco). It is one of the most powerful policy levers for influencing health at the population level Health in All Policies (HiAP): HiAP is a collaborative approach that integrates and articulates health considerations into policymaking and programming across sectors, and at all levels, to improve the health of all communities and people

Answer 81

ECCC-ECCI 1. Establish a sense of urgency 2. Create a powerful guiding coalition 3. Create a vision of change 4. Communicate the vision 5. Empower others to act on the vision 6. Create short-term wins 7. Consolidate improvements and produce more change I - Institutionalize the change, and anchor within the organizational culture

Answer 82

Population Health Assessment: Describes the health status of a community, including the SDOH -Planning -Data Collection -Analysis and Interpretation -Repot -Action Situational Assessment (Health Needs Assessment): Reviews the context and health needs of a community, considering SDOH -Planning -Data collection -Analysis and Interpretation -Report -Action Health Impact Assessment: Reviews the health effects associated with a non-health policy, program, or initiative -Screening -Scoping -Assessment/Appraisal/Analysis -Report -Monitoring and Evaluation Health Equity Impact Assessment: Reviews the effect on health inequities and disadvantaged groups associated with a policy, program or initiative. -Scoping -Potential Impacts -Mitigation -Monitoring -Dissemination

Answer 83

1. 5C's of a healthy community * Complete: mixed land use, availability of services and goods, healthy food options, schools, employment, public transit, and open green spaces * Compact: decrease land use by efficient planning * Connected: efficient and safe networks, direct routes to destinations, safe/complete streets * Cool: parks, trees, green spaces provide shade and improve air quality, making community cooler * Convivial: attractive and lively public spaces where people can easily connect with each other 2. Domains of a healthy built environment: Healthy Neighborhoods Need Food and Transit ● Housing - affordable, well-designed, and diverse housing options ● Neighborhood Design - land use focused on the 5 c's ● Natural Environments - preserves and connects the surrounding natural environment ● Food Systems - access and affordability of healthy foods through planning and design ● Transportation Systems - supports active transportation modalities

Answer 84

-Promote physical activity -High residential density -Connected streets -Place to walk and ride a bike -Close to stores, school and work -Attractive areas -Parks, green spaces and recreation facilities -Good public transit Provide healthy food options -Stores that sell healthy food nearby -Farmers' markets -Community gardens Create a supportive environment -Places to gather -Front porches, front yards -Good sidewalks -Access to attractive and green spaces -Cultural spaces, architecture, public art

Answer 85

Healthy built environment: Designing the manmade or modified physical environment where people live, work, study and play so that healthy choices are easier choices. Design features for specific populations * Children: traffic calming, limit access to unhealthy food near schools * Older adults: walkability for those with mobility issues, social isolation, benches to rest * Disability: good accessibility, safe streets, open spaces, low traffic density * Indigenous: challenges include lack of housing, safe drinking water, food availability, security, safety, access to health care Health impacts: decrased premature death decreased obesity, diabetes, CVD decreased cancer decreased mental health illness Actions: * Consider population health when developing and implementing major infrastructure projects * Avoid worsening health inequity by considering the needs and circumstances of populations experiencing inequities * Evaluate the health impacts of community design features by enlisting public health expertise * Strengthen existing approaches, share lessons learned and best practices * Collaborate to collect standardized data and engage citizens * Innovate so that the healthy choices are the easy choices

Answer 86

Objective: promote healthy eating, overall nutritional well-being, and support improvements to the Canadian food environment Health rationale: - Fibre reduces CVD, colon cancer, diabetes - Vegetables and fruits reduce CVD - Plant based protein and nuts  LDL cholesterol Recommendations - Have plenty of vegetables and fruits - Make water your drink of choice - Eat plant-based proteins - Choose whole grain foods - Be mindful of eating habits - Use food labels - Cook more often - Enjoy your food and eat meals with others - Be aware of food marketing - Limit foods high in sodium (<2300mg/day), free sugars (<10% total energy intake), saturated fat (<10% total energy intake), processed meat (none), red meat (Canadian Cancer Society recommends limiting to 3 servings per week) Fruits, Vegetables, Water, Whole Grains, and Plant-based Proteins Make (Mindful eating) Cooking Really (Read food labels) Enjoyable (Enjoy meals and eat with others) and Build Amazing (Be aware of food marketing) Lives (Limit sodium, free sugar and saturated fat) Other: Trans and saturated fats increase LDL and thus atherosclerosis which causes heart disease. Both fats are used to keep foods stable at room temperature, prolong shelf life, enhance flavour

Answer 87

Food security: exists when people have physical and economic access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life Monitor through National Nutritious Food Basket - monitors the cost and affordability of healthy eating in Canada through determining the cost of a group of foods that represent a healthy diet for a certain demographic

Answer 88

* Definition: sudden death of an infant < 1 year, cannot be explained despite investigation/autopsy * Risk factors - Non-modifiable: male, premature birth, low birth weight, poverty, Indigenous population - Modifiable: prone sleeping position, maternal smoking during pregnancy, exposure to second-hand smoke, overheating Prevention * Back to sleep campaign reduced SIDS by 50% * Safe sleep: supine, firm mattress, fitted sheet, no items in crib, room sharing, one-piece sleep wear

Answer 89

Benefits: Mother - Postpartum weight loss, decrease in breast and ovarian cancer, decreased metabolic disease, cost-saving, delayed ovulation Child - Improved bonding, transfer of immunoglobulins, decrease in infections, reduced atopy, prevention of diabetes/obesity/IBD, optimal nutrition, decreased SIDS, NEC Society - Cost savings from mother/child health benefits, less environmental impact Contraindications: -HIV with detectable viral load -HSV with active lesion on breast -Certain medications e.g. cytotoxic, radioactive -Ebola -Varicella -Active pulmonary tuberculosis while contagious

Answer 90

BFHI is an international program established by the WHO to help families make informed decisions about infant feeding and breaks down barriers to breastfeeding MAW BIRTHED - 6 Months exclusive breastfeeding - Avoid substitutes - Written policy - Baby-led feeding - In-to-out of hospital (seamless transition) - Rooming: keep mothers and infants together in room for 24 h - Training of staff - Help technique: assist with lactation - Education on importance of breastfeeding - Direct skin-to-skin contact in first hour of life

Answer 91

o No advertising of products (i.e., formula, bottles, nipples, pacifiers) to the public o No free samples to mothers o No promotion of artificial feeding products in health care facilities, including the distribution of free or low cost supplies o No company representatives to advise mothers o No gifts or personal samples to health workers o No words or pictures idealizing artificial feeding, including pictures of infants on the labels of products o Information to health workers should be scientific and factual o All information on artificial infant feeding, including the labels, should explain the benefits of breastfeeding, and cost and hazards associated with artificial feeding o Unsuitable products, such as sweetened condensed milk, should not be promoted for babies

Answer 92

Adverse Childhood Experiences (ACEs) Definition: negative, stressful, traumatizing events that occur before the age of 18 and confer health risk across the lifespan. The ten most studied ACEs are divided into three umbrella areas: - Abuse: emotional, physical, sexual - Neglect: physical and emotional - Household dysfunction: witnessing intimate partner violence, household substance abuse, mental illness, parental separation or divorce, having an incarcerated relative, death of a parent Epidemiology: 33% of Canadians aged 15 and older experienced some form of maltreatment during childhood Outcomes: graded, dose-response relationship between ACE and poor health - Mental health: depression, anxiety, suicide, PTSD - Maternal health: unintended pregnancy, pregnancy complications, fetal death - Infectious disease: HIV, STIs - Chronic disease: cancer, diabetes - Risky behaviour: alcohol abuse, drug abuse, unsafe sex - Missed opportunities: education, occupation, income - Other: early death

Answer 93

Comprehensive school health is an internationally recognized framework for supporting improvements in students’ educational outcomes while addressing school health in a planned, integrated and holistic way. - Social and Physical Environment - relationships, emotional wellbeing, building, play space, equipment, sanitation, air quality - Teaching and Learning - resources, activities, curriculum - Partnerships and Services - support student and staff health/well-being - Healthy School Policy - rules, procedures and management practices

Answer 94

Mental health: state of well-being in which the individual realizes their own potential, can cope with the normal stresses of life, can work productively, and is able to make a contribution to their community Mental illness: full range of patterns of behaviour, thinking or emotions that bring some level of distress, suffering or impairment in areas such as school, work, social and family interactions or the ability to live independently - At any time, 1 in 5 Canadians have a mental illness or addiction - By age 40, 1 in 2 Canadians have experienced mental illness

Answer 95

-Recommends screening for breast cancer with mammography if the patient would like it every 2-3 years from age 40-74 (used to be 50-74) -Recommends screening for lung cancer with annual low-dose CT x 3 in health care settings with expertise and diagnosis and treatment of lung cancer for people aged 55-74 with 30 pack year smoking history who currently smoke or quit smoking less than 15 years ago. Recommend against lung cancer screening with low dose CT for all other adults, and recommend against chest X-ray for lung cancer screening. -Recommends cervical cancer screening every 3 years for women aged 25-69. Recommends ceasing at age 70 or when 3 successive negative tests. -Recommends screening for colorectal cancer with FOBT every 2 years or flexible sigmoidoscopy every ten years for adults ages 50-74. Recommends not screening adults 75 and over, and not screening using colonoscopy. -Recommends against screening adults with chronic GERD for esophageal adenocarcinoma or its precursors -Recommends against screening all men for prostate cancer with PSA -Recommend against routine screening for depression in adults and subgroups of adults at increased risk of depression -Recommend against screening for depression in pregnancy and postpartum period for all individuals using a tool with cut-off scores -Recommends against instrument-based screening of asymptomatic older adults (≥ 65 years) for cognitive impairment -Recommends asking children and youth aged 5-18 or their parents about tobacco use opportunistically, and offering support accordingly -Recommends against screening nonpregnant asymptomatic adults for thyroid dysfunction -Recommends one time screening with ultrasound for abdominal aortic aneurysm for men aged 65 to 80. -Recommends blood pressure measurement to check for hypertension and interpretation according to CHEP recommendations at all appropriate primary care visits. -Recommends screening pregnant women with urine culture once in the first trimester for asymptomatic bacteriuria -Recommends opportunistic screening in primary care visits for chlamydia and gonorrhea for sexually active individuals under the age of 30 not belonging to high-risk groups using self-collected or physician collected sample. -Recommends against screening for developmental delay in children aged 1-4 with no signs or concerns of development issues -Recommends screening for diabetes type 2 for adults at high (q 3-5 y) and very high (q 1 y) risk. Recommends against routine screening for adults at low to moderate risk -Recommends screening to prevent fragility fractures with FRAX +/- BMD in women aged 65 and over. Recommends against screening for men, and for women aged 40-64. -Recommends against screening for HCV for adults who are not at increased risk - Recommends against primary care screening for impaired vision for community-dwelling adults aged 65 and over -Recommends against screening pelvic examination in asymptomatic women

Answer 96

Risk factors: - Tobacco use - Alcohol use - Unhealthy diets high in sugar - Low income Dental health interventions o Tooth brushing with fluoride toothpaste o Fluoride to prevent tooth decay. Sources include toothpaste, water, varnishes, mouth rinses, gels and foams, supplements o Promoting a well-balanced diet low in free sugars and high in fruit and vegetables, and favouring water as the main drink o Stopping use of all forms of tobacco, including chewing of areca nuts o Reducing alcohol consumption

Answer 97

Community Water Fluoridation (CWF) * Background: monitoring fluoride level in drinking water to optimal level for caries prevention, reduces the frequency of dental caries by 50% * Health benefits: inhibits tooth demineralization, enhances re-mineralization, inhibits enzyme activity of plaque bacteria * Potential harms: dental fluorosis, skeletal fluorosis, IARC Group 3 * Fluoride drinking water guidelines: MAC of 1.5 mg/L, based on prevention of moderate dental fluorosis (based on cosmetic effect, not health). Optimal concentration for dental health: 0.7 mg/L A growing body of evidence suggests that fluoride in drinking water may be associated with reduced IQ scores in children at fluoride levels that may be found in Canadian drinking water. Fluoride is a mineral found in the environment, mainly soil, food, can naturally be in water.

Answer 98

Leadership is developing a vision and inspiring others by giving them a why and directing them towards the vision. Management is organizing, planning, controlling and directing an organization's resources to achieve defined objectives. Involves day to day administration.

Answer 99

1. Servant leadership - Instead of people working to serve the leader, the leader exists to serve the people and invest in them 2. Authoritative (visionary) leadership - Inspiring, move people toward a common goal. Tells their teams where they're all going, but leaves it up to team members to find their way to the common goal 3. Coaching leadership - Connects people's personal goals with the organization's goals. Focused on developing others for future success 4. Coercive leadership - Autocratic approach depends on orders and often unspoken threat of punishment, and tight control. Use in crisis situations or with problem employees 5. Democratic (collaborative) leadership - Leaders focus on collaboration by actively seeking input from their teams, and they rely more on listening than directing

Answer 100

Represents the skills, behaviours, abilities, and knowledge required to lead all levels of the health system Lead self - self-aware, emotional intelligence, self-reflection, self-regulation, empathy, motivation Engage others - foster development, social skills, build teams Achieve results - set direction, take action Develop coalitions - build partnerships, navigate socio-political environments Systems transformation - demonstrate critical thinking, support innovation, champion change

Answer 101

- Consensus-reaching method - Repeated rounds of anonymous questionnaires sent to a panel of experts - Anonymous results of the previous questionnaire are provided to the panel between each round - Individuals can change their answers in light of this new information Strengths: - Rapid consensus can be achieved - Individuals are able to express their own opinions as opposed to “Group think” - Offers a method which can be used where data are lacking Weaknesses: - Does not cope well with widely differing opinions or large changes in opinions (paradigm shifts) - Differing opinions may not be sufficiently investigated

Answer 102

Benefits: - Improved organizational effectiveness - Aids decision-making - Promotes strategic thinking - Gives organization legitimacy Components: -Mission: Core purpose of the organization, the "why" -Vision: Statement of where the organization should go, "what we want to be" -Values: Beliefs and underlying assumptions that guide the organization -Strategic Directions: Broad objectives to achieve the mission and vision -Goals and Measures: Medium-term (3-5 yr) objectives that fit within the directions, should be SMART

Answer 103

TAGOPIE T - assemble Team: including staff, external partners (A MANIC HUG), community members, do stakeholder and PESTLE analysis A - Analysis: Stakeholder and PESTLE, then SWOT analysis (Internal strengths, internal weaknesses, external opportunities, external threats) G - Goals: Set strategic goals/directions O - Objectives: Set objectives under each strategic direction and also determine metrics for measuring success, aka performance oversight (could be a dashboard, scorecard, etc) P - Planning: Draft the strategic plan document and ensure agreement with key stakeholders I - Implement: finalize strategic plan and communicate internally and externally (e.g. annual reports E - Evaluate: Monitor progress using performance oversight framework

Answer 104

Thomas Killman Framework of Conflict Resolution Accommodating (Mexicoing): Lose-win. Unassertive and cooperative. Letting the other side get what they want, good when preserving the relationship is important. Avoiding (Britain and France in 1930-ing): Delay. Unassertive and uncooperative. Postponing discussion, good when more time is needed. Compromising (Canada-ing): Middle ground. Intermediate assertiveness and cooperativeness. Exchanging concessions, good when parties have mutually exclusive goals. Collaborating (EUing): Win-win. Assertive and cooperative. Work through differences, good for complex or important issues, and when one party cannot solve the problem alone. Competing (TRUMPing): Win-lose. Assertive and uncooperative. Imposes decisions, good when quick decision is required.

Answer 105

RIP NANIE R - Rules of engagement - honesty and clear communication are important I - Information gathering - let individuals express themselves P - Problem identification - meet with employees separately first N - Needs of all groups involved - find out what each side is hoping for A - Assess potential solutions - look for areas of agreement N - Negotiate one or more solutions with groups - make sure there is buy-in from all involved I - Implement solutions E - Evaluate and debrief - follow up to see how the parties are doing, ensure the conflict is resolved If conflict is not resolved, may need to consider coaching, performance evaluations, disciplinary action

Answer 106

Quality control: activities to test or inspect a product or service to identify problems before the product or service reaches the customer; “find it, fix it” (retrospective) Quality assurance: activities to identify problems in a process that might lead to problems with a product or service; “looking further up the line” (prospective) Quality improvement: continuous and ongoing effort to achieve measurable improvements in the efficiency, effectiveness, performance, accountability, outcomes, and other indicators of quality in services or processes which achieve equity and improve the health of the community

Answer 107

Six Sigma Goal: to eliminate defects in products and variation in process through continuous process improvement Lean: Goal: eliminate waste and increase efficiency in process through a systematic approach in identifying and eliminating waste (non-value-added activities) through continuous improvement

Answer 108

- A specific plan for the use of the organization's resources to pursue the strategic plan - Details specific activities to be undertaken to implement strategies - Annual plan for day-to-day management of the organization - Produced by CEO and staff

Answer 109

Budgeting: Estimation of revenue and expenditure over a set period of time, often defined as a fiscal year NB: Salary/Wages/Benefits is ~80% of budget o Zero-based budgeting: new budget is based on the justification of the expense, regardless of the amount budgeted in previous years o Incremental budgeting: new budget is the product of incremental, small changes to the previous budget o Program-based budgeting and marginal analysis (PBMA): Review budgets at the program level, identifies where funding could significantly improve program, and where loss of funding would have minimal impact on program, and allocates funds accordingly

Answer 110

Increase revenue or decrease expenditures. To increase revenue, can increase fees, sell capital assets, draw from reserves, or cash out investments To decrease expenditures, can decrease or modify number of staff, find efficiencies, freeze spending, or cut benefits. Can also consider global reductions (more fair but may make some programs unsustainable) vs targeted reductions (harder choices to be made, but strategic)

Answer 111

- Show strategic alignment between me and funder - Describe expected business outcomes - Give a problem statement - Describe the scope of the investment - Analysis - give different possible options including status quo, and explain why the option chosen is best - Show cost-benefit - Provide a schedule and implementation plan - Include a budget - Identify risks and show how you intend to mitigate it

Answer 112

Project charter: comprehensive overview of the project that is vital to ensuring that everyone are aware of the project’s purpose and objectives Components: - Scope and background - Goals and objectives (SMART) - Project governance (use RASCI matrix) - Key partnerships (Internal and external) - Key performance measures - Milestones, deliverables (with timelines) - Resources and costs - Risk analysis/mitigation, dependencies/ contingencies, assumptions, HEIA should be done Add on: Can use a Gantt chart as a visual depiction of project schedule

Answer 113

Logic model: Visual illustration of a program's resources, activities and outcomes Target Audience: Main population to be impacted by the program Inputs: Resources put in to program Activities/Processes: Planned activities/interventions to achieve program objectives Outputs: Immediate results at the program level through the execution of activities (LSEE absolute number) Outcomes: Short- or intermediate- results at the population level (LSEE percentage) Impact: Overall goal or long-term outcome the program hopes to achieve (LSEE rate or percentage)

Answer 114

Recruitment: Process of searching for and hiring candidates to fill a vacant position in an organization. Should include job evaluation - systematic process of assessing the value of jobs in an organization in order to determine the worth of individual jobs and the compensation to be paid to employees who hold those jobs. Ensures workers are paid fairly Hiring Steps: Write Job Description: Essential functions and qualifications needed to successfully perform a job. Helps employee to know what is expected of them. Job posting: Official advertisement for a job opening, used as a marketing tool to support recruitment. Review applications: With assistance of HR Interviews: Group, panel, or one-on-one Background check: Verify employment history Reference check: Job performance, workplace conduct Selection and decision: Ensure all relevant staff involved Job offer: Should contain salary, benefits, vacation, start date, etc. Onboarding Other considerations: -Document all decisions, rankings -Do not discriminate (race, ethnicity, gender, sexual orientation, age, marital status, family status, etc.

Answer 115

Employee performance management: Process for establishing a shared understanding about what is to be achieved and how it is to be achieved (align individual with organizational goals) 1. Engage high-performers - provide constructive criticism, recognize hard work. keep happy 2. Address poor performance. Can be due to: -Knowledge/skill deficiency -Workplace constraints -Interpersonal/behaviour issues -Personal challenges -Serious issues (violence, theft, fraud)

Answer 116

Process: 1. Performance planning - Set SMART goals 2. Coaching - help employee find their own way 3. Check-in - provide feedback, document progress 4. Performance assessment: Formal documentation, recognition Performance evaluations: 1. Objective: based on previously-agreed objectives 2. Narrative: written description 3. Competency: employee assess based on list of competencies 4. Multi-rater: 360 evaluation by multiple individuals

Answer 117

- Halo effect: employee’s strong performance in one domain falsely increases impression of overall performance; or the reverse, with weak performance - Recency effect: most recent performance influences entire assessment - High performer bias: highly rating a person who shows great potential, but has not yet met many of their goals - Past performance bias: outcomes of previous assessment influence current assessment - Status effect: rating a person based on their status within an organization, rather than their performance - Groupthink: Set aside own perspective and accept perspective of the group -Confirmation bias: rating a person in such a way to confirm own beliefs, such as incorrectly poorly rating employee after feeling disdain towards choice of attire

Answer 118

Before disciplining: -Gather information -Identify expectations -Identify issues, e.g. written warning that employee is not meeting job expectations -Identify solutions, e.g. training, supervision, instruction Plan: Set SMART objectives Monitor: After reasonable amount of time has been given, assess for improvement Evaluate: Formal documentation needed Above is good approach for incompetence, and if performance doesn't improve SHOULD dismiss quickly (if you don't dismiss you are condoning poor work performance and then can't use it as a reason for dismissal) When dealing with progressive discipline for misconduct take the following approach (with the exception that if severe - violence, fraud, theft - should immediately dismiss): 1. Verbal warning 2. Written warning 3. Suspension 4. Termination

Answer 119

1. Employment Equity Act - Encourages the establishment of working conditions that are free of barriers, corrects the conditions of disadvantage in employment and promotes the principle that employment equity requires special measures and the accommodation of differences for the four designated groups in Canada (women, Aboriginal peoples, persons with disabilities, members of visible minorities) 2. Employment Insurance Act - Outlines EI benefits and contributions. Designed to provide income protection for employees who are unemployed for various reasons. 3. Pay Equity Act - Federal employers should ensure employees are paid equally for work with is of “equal value” to the employer and not just for work which is substantially similar (considers the skill, effort, and responsibility of the employee)

Answer 120

Collective agreement - Contract negotiated between union and employer Collective bargaining - Process of negotiating collective agreement Conciliation - Process where officer meets with union and employer to try to finalize a collective agreement Mediation - Voluntary process where neutral third part assists union and employer to reach collective agreement, mediator makes non-binding recommendations Work stoppage - Through strike or lockout Arbitration - process where arbitrator makes binding and final decision to achieve collective agreement Ratification - Union members vote on collective agreement to bring it into effect Grievance - Written complaint alleging a contravention of the collective agreement Contingency planning for labour dispute: -Prioritize critical organization functions -Identify minimum staffing levels -Develop strategies to minimize labour disruptions

Answer 121

Types of public health communication o Health education: individual level o Social marketing: community level o Mass media campaigns: population level o Media advocacy and agenda-setting: policy level Considerations: speaker, audience, medium, message (SAMM)

Answer 122

Product - Core benefit of behaviour, goods or services being promoted for behaviour adoption Price - Monetary and non-monetary costs of the behaviour, aka perceived risks and barriers such as money, time, effort Place - Where and when the target will perform the desired behaviour Promotion - Persuasive communication to inspire the target audience to do the behaviour using various communication channels e.g. social media, signage and displays

Answer 123

Conflict of interest: personal, financial, professional, or political interests that may impact professional judgment or actions Approach: -Awareness -Identification and Disclosure -Evaluation -Manage

Answer 124

First Nations - OCAP Principles -Ownership -Control -Access -Possession Metis - OCAS -Ownership -Control -Access -Stewardship Inuit - Qanuippitaa (National Inuit Health Survey) -Inuit-determined -Inuit-owned -Strengths-based -Collaborative -Rigorous in methods -Innovative -Focused on Inuit health and social equity

Answer 125

Health equity is the absence of unfair systems and policies that cause health inequalities. Health equity seeks to reduce inequalities and to increase access to opportunities and conditions so that everyone has a fair opportunity to live a healthy life. Aka have health for all. Health inequity refers to health inequalities that are unfair or unjust and modifiable. For example, Canadians who live in remote or northern regions do not have the same access to nutritious foods such as fruits and vegetables as other Canadians.

Answer 126

Stereotyping (how we think): Happens when we view or judge an individual based on generalizations we make about their group Prejudice (how we feel): Holding a judgmental attitude and negative feelings toward a person, based solely on membership in a group Discrimination (how we behave): Treating someone differently because of their membership in that group Harassment (workplace): harassment and violence means “any action, conduct or comment, including of a sexual nature, that can reasonably be expected to cause offence, humiliation or other physical or psychological injury or illness to an employee, including any prescribed action, conduct or comment.” This includes all types of harassment and violence, including sexual harassment, sexual violence and domestic violence. Another definition: engaging in vexatious conduct (intention to harass) against a worker that is known or ought to be known to be unwelcome

Answer 127

Cultural awareness: Knowing that there are differences in other cultural groups and that those differences can affect health and wellbeing Cultural sensitivity: Recognizing the need to respect and consider cultural differences in interactions with others Cultural competence: Requires self-awareness, it is knowing the importance of different cultures’ impact on a patient’s perspectives, and adjusting approach accordingly to provide quality care Cultural safety: Safety goes beyond competence to advocate actively for the patient’s perspective and considers the broader socio-political and historical context. The patient/community decides whether the care provided is culturally safe. Other factors: Cultural humility: Process of self-reflection to understand personal biases and privilege Anti-racism: An approach to reduce power differences by uplifting oppressed racialized groups Trauma-informed care: Understanding root causes of a persons trauma and committing to provide services in a way that recognizes the special needs of those affected by trauma

Answer 128

APIP Assessment: Identify impact of health inequities and strategies to reduce them Partnerships: Work with government and community organizations to reduce inequities and improve health outcomes Intervention: Reduce inequities, with an understanding of the unique needs of populations who are marginalized Policy: Lead, support, participate, and advocate with other organizations in policy analysis and development

Answer 129

Internalized racism - Stigmatized race believes what society has assumed about them, and they act according to the stigma around them Interpersonal racism - Treating a person a certain race differently because of their race in person-to-person interactions. Often unintentional Systemic racism - Societal and organizational discrimination leading to a certain race facing disadvantage through inequitable treatment under the law, unfair policies, rules, and regulations. It is pervasive, subtle, and not always intentional. Race - A social construct used to judge and categorize people based on perceived differences in physical appearance in ways that create and maintain power differentials within social hierarchies. There is no scientifically supported biological basis for discrete racial groups. However, interpersonal and structural racism and discrimination create inequities in health care access, quality, experiences and outcomes. Ethnicity - A multi-dimensional concept referring to community belonging and a shared cultural group membership. It is related to socio-demographic characteristics, including language, religion, geographic origin, nationality, cultural traditions, ancestry and migration history, among others.11

Answer 130

Stigma is negative attitudes, beliefs or behaviours about or towards a group of people because of their situation in life. (Implicit bias refers to attitudes and stereotypes that occur unconsciously and inform our thinking, beliefs, and behaviours about social groups.) Impacts: - reduced access to care and social services - increase in chronic stress/poor coping - puts stigmatized people at higher risk of assault Outcomes: -anxiety, depression, suicide -CVD, hypertension, injury -Decreased birth weight, prematurity

Answer 131

IME: Foreign nationals (except refugees) can be inadmissible if likely to be a danger to public health, public safety, cause excessive demand on health or social services 1. Active tuberculosis screening with Chest X-Ray, to be treated before arrival 2. Urinalysis for CKD screening, may be reason to be deemed inadmissible 3. Syphilis, to be treated before arrival 4. HIV, may be a reason to be deemed inadmissible Other preventions to consider: Vaccination: MMR, Varicella, Tdap, Hep B if susceptible/incomplete records Screening: Hep B, Hep C, HIV, syphilis, intestinal parasites, diabetes, iron-deficiency anemia, depression, dental disease

Answer 132

A community set up to help seniors live safely, enjoy good health and stay involved. Key characteristics: - outdoor areas and public buildings are pleasant, safe and accessible - housing is affordable, safe and well designed for seniors - roads and walkways are accessible and kept in good shape - public transportation is affordable and accessible - neighbourhoods are safe - relationships are respectful - health and community support services are available - opportunities for seniors to be socially active exist - seniors can take part in volunteer, political and employment positions

Answer 133

ACAFVIE (sounds like "a café vibe") - Acknowledge that current Indigenous health is the result of government policies - Close health gaps and publish reports in consultation with Indigenous people - Address off reserve FNIM distinct health needs - Fund Indigenous healing centres - Value Indigenous healing practices and use them when requested, with healers - Increase number of Indigenous health providers, retain in Indigenous communities, and require cultural competency training for all HCPs -Educate students on Indigenous issues

Answer 134

APDIE (Problem Identification) Agenda-setting Policy formulation Decision-making Policy implementation Policy evaluation

Answer 135

U EFACED Unintended effects: What are the unintended effects of this policy? Effectiveness: What effects does the policy have on the targeted health problem? Feasibility: Is this policy technically feasibly? Acceptability: Do the relevant stakeholders view the policy as acceptable? Cost: What is the financial cost of this policy? Equity: What are the effects of this policy on different groups? Durability/sustainability: capacity of policy to be sustained over time and continue producing effects

Answer 136

o Community activism: enable communities to address the causes of poor health at a policy level o Social policy reform: champion legislative reform that redresses health inequities o Community development: enable individuals to identify and address their own needs o Representational/client advocacy: representing the rights and interests of those unable to represent themselves

Answer 137

PC DS DR (Piece 'dis (together), doctor!) 1. Pre-planning and project management - assemble team, create work plan, timeline, roles and responsibilities 2. Conduct a situational assessment - planning, data collection, data interpretation and analysis, reporting, action 3. Develop overall program objective - SMART goal, include audience and desired outcomes 4. Select strategies and activities - create your logic model, determine activities, outputs 5. Develop indicators - process and outcome indicators, they should be specific, observable and measurable 6. Review and adjust the program plan

Answer 138

Cost-benefit analysis: Determine if monetary valuation of an intervention benefits exceeds its cost, and its magnitude. Measured in dollar, and expressed as a ratio or difference. Can use to compare different health and non-health interventions. Not as commonly used in healthcare. Cost-effectiveness analysis: Compare health interventions with the same health objectives. Usually compares new intervention to accepted intervention. Outcome is ICER. Downside is can only look at the same health outcome. Cost-utility analysis: Sub-type of CEA used when focus is on quality of life or if treatments have many outcomes. Measured in $/QALY. Creates a common unit that can be used to compare different health outcomes. NB. <$20,000/QALY considered excellent value, >$50-80,000/QALY considered poor value.

Answer 139

Knowledge translation (KT) is the process of taking findings and ensuring they are effectively shared, understood, and applied in real-world settings to improve policies, practices, and outcomes.

Answer 140

o Policy proposal: submitted to and considered by Cabinet; if Cabinet approves, a bill is drafted o First reading: presentation of the bill to the House of Commons o Second reading: debate of the principle of the bill; if the principle is adopted, it moves to committee o Committee: hears witnesses, examines the bill clause by clause, and suggests amendments o Report stage: committee reports its amendments to the House of Commons; House votes for or against amendments o Third reading: amended bill is reviewed in the House of Commons for the final time (debate, then vote) o Senate: bill goes through first, second, committee, and third readings again within the Senate o Royal Assent: given by the Governor-General and bill becomes a law

Answer 141

Executive branch - Enforces and applies the law Judiciary branch - Interprets and upholds the law Legislative branch - Makes the law

Answer 142

International Health Regulations (IHR): A series of regulations agreed to by WHO member states that enables to prevention, control, and response to international public health emergencies. Requires capacity for surveillance and response, and immediate reporting to WHO of potential emergencies of international significance. Smallpox, new subtype of human influenza, SARS, and wild-type polio must be reported. Otherwise report when 2 of the following 4 criteria are met: -Event is unusual or unexpected -Event has serious public health impact -Event has significant risk of international spread -Event has significant risk of international travel or trade restrictions Potentially notifiable diseases: Plague, cholera, VHF (e.g. ebola, Marburg, yellow fever, dengue) Framework Convention on Tobacco Control (FCTC): Created to have international coordination for tobacco control. Specific steps outlined in MPOWER: M: Monitor tobacco use and prevention policies P: Protect people from tobacco smoke O: Offer to help quit tobacco use W: Warn about the dangers of tobacco E: Enforce bans on tobacco advertising, promotion, and sponsorship R: Raise taxes

Answer 143

 Universality: all eligible residents are entitled to uniform health insurance coverage  Public administration: health insurance plan must be administered by a non-profit, public authority  Portability: coverage for insured services must be maintained when an insured person moves within Canada  Accessibility: insured persons must have reasonable access to necessary hospital and physician services and may not be impeded by financial or other barriers  Comprehensiveness: all medically necessary services provided by hospitals and doctors must be insured

Answer 144

Emergency Act: Authorizes the taking of special temporary measures to ensure safety and security during national emergencies. Gives the federal government powers to regulate travel, evacuation, and establish emergency hospitals. Power to compel action to prevent the spread of disease -PIPEDA: Applies to federally regulated organizations across Canada that collect, use or disclose personal information. People have the right to access their personal information held by an organization. Public Safety Act: Empowers the Minister of Public Safety and Emergency Preparedness to issue interim orders if there is a significant risk to health or safety Quarantine Act: Protects public health by taking comprehensive measures to prevent the introduction and spread of communicable diseases. Authorizes the Minister of Health to establish quarantine stations and quarantine facilities anywhere in Canada

Answer 145

o First Nations on-reserve, inclusive of First Nations who have assumed responsibility for health services under a transfer agreement o Active members of Canadian Forces o Federal offenders or inmates of federal penitentiaries o Refugee claimants, protected persons, detainees under the Immigration and Refugee Protection Act, and rejected refugee claimants o Canada-based staff at missions abroad

Answer 146

o Social insurance fund: publicly financed system; government collects premiums from citizens specific for use in healthcare (contrast to Canada’s usage of general taxes). This form of financing is used to fund workers’ compensation o Co-payments: healthcare payment is partly financed by the public sector and partly financed through either out-of-pocket payments or private insurance o Group-based publicly funded coverage: certain population sub-groups are eligible for publicly-covered health care; the rest of the population must pay out-of-pocket or through private insurance o Sectoral coverage: certain health care sectors are publicly covered, while the rest are not o Parallel public and private systems

Answer 147

Privacy: An individual’s right to be free from intrusion or interference by others Confidentiality: The duty or obligation to protect entrusted information from unauthorized access, use, disclosure, modification, loss, or theft Personal Health Information (PHI): Any identifiable information about an individual, written or verbal, that relates to the provision of health care

Answer 148

CALI-SOCIAL Consent - Knowledge and consent of the individual are required for the collection, use, or disclosure of personal information Accountability - Organization responsible for personal information and must appoint someone to be accountable Limiting collection - Collection of personal information must be limited to that which is needed for the purposes identified Identify purpose - Purposes for which the personal information is being collected must be identified Safeguards - Personal information must be protected by appropriate security mechanisms Openness - An organization must make detailed information about its policies and practices relating to the management of personal information publicly and readily available Challenging compliance - An individual shall be able to challenge an organization’s compliance with the above principles (usually their Chief Privacy Officer) Individual access - Upon request, an individual must be informed of the existence, use, and disclosure of their personal information and be given access to that information Accuracy - Personal information must be as accurate, complete, and up-to-date as possible Limiting use, disclosure, and retention - Personal information can only be used or disclosed for the purposes for which it was collected

Answer 149

RCNRD Respond: Notify relevant staff Contain: Secure PHI Notify: All affected individuals, and notify of extent of breach Remediate: Review circumstances, update existing policies/procedures/training as appropriate Discipline: If liable may face fine

Answer 150

Comprehensive, collaborative, compassionate and evidence-based approach to drug policy 4 Pillars: -Prevention and Education -Substance use services and supports (treatment and harm reduction) -Evidence (research) -Controls (enforcement) All supported by a strong evidence base

Answer 151

-25% of youth engage in high risk drinking behaviour -Opioid-related hospitalizations have been increasing among young adults -Youth use substance for the social aspect (#1) and to cope with stress (#2) -Youth are more likely to use cannabis than adults Interventions should: -Target primordial factors like poverty and housing -Promote positive social norms -Help youth develop resilience and skills -Come early for youth that need support

Answer 152

Harm reduction: policies, programmes, and practices that aim to minimize negative health, social and legal impacts associated with drug use, drug policies and drug laws Examples: -Needle exchange programs -Safe injection sites -Naloxone kit programs -Drug checking services -Managed alcohol programs Core principles: FUSION - Focus on harm: decreasing negative impacts rather than eliminating use - Understand: use occurs for range of reasons - Support: non-judgmental, respect for autonomy - Involve: empower people who use drugs - Options: recognize variety of approaches - Needs met: meet people where they are

Answer 153

Short-term: Alcohol poisoning, violence, injuries/risky behaviour Long-term: Liver cirrhosis, hypertension, cancer (oral, pharyngeal, laryngeal, esophageal, liver, breast, colon, rectum) low birthweight, prematurity, FASD, hepatitis, pancreatitis, neuropathy

Answer 154

Low-risk drinking guidelines: max 10 drinks per week for women, max 15 drinks per week for men Canada's guidance on alcohol and health: 0 drinks per week - safest 1-2 drinks per week - low risk 3-6 drinks per week - moderate risk, increased risk of cancers 7+ drinks per week - high risk, increased risk of heart disease and stroke Additionally: -No safe amount of alcohol in pregnancy -Not drinking while breastfeeding is best -Drink lots of water while drinking -Eat before and while drinking -More than two drinks per occasion has increased risk of harm including violence and injuries

Answer 155

High-impact strategies that can help governments to reduce the harmful use of alcohol and related health, social and economic consequences S - Strengthen restrictions to alcohol availability A - Advance and enforce drunk driving counter measures F - Facilitate access to screening, brief interventions and treatment E - Enforce bans or strict restrictions on alcohol advertising, sponsorship and promotion R - Raise prices on alcohol through excise taxes and pricing policies

Answer 156

- The prevalence of current cigarette smoking among Canadians aged 15 years and older in 2022 was 11% - In 2022, the prevalence of current cigarette smoking among youth aged 15 to 19 years was 4% - Higher rates in Indigenous populations, LGBTQ+, young men aged 20-24, and construction workers - Tobacco is the largest single cause of premature death globally - Smoking tobacco accounts for 85% of lung cancer in Canada - Laryngeal, esophageal, oral, nasopharyngeal, stomach, colorectal, liver, pancreatic, ovarian, kidney, bladder cancers as well - In fetus/infants: Stillbirth, premature birth, low birth weight, sudden infant death syndrome - In children: Asthma exacerbation, pneumonia, bronchitis, leukemia, lymphomas, brain tumours, otitis media

Answer 157

- In 2022, youth (15 to 19) and young adults (20 to 24) have the highest rates of ever vaping, 30% and 47.5% respectively - The most common reasons for vaping among youth aged 15 to 19 years were to reduce stress , for curiosity, and because they enjoy it. Among adults aged 25 years and older, the most common reasons were smoking cessation and to avoid returning to smoking. - Vaping nicotine was increased amongst those with less than a university degree, those who identified as a visible minority, those who identified as Indigenous, those who were not heterosexual, and those who rated their mental health as fair or poor - Nicotine is highly addictive and can lead to dependence and nicotine addiction - Can affect memory and concentration, it can alter teen brain development through reduced impulse control/cognitive and behavioural problems - E-cigarette use is associated with subsequent smoking initiation among youth and young adults - Second-hand vapour: health effects are unknown. E-cigarette use increases airborne concentrations of particulate matter, nicotine and other toxicants in indoor environments compared with background levels -EVALI: Hundreds of cases and several death. No cause found in Canada. Vitamin E acetate was the cause in the US - Novel nicotine products: Includes electronic nicotine delivery systems (ENDS aka vapes), heated tobacco products, and nicotine pouches, amongst others. - In July 2023 Health Canada approved Zonnic, a nicotine pouch, under the Natural Health Products Regulations as a nicotine replacement therapy - This approval led the pouches to be sold without adhering the Tobacco and Vaping Products Act, which meant there was no age restriction, no plain and standardized packaging requirements, no restrictions of promotions and product displays, and no flavour restrictions - Advocacy from various health organizations led to Minister of Health introducing new measures for NRT to decrease recreational use amongst people who do not smoke, particularly youth, in August 2024. The measures include: - Prohibit advertising or promotion, including labelling and packaging, that could be appealing to youth. - Require NRTs in new and emerging formats, such as nicotine pouches, to be sold only by a pharmacist or an individual working under the supervision of a pharmacist, and to be kept behind the pharmacy counter. - Prohibit NRTs in new and emerging formats, such as nicotine pouches, from being sold with flavours other than mint or menthol. - Require a front of package nicotine addiction warning, as well as a clear indication of the intended use as a smoking cessation aid for adults trying to quit smoking.

Answer 158

- 40% of Canadians report ever using cannabis; 10% report use in the last year - Age of initiation is 16 - 1 in 6 youth who use will develop a cannabis use disorder Legalized in 2018 to protect youth, reduce judicial burden, protect public from black market and promote research Health impacts: - Reduced cognitive function - Psychosis - Addiction/dependence - Depression/anxiety - COPD - Hyperemesis - Injury

Answer 159

F-IRONCLADS Frequency - limited Inhaling deeply - avoid Risky behaviour - avoid Operating vehicles or heavy machinery - avoid Natural - no synthetic Contraindicated populations - pregnant, personal/family history of psychosis or substance use disorder Low strength, low THC Abstinence is best Delay until after adolescence Smoking - avoid

Answer 160

- Opioid related hospitalizations and deaths in Canada are on the rise - Most deaths occurred among males aged 30-39 - Indigenous and people with mental health conditions are at increased risk for opioid toxicity and death Health effects: respiratory depression causing death, addiction, constipation, injuries from falls and road accidents -When starting opioid-naive patients on opioids for chronic non-cancer pain, do not exceed 90 mg morphine equivalents daily, ideally less than 50

Answer 161

o Prevent overdose deaths o Facilitate entry into drug treatment services o Reduce the risk of disease transmission (such as Hepatitis C and HIV) caused by unhygienic practices, such as needle sharing o Reduce public disorder o Prevent public consumption of illegal substances o Prevent consumption equipment being discarded in community o Connect people who use drugs with basic health and social services (drug treatment, counselling, withdrawal management, access to detoxification for people that are ready and willing to seek treatment, housing services) o Reduce impact on Emergency Medical Services attending to drug overdoses

Answer 162

Primordial prevention - prevent risk factors for disease by modifying social determinants of health. E.g. improved sanitation, early childhood development programs, basic income Primary prevention - prevent the onset of disease. E.g. Vaccination programs, fluoridation, smoking cessation (to prevent lung cancer) Secondary prevention - prevent disease progression through early diagnosis. E.g. cervical cancer screening, colonoscopy, mammography Tertiary prevention - minimize impact of disease on patient function and quality of life. E.g. cardiac rehab, weight loss for diabetes

Answer 163

Universal approach - Apply the same intervention to an entire population. Targeted approach - Apply the intervention only to priority groups, e.g. equity-seeking groups Targeted universalism - Everyone is offered the same intervention, but steps are taken to promote the intervention to high-risk groups Proportionate universalism - The intervention is modified based upon the risk level of the group involved (e.g. various levels of support for new mothers ranging from a phone call to home visiting services)

Answer 164

- Demographic transition: evolution from high to low fertility and mortality rates, decrease in the proportion of children and young adults and an increase in the proportion of older persons in the population - Epidemiologic transition: shift from mortality primarily caused by infectious disease to mortality primarily caused by chronic disease

Answer 165

- Greatest burden of disease is mental health, cancer, cardiovascular disease (including) For cancer, in 2024: -45% (2 in 5) of Canadians will be diagnosed with cancer in lifetime -Most common cancers are 1. lung, 2. breast, 3. prostate, 4. colorectal -22% (1 in 4) of Canadians will die from cancer -Most common cancer mortality is 1. lung, 2. colorectal, 3. pancreas, 4. breast, 5. prostate -economic burden of cancer will continue to increase -Leading causes of cancer: number one is smoking (22% of cancers), others are HPV, HBV, HCV, schistosomiasis, EBV, HIV, alcohol, radiation, H. pylori, arsenic -Skin cancer incidence is increasing Amongst Canadians ages 65 and over in 2021: -Most common chronic diseases are 1. hypertension, 2. periodontal disease, 3. osteoarthritis, 4. ischemic heart disease, 5. diabetes Amongst Canadians ages 20 and over in 2021: -Most common chronic diseases are 1. hypertension, 2. osteoarthritis, 3. mood or anxiety disorder, 4. osteoporosis, 5. diabetes For mental health in 2012: -1 in 3 will be affected by mental illness in lifetime Top causes of death (2022): 1. cancer 2. heart disease 3. covid-19 4. injury 5. cerebrovascular disease (CVD)

Answer 166

Burden of disease: measure of the severity of a health setback for an individual or population, measured by cost, mortality, morbidity, and other key indicators Challenges: Temporality - Long disease latency makes it difficult to attribute causality Disease course - Protracted disease course with exacerbations and remissions Cause of disease - Often no single cause; complex interaction of triggers and risk factors Data sources - Databases usually not designed for surveillance Data collection - Event-oriented (e.g., hospitalizations, primary care visits) rather than person-oriented Comorbidity - Common and important for service planning; treating one comorbid condition often impacts another Authority - With the exception of cancer registries, no legislated authority to collect chronic disease data (unlike reportable diseases)

Answer 167

Screening - Systematic process to identify individuals with a disease in asymptomatic phase Wilson and Jungner criteria: NIL AS AP FOE Disease (NIL): Natural history known Important health problem Latent/early symptomatic stage Test (AS): -Acceptable test -Suitable test Treatment (AP) -Acceptable treatment -Policy on who to treat System (FOE) -Facilities available for treatment -Ongoing screening occurs -Effective from cost perspective (cost-effective) Other things to consider (Andermann 2008): -Defined target population -Scientific evidence of effectiveness -Quality assurance to minimize risk of harm -Informed choice, confidentiality and autonomy -Equity -Plan for programme evaluation -Benefits outweigh the harms

Answer 168

CRAASSS C - Cost-effectiveness (QALYs/DALYs) R - Repeatability (consistent results) A - Accuracy A - Acceptability S - Sensitivity S - Specificity S - Simplicity (easy to perform and interpret)

Answer 169

- Selection bias: healthy people more likely to be screened - Lead-time bias: overestimate survival because the cancer is diagnosed earlier in the natural history of the disease but the patient still dies of the cancer - Length-time bias: overestimate survival by only detecting slowly progressing disease Overdiagnosis bias: Severe case of length-time bias where cases that would not cause death are detected, leading to overestimate of survival

Answer 170

1. Lung cancer -Small cell is linked to smoking, fast-growing -Risk factors are tobacco smoke, radon, air pollution particulate matter, occupational exposures, and other toxin exposures 2. Breast cancer -1 in 8 women will be diagnosed, 1 in 33 women will die from it -Mostly in women over age 50 -Risk factors are female sex, early menarche, late menopause, first pregnancy after 30, family history, BRCA1/BRCA2/HBOC, alcohol, HRT 3. Colon cancer -90% are adenocarcinomas -Risk factors are IBD, age over 50, male sex, family history, familial disease such FAP and Lynch syndrome, diet high in red meat, polyps, alcohol, obesity, sedentary lifestyle 4. Prostate cancer -1 in 9 men will be diagnosed -Risk factors are age, family history, African ancestry, diet high in red meat, family history, hereditary genetic mutation Cervical cancer -Incidence decreasing due to Pap smears -70% of cervical cancers are caused by HPV Type 16 and 18 -Risk factors are young sexual debut, multiple sexual partners, partner with multiple sexual partners, smoking, immunosuppression, multiparity -One dose HPV recommended for age 9-20, two dose for age 21-26

Answer 171

- In Canada, almost two in three adults and one in three children and youth are overweight or living with obesity. - One in three adults are obese - Interventions to prevent: - Individual level: behaviour modification, improved diet, physical activity, bariatric surgery - Community level: social marketing, school based intervention, menu labelling, work-based programs for adults - Policy: subsidy program for health food or physical activity, urban planning, regulate food advertising, taxation, zoning unhealthy food Metabolic syndrome: Clustering of 5 risk factors that increase a person’s risk of CVD and diabetes - increased waist circumference - increased blood pressure - increased plasma triglycerides - increased fasting blood glucose - decreased high-density lipoprotein

Answer 172

Cardiovascular disease precursors: hypertension, diabetes, dyslipidemia, obesity Cardiovascular disease outcomes: ischemic heart disease, myocardial infarction, stroke, arrhythmia, heart failure Risk factors: smoking, poor diet, sedentary behaviour, age, sex, family history, ethnicity, education level, income Interventions: CHEP guidelines for hypertension health behaviour management: o Alcohol consumption: reduce or abstain from alcohol consumption to prevent hypertension o Physical activity: 30-60 minutes of moderate-intensity dynamic exercise 4-7 days per week (150 min per week, 60 min a day for children/youth, 180 min per day of any activity for preschoolers) - NOTE: Moderate = walking quickly, cycling, Vigorous = running, basketball, soccer o Weight: maintain a healthy body weight (BMI: 18.5-24.9, and waist circumference < 102 cm for men and < 88 cm for women) o Diet: consume a diet that emphasizes fruits, vegetables, low-dairy fat products, whole grain foods rich in dietary fibre, protein from plant sources o Sodium: reduce sodium intake toward 2000mg a day o Smoking: advise patients to quit smoking o Stress: reduce stress if it is present

Answer 173

Dementia risk factors: Low education, midlife hypertension, obesity, hearing loss, smoking in later life, depression, physical inactivity, diabetes, social isolation National Dementia Strategy: - Prevention through research and awareness of modifiable and protective factors, effective interventions - Advanced therapies and find a cure - Improve the quality of life of people living with dementia and caregivers

Answer 174

-Preventing occurrence of injuries and limiting related impact on health (e.g., disability, death) -Eliminating hazards and managing risk while still allowing communities to be healthy and active -Injury is the leading cause of death amongst individuals ages 1-34 years and responsible for 6% of all deaths in Canada -Leading cause of injury death by age: infants = suffocation, children = MVC, drowning, choking, adolescents = MVC, 20-64 = suicide, 65+ = falls -Increasing burden of poisonings due to opioid crisis -Among youth (aged 15 to 24), suicide is the second leading cause of death -Suicide is 5-20X more common in some First Nations and Inuit communities -Of all violent crime, ~25% is from family violence with ~70% of victims being women and girls (2016) -8 in 10 victims/survivors of police-reported IPV in 2022 were women and girls, with rates of IPV more three times higher among women and girls than among men and boys -Risk factors for family violence: Women, age (children, elderly), Indigenous, people with disabilities, LGBT+ individuals, history of child abuse or neglect, substance use, stress -Chronic stress from ACES/violence leads to obesity, hypertension, cardiac disease, cancer

Answer 175

-Between 20-30% of seniors fall each year -Amongst seniors, falls are the leading cause of injury-related hospitalizations -Risk factors: elderly, cognitive impairment, balance/gait deficits, vision impairment, substance use, polypharmacy, limited social network, environmental hazards, poor weather, malfunctioning assistive devices -Outcomes: Fractures (95% of hip fractures are from falls), depression, social isolation Interventions: falls risk assessment, exercise programs, assistive devices, home modification, management of acute and chronic illness including vision, medication deprescribing

Answer 176

Vision Zero: strategy to eliminate all traffic fatalities and severe injuries while increasing safe, health, equitable mobility for all. Recognizes that people make mistakes and aims to ensure those mistakes do not result in deaths. Safe users: Helmets, graduated licensing, distracted driving, impaired driving Safe vehicles: Crumple zone, winter tires, seatbelts, child restraint devices Safe infrastructure (speeds, roads): Top contributor to MVC fatalities, risk of serious injury doubles every 5 km over 60, traffic calming, public transit, cycling infrastructure, pedestrian-centred intersections

Answer 177

In order of hospitalizations 1. Norovirus 2. Salmonella 3. Campylobacter 4. E. Coli O157 2,3 and 4 cause bloody diarrhea, along with Yersinia enterolytica and Shigella Greatest cause of death is Listeria

Answer 178

Naylor report - need for a federal public health agency, led to the establishment of PHAC. Defined the core functions of public health in Canada. Walker report - need for better public health and IPAC capacity, led to the establishment of PHO and PIDAC Campbell report - no individual failures/blame, but showed there was a broken public health system and the system failed during the outbreak. Emphasized the importance of the precautionary principle. Need to be better prepared for future infectious disease threats.

Answer 179

DTaP-IPV-Hib vaccine should be given at 2, 4, 6 and 12 to 23 months of age. Booster of DTaP-IPV at 4 to 6 years of age (school entry), and booster of Tdap at 14 to 16 years of age Booster of Hib at or above age 5 for children with chronic diseases that predispose to Hib: asplenia, cochlear implant, primary immunodeficiency, hematopoetic stem cell transplant, solid organ transplant, malignant hematologic disorder, HIV

Answer 180

Chikungunya Dengue Ebola Hantavirus Lassa fever Marburg virus Rift valley fever Yellow Fever

Answer 181

o Surface antigen (HBsAg): protein on surface of virus; detection of HBsAg indicates that an individual is HBV+ and infectious (HBsAg is used to make the HBV vaccine); up to 50% of individuals with chronic infection with clear HBsAg o Surface antibody (Anti-HBs): antibodies produced in response to HBsAg, either due to natural infection or immunization; indicate immunity to HBV; titres may decline to undetectable levels, but individual may retain anamnestic immunity (titre > 10 IU/mL indicate definitive immunity) o Core antigen (HBeAg): soluble protein “envelope” contained in the viral core; presence indicates high% infectivity o Core antibody (anti-HBc): antibodies produced in response to HBcAg; indicates current (IgM) or previous (IgG) HBV infection Surface antigen HBsAg Surface antibody Anti-HBs Core antigen HBeAg Core antibody Anti-HBc Interpretation IgM IgG Negative Negative Negative Negative Negative Susceptible No viral exposure and no immunization Negative Positive Negative Negative Negative Immune due to vaccination Negative Positive Negative Negative Positive Immune due to infection Positive Negative Positive Positive Negative Acute infection Positive Negative Positive Negative Positive Chronic infection Negative Negative Positive Negative Negative Resolve infection, false positive, low level chronic infection, or resolving acute infection and chronic developing

Answer 182

Infant program * 90% of infants who are infected with HBV go on to develop cirrhosis (~1-5% of adults) * Despite targeted immunization for infants born to HBV+ mothers, some infants are missed and acquire HBV; a universal infant program would prevent these cases * Most effective at reducing the number of chronic carriers Adolescent program * Most reported acute HBV infections occur in adolescents and adults; there is a rapid drop in antibodies following immunization, so individuals have maximum protection at time of greatest risk (caveat: 90% of 18-year-olds will mount an anamnestic response after a primary infant series) * Most effective at reducing the number of acute infections

Answer 183

* Infants born to a mother with acute or chronic hepatitis B infection o Unknown status: if maternal HBV status is not available within 12 hours of delivery administer HBV vaccine and give HBIg if there is any suspicion that the mother is infected o Infected mother: administer monovalent HB vaccine and HBIg within 12 hours of birth followed by complete series  Do not be test infant for HBsAg prior to 9 months of age, in order to avoid detection of passive anti-HBs from HBIg administered at birth and to maximize the likelihood of detecting late HB virus infection  Testing should be conducted 1-4 months after the last dose of vaccine is administered  If HBsAg is present, the child will likely become a chronic carrier

Answer 184

Candidiasis M. tuberculosis Pneumocystis jirovecii pneumonia Coccidiomycosis Cryptococcosis Histoplasmosis Toxoplasmosis Kaposi's sarcoma Burkitt's lymphoma

Answer 185

* Anaphylaxis, suspected hypersensitivity or non-anaphylactic allergy to previous influenza vaccine or its components, exception of egg. * Egg-allergic individuals may be vaccinated against influenza without prior influenza vaccine skin test and with the full dose, irrespective of a past severe reaction to egg, and without any extraordinary precautions * Guillain-Barré Syndrome within six weeks of influenza vaccination * Live-attenuated influenza vaccine (LAIV) is contraindicated in:  Children < 24 months of age, due to increased risk of wheezing.  Severe asthma defined as on oral or high-dose inhaled steroids, active wheezing, or medically attended wheezing in 7 days prior  Pregnant women  Immune compromising conditions, due to underlying disease, therapy, or both, as the vaccine contains live attenuated virus  New in 2020, NACI now recommends LAIV as an option for children 2 – 17 with HIV. It remains contraindicated in adults

Answer 186

● These vaccines are already approved and available. ● Vaccination against seasonal influenza infection for selected groups at increased risk of exposure to animal influenza viruses could be considered as a way of reducing the probability of human co-infections with both animal and human influenza viruses. Fewer such infections will reduce the opportunities for viral reassortment through antigenic shift and the emergence of influenza viruses with pandemic potential.

Answer 187

o Antigenic drift - Influenza A has an RNA genome, which is more prone to errors during replication because RNA polymerase lacks proofreading ability. - High mutation rate due to error-prone RNA replication, and short generation time (rapid replication cycle) speeds up evolution.  Minor changes/mutations in viral surface glycoproteins lead to emergence of new strains of influenza  Responsible for seasonal influenza (i.e., annual influenza epidemic) as previous year’s infection or vaccination provides only partial immunity to new antigens; subtype does not change o Antigenic shift  Major changes in hemagglutinin and/or neuraminidase subtypes that have never or have not recently been circulating in humans  Responsible for pandemic influenza because a substantial portion of the world’s population has no immunity, can result in a new subtype (e.g. H1N1) - Influenza A can infect multiple species (humans, birds, pigs, etc.). - If two different influenza A viruses infect the same host cell, they can swap genetic segments, creating a new hybrid strain. This sudden genetic reassortment can lead to pandemic strains, like the H1N1 "swine flu" pandemic in 2009. 1. Antigenic Drift (Frequent Small Mutations) As the virus replicates, small random mutations occur in its hemagglutinin (HA) and neuraminidase (NA) proteins, which are the main targets of the immune system. Over time, these mutations accumulate, causing gradual changes in the virus, allowing it to evade immune responses. This is why flu vaccines need to be updated regularly.

Answer 188

Children under 18: 2 doses of measles vaccine after the age of one Adults over 18: 0 doses if born before 1970, 1 dose if born after 1970 Health care workers: 2 doses of measles vaccine after age one Military personnel: 2 doses of measles vaccine after age one Travelers: 1 doses if born before 1970, 2 doses if born after 1970 Students in post-secondary institutions: 1 dose if born before 1970, 2 doses if born after 1970 In the event of an outbreak, immunocompetent individuals with 1 dose only should receive a second dose while awaiting serology results. Health care workers should be excluded while awaiting serology results. Children who have not received second dose should be excluded until they receive second dose. Exclusion is from 5 to 21 days after last exposure to case.

Answer 189

Immunocompromising medical conditions: Congenital immunodeficiencies involving any part of the immune system, including B-lymphocyte (humoral) immunity, T-lymphocyte (cell) mediated immunity, complement system (properdin, or factor D deficiencies), or phagocytic functions Immunocompromising therapy, including use of long-term corticosteroids, chemotherapy, radiation therapy, and post-organ transplant therapy HIV infection Hematopoietic stem cell transplant (recipient) Malignant neoplasms, including leukemia and lymphoma Solid organ or islet transplant (recipient) Nephrotic syndrome Non-immunocompromising medical conditions: Chronic kidney disease, particularly those with nephrotic syndrome, on dialysis or with renal transplant Chronic liver disease, including biliary atresia and hepatic cirrhosis due to any cause Functional or anatomic asplenia, including sickle cell disease and other hemoglobinopathies, congenital or acquired asplenia, or splenic dysfunction Chronic cerebrospinal fluid (CSF) leak Cochlear implants, including those who are to receive implants Chronic neurologic conditions that may impair clearance of oral secretions Chronic heart disease, including congenital heart disease and cyanotic heart disease Diabetes mellitus Chronic lung disease, including asthma requiring medical care in the preceding 12 months Environmental or living conditions for individuals: Who are underhoused or experiencing homelessness Who live in communities or settings experiencing sustained high IPD rates Who smoke With substance use disorders (i.e., cocaine use and injection drug use) With alcohol use disorder Who are in residential care, including long-term care homes and residential care homes for children with complex medical needs

Answer 190

OPV can cause illness identical to polio in 2 ways: 1, OPV consists of live, weakened poliovirus that rarely can cause paralysis in the vaccine recipient or their close contacts (referred to as vaccine-associated paralytic polio or VAPP). The risk of VAPP is estimated at one in 750,000 with the first dose of OPV and one in 2.4 million for all doses of OPV. 2. If the strain of poliovirus in the OPV circulates in populations with low vaccine coverage, or replicates in an immunocompromised host, it can undergo mutations and revert to a form that causes paralytic disease indistinguishable from wild polio. This is called vaccine-derived poliovirus (VDPV). If VDPV circulates in the community resulting in several detections, it's referred to as circulating vaccine-derived poliovirus (cVDPV). Genetic sequencing can be used to distinguish the OPV vaccine strains from VDPV. Canada stopped using OPV and began using IPV exclusively as of 1996. cVDPV occurs when a routine immunization program is poorly conducted or there is low vaccination coverage, leaving a significant proportion of the population susceptible to poliovirus

Answer 191

Wild virus * Imported: travel in or residence in a polio-endemic area 30 days or less before onset of symptoms * Import-related: epidemiologic link to someone who has travelled in or resided in a polio-endemic area within 30 days of onset of symptoms * Indigenous: no travel or contact as described above. There have been no indigenous cases of poliomyelitis in Canada since 1977 Vaccine-associated virus * Recipient: the illness began after the patient received OPV * Contact: case was shown to have been in contact with an OPV-recipient and became ill 7 to 60 days after the contact was immunized * Possible contact: case had no known direct contact with an OPV-recipient and no history of receiving OPV, but the paralysis occurred in an area in which a mass vaccination campaign using OPV had been in progress 7 - 60 days before the onset of paralysis * No known contact: case had no known contact with an OPV-recipient and no history of receiving OPV, and the paralysis occurred in an area where no routine or intensive OPV immunization had been in progress

Answer 192

Factors to Consider Animal 1. How prevalent is rabies in the species of animal involved in the exposure? (In North America, rabies occurs mainly in bats, foxes, skunks, raccoons and stray dogs and cats.) 2. Is the animal a domestic pet, wild animal or stray animal? (Domestic dogs and cats are less likely to be rabid than stray dogs or cats) 3. Is the wild animal available for testing? (In the event of exposure to a fox, skunk, raccoon or bat in areas where rabies is known to occur in these animals, post-exposure prophylaxis should begin immediately unless the animal is available for rabies testing and rabies is not considered likely. Post-exposure prophylaxis should not be delayed beyond 48 hours while waiting for test results in wild animals.) 4. Is the dog, cat or ferret available for observation? (If the dog, cat or ferret is healthy after a 10-day observation period, the animal would not have been shedding rabies virus in their saliva and would not have been infectious at the time of the exposure.) 5. If the dog, cat or ferret is available, is it clinically healthy? (If the dog, cat or ferret has or develops signs of rabies, post-exposure prophylaxis should be initiated as soon as possible.) 6. Was the animal behaving unusually? (Abnormal behaviour in a domestic pet may indicate that the animal is rabid. Generally, it is not possible to assess animal behaviour in wild animals.) 7. If the animal is a domestic pet, what is the vaccination status of the animal? (Domestic pets with up-to-date rabies vaccination are unlikely to be infected with rabies.) 8. If the animal is a domestic pet, has it been exposed to wild or outdoor animals? (Rabies may be transmitted to domestic pets during exposure to rabid wild or outdoor animals. Indoor animals have little opportunity to be exposed to rabid animals.) Geographic 1. In what geographic area did the exposure occur? 2. How prevalent is rabies in the involved species in the geographic area? 3. How prevalent is rabies in other animal species in the geographic area? Exposure 1. What was the type of exposure: bite, non-bite (e.g., salivary contact on open skin or mucous membrane), or bat? (Transmission rarely occurs from non-bite exposures. Exception is bats, as bites can be inapparent. Petting a rabid animal or handling its blood, urine or feces are not considered exposures.) 2. Can a bite or saliva exposure into a scratch, wound or mucous membrane be ruled out? (Rabies transmission occurs most commonly through a bite.) 3. What were the circumstances of the exposure (e.g., provoked or unprovoked attack)? (An unprovoked attack is more likely to indicate that the animal is rabid.) Person 1. What is the age of the exposed person? Is the exposed person able to provide a reliable history? (The history obtained from a child or cognitively impaired adult may be difficult to interpret and, potentially, unreliable.) 2. What is the location and severity of the wounds? (Bites on the face, neck or hand are considered higher-risk exposures due to the density of nerve endings in these areas. More severe bites may suggest the animal is rabid and also provide more opportunity for transmission.)

Answer 193

Primary syphilis: 4-fold drop at 6 months, 8-fold drop at 12 months Secondary syphilis: 8-fold drop at 6 months, 16-fold drop at 12 months Early latent syphilis: 4-fold drop at 12 months

Answer 194

- Bacterial burden (smear positivity) -Cavitary disease or upper lung disease seen on Chest X-ray (NB: bacilli are encased by macrophages in granulomas in lung due to cell-mediated immune response that occurs approx 3-8 weeks after infection) - Laryngeal disease - Amount and severity of cough - Duration of exposure of the contact - Proximity of the contact to the case - Crowding and poor room ventilation - Delays in case receiving effective treatment Highest risk of progression to active TB disease: - Child, elderly, or immunocompromised contact - HIV - Silicosis Other high-risk: immunosuppressed, transplant, cancer

Answer 195

Use IGRA for children between age 2 and 10 who have received the BCG vaccine, and for people above 10 who received the BCG vaccine older than 1 year of age. Also when there are not people available who are trained to read TSTs, people are unlikely to return for TST reading, or TST contraindication. In all other situations TST is preferred. TST is considered positive above 5 mm for people with HIV, recent contact with TB case, evidence of untreated disease on Xray, transplant patients, people on immunosuppressant drugs, and severe CKD TST is considered positive at 10 mm for all others.

Answer 196

Goals of treatment are to prevent resistance, kill bacilli, prevent relapse and ensure overall health Treatment: RIPE Intensive: Rifampin (turns things orange), isoniazid (risk of hepatitis), pyrazinamide (hepatotoxicity), ethambutol (vision, can be removed once susceptibility testing is back) x 2 months Continuation: Rifampin, isoniazid, +/- ethambutol x 4 months Also give pyridoxine to prevent peripheral neuropathy MDR-TB is resistant to rifampin and isoniazid preXDR-TB is resistant to rifampin, isoniazid, and fluoroquinolones XDR-TB is resistant to rifampin, isoniazid, fluoroquinolones, and bedaquiline or linezolid Reasons for drug-resistant TB: inadequate dosing, incorrect treatment, treatment interruptions, inadequate supervision, poor adherence, living in a country with drug resistant TB NB: TST/IGRA should also be used to support diagnosis of TB disease in children under the age of 12

Answer 197

Prevention: Screening high-risk population such as those with HIV infection, BCG vaccine program in high-incidence Northern communities Diagnosis: Early identification of TB cases, Identification of LTBI in high risk groups such as health care workers Treatment: Rapid initiation (<72 h) of treatment of pulmonary TB cases with RIPE regimen, public funding of TB medications, Direct observed therapy program, Treatment of LTBI in those at high risk of conversion to active disease Contact tracing: Evaluation of close contacts of active TB cases, window treatment for exposed children under the age of 5 (with INH or RFP) Surveillance: National surveillance system Canadian TB Reporting System Targeted programs: CXR on immigration medical exam for foreign born Canadians, medical surveillance for recently arrived refugees and asylum seekers Addressing SDOH: Supportive housing programs for marginally housed populations Other: Public Health/Health Protection legislation

Answer 198

Highest priority Anthrax Botulism Plague Smallpox Tularemia Viral hemorrhagic fever Brucella Q fever Hantavirus Nipah virus Epidemiological clues that indicate a deliberate epidemic: o Highly unusual event with large numbers of casualties o Higher morbidity or mortality than expected o Uncommon disease (e.g., vector-borne disease in an area without a competent vector) o Point-source outbreaks o Multiple epidemics, especially if a single agent at multiple locations o Lower attack rates in protected individuals (e.g., individuals in buildings with filtered air supply) o Dead animals (many bioterrorism agents are zoonoses) o Reverse spread: zoonoses typically affect susceptible animals and then humans; consider deliberate spread if human disease precedes animal disease o Unusual disease manifestation (e.g., inhalational rather than cutaneous anthrax) o Downwind plume pattern: cases cluster in a downwind plume pattern (may indicate aerosol release)

Answer 199

NACI If available, a dose of the RSV monoclonal antibody nirsevimab is recommended for all infants entering, or born during, their first RSV season. Increased risk = immunocompromised, premature born before 37 weeks, social deprivation due to bring FNIM. Nirsevimab is recommended over palivizumab. Pregnant people can opt for RSV vaccine at 32-36 weeks to protect unborn child, but not as effective as monoclonal antibody. For older adults, especially those at higher risk, one dose of either RSVpreF or RSVPreF3 is optimally administered just before the start of the RSV season. Older = 75+, or 60+ who are in LTC. Additional doses are not yet recommended.

Answer 200

Bias - Systematic deviation of a study’s result from a true value leading to an overestimation (positive bias) or underestimation (negative bias) of the measure of association Information bias - systematic error in measurement or in collection of study participant information, producing differential accuracy of information by level of exposure, outcome, co-variate (e.g., recall, reporting, observer)  Measurement/misclassification bias: systematic error in classifying subjects with regard to exposure or outcome status  Recall bias: can occur when there is differential recall about past exposure status between those who have the outcome and those who don’t, typically cases recall exposures more accurately than non-cases  Interviewer bias: can occur when the interviewers’ awareness of the subjects outcome status influences how they solicit, record, or interpret information on the subjects exposure status Selection bias - systematic error in a study resulting from manner in which subjects are selected or from factors that influence ongoing participation in the studying  Sampling bias: can occur when some members of a population are systematically more likely to be selected in a sample than others  Attrition bias: can occur when significant losses to follow-up result in a sample systematically different from the original in terms of exposure frequency or outcome susceptibility  Volunteer bias: can occur because those who volunteer for studies tend to be systematically different from the general population  Nonresponse bias: can occur because of systematic differences between those who participate in studies and those who do not  Publication bias: can occur when the outcome of an experiment or research study influences the decision whether to publish or otherwise distribute it  Incidence-prevalence bias: results from using prevalent cases in a case-control study, because cases must have survived until the point of study recruitment Healthy worker effect - form of selection bias, generally workers will have less disease than the general population so workers are pre-selected to be healthier, workers who become ill often will retire/quit (self-select out of the workforce)  The population studied would, other things being equal, have a lower mortality rate than the comparison general population (standardized mortality ratio often < 1.0 or not statistically significant)  Can lead you to conclude that a harmful exposure is not harmful

Answer 201

Critical appraisal - Systematic evaluation of a study ODDCHAIR Objectives: study hypothesis Design: appropriateness of the design to study question Definitions: subjects, intervention, exposure, outcomes (PICO) Collection: measurement tools, sources of bias Handling: confidentiality, ethics approval Analysis: appropriate statistical testing Interpretation: results, internal and external validity, relevance Reporting: publication bias, conflicts of interest

Answer 202

Ratings are High, Moderate, Low, and Very Low. Recommendations can be Strongly for, Weakly for, Weakly against, Strongly against o Grade is reduced for: publication bias, inconsistency of results, indirectness of evidence, imprecision, and risk of bias o Grade is increased for: large magnitude of effect, dose-response gradient, and when all residual confounding is expected to reduce the effect size

Answer 203

* Participant observation: Field strategy that simultaneously combines document analysis, interviewing, direct participation and observation and introspection * Interviews: structured conversation and a purpose - Individual interviews: structured, unstructured, semi-structured, in-depth - Group interviews: focus groups, consensus panel (Delphi), natural group, community interview * Nominal groups: highly structured technique designed to keep personal interaction at a minimum level during the process of new idea generation, while maximizing the individual contribution of each respondent. Avoids problems of group dynamics seen with Delphi and focus groups * Focus groups: collect data through group interaction on a topic determined by the researcher. It is the researcher’s interest that provides the focus, whereas the data themselves come from the group interaction * Documents: text (media articles, research articles, diaries, etc.), photographs, videos

Answer 204

o Typical case sampling: sampling the usual cases of a phenomenon o Deviant case sampling: sampling the most extreme cases of a phenomenon o Critical case sampling: sampling cases that are predicted to be particularly illuminating, based on theory or previous research o Maximum-variation sampling: sampling as wide a range of perspectives as possible to capture the broadest set of experiences o Confirming-disconfirming sampling: sampling cases whose perspectives are likely to confirm or challenge the researcher’s understanding of the phenomenon o Theoretical sampling: used in grounded theory approach, sampling cases whom the researchers predict would add new perspectives to those already represented in the sample o Purposive sampling: sampling cases who have the most information about the topic (subtypes: critical case, opportunistic - follows new leads, stratified purposeful sampling) o Snowball sampling: sampling cases of interest from people who know people who know which cases are information rich o Convenience sampling: saves time, money and effort at the expense of information and credibility

Answer 205

o Clinical data: lab, diagnoses, prescriptions o Surveys: CCHS o Insurance data: MD claims, drug claims o Administrative data: hospital discharge o Vital statistics: births, deaths o Registries: cancer, trauma o Digital media: social media, news media

Answer 206

Quality-Adjusted Life Year measures the quantity and quality of life lived. Disability-Adjusted Life Year measures the health gap between the current state of population health and an ideal situation where everyone reaches the age of standard life expectancy in perfect health. -QALY measures health gains due to intervention, whereas DALY measures health loss due to illness, disability, or premature death. -Higher QALY and lower DALY are better - QALY focuses on quality and quantity of life, whereas DALY focuses on disease burden (disability + early death). - QALY is used in healthcare cost-effectiveness analysis, whereas DALY is used in public health and global disease burden studies. - QALY: Patient-centered (individual quality of life), DALY: Population-centered (overall impact of disease).

Answer 207

Demographics - Age Socio-economic status - Income Living and working conditions - Work stress Geography - Urban vs. Rural vs. Remote Mortality and Morbidity - Cause of death Health and Wellness - Self-rated health Health Services Seeking Behaviours - Screening Health Behaviour - Tobacco use Elements of behaviour change - Awareness of climate change Social environment - Food affordability Natural and built environment - Presence of green space Socio-political aspects of environmental change - Access to early warning information

Answer 208

-Definition: structural approach to examining the linkages between actors, using mathematical and computational models -Data analysis  Network visualization: visual representation of the social network  Descriptive analyses: description of the role of individual actors in the network (e.g., highly connected individuals, bridge individuals), description of subgroups, and description of the type of network (e.g., hierarchical, dense)  Statistical analysis: descriptive statistics (e.g., distance, density) and inferential statistics (usually using stochastic or longitudinal models) * Distance: the length of the shortest path between actors * Density = total number of relational ties divided by the total possible number of relational ties -Uses in public health  Disease transmission networks * Outbreak investigation * Disease modelling  Information transmission networks (e.g., who should we target with our messaging?)  Social support networks (e.g., how does social capital flow?)  Organizational networks (e.g., how are health organizations related to one another?)

Answer 209

Federal - Responsible for water for national parks armed forces, border crossings, First Nations - Legislation: Canada Water Act, Canadian Environmental Protection Act, Fisheries Act - Health Canada has created Canadian Drinking Water Quality Guidelines, which outlines basic parameters of water systems and maximum allowable concentrations of substances and contaminants - Health Canada also has Guidelines for Recreational Water Quality for any body of water used for recreation Provincial: Responsible for oversight of drinking water quality, and performance monitoring Municipal: Providers of water, funding for infrastructure

Answer 210

Source water: surface water (river, lakes), ground water (fresh water beneath Earth’s surface), and aquifers (sand/gravel bedrock saturated with water) Threats to source water: Natural - rainfall, wildlife Manmade - agricultural runoff, mining, recreation, urban development, wastewater Source water protection: Protection of surface water and ground water from vulnerabilities, through methods such as restricting access, restricting development, inspection programs, waste management, storm water and landfill runoff diversion

Answer 211

1. Confirm accurate information (with testing lab or system operator) 2. Assemble team by notifying relevant authorities (PHU, Ministry of Health, Ministry of Environment) 3. Investigate system by re-sampling 4. Gather data (turbidity, chlorine residuals) 5. Operationalize corrective action - increase disinfection, flush lines, repair equipment, issue public notice E. Coli and fecal coliforms require immediate action Low chlorine residuals require urgent action Chemical contaminants require investigation, especially at low levels

Answer 212

Some People Can Find Safe, Fresh Drinking Water S - Screening: Water forced through screens to remove debris P - Pre-chlorination: Addition of chlorine to source water to stop biological growth C - Coagulation: Positively charged chemicals bind to negatively charged debris F - Flocculation: Gentle mixing increases bound particle size to form floc S - Sedimentation: Floc settles out at the bottom of the water supply F - Filtration: Clear water passes through filters to remove particles including bacteria, parasites, viruses, chemicals D - primary Disinfection: Kills or inactivates bacteria, viruses and pathogens before water enters the distribution system W - Wait, secondary disinfection: Longer-lasting treatment as water moves through pipes

Answer 213

Chlorine -Pros: Cheap, easy to monitor chlorine residuals -Cons: Harmful byproducts (chloroform, trihalomethane), can impact taste/odor, does not inactivate crypto Ozone -Pros: High quality disinfectant, inactivates crypto, good taste/odor -Cons: Expensive, energy-intensive, requires secondary disinfection as no residual UV radiation -Pros: Inactivates crypto, simple, good taste, -Cons: No residual so needs secondary disinfection, large particles can shield microorganisms from disinfection, can be expensive

Answer 214

Do not use: Issued when there is a contaminant that can have harmful effects from dermal or inhalational exposure. e.g. gasoline, hazardous waste Do not consume: Issued when there is a contaminant, typically chemical, that could cause concern with ingestion but not dermal exposure e.g. heavy metals, nitrates Boil water advisory: Issued when there is a microbe contaminant, or turbidity (which suggests microbe contaminant. Includes bacteria, viruses, parasites Reasons to consider issuing precautionary BWA: planned repairs that may cause a significant pressure drop, persistent presence of total coliforms despite remediation, minor equipment malfunction, changes to source water, unexpected changes to pressure, turbidity or residuals, broken water main Can end BWA when: -2 negative sets of bacterial samples at least 24 hours apart -Operational malfunction corrected -Outbreak ended

Answer 215

-Test every 6 months -Locate well far from septic tanks, manure, farmyards, petroleum tanks, pesticide storage -Treat water if test results show contamination -Regularly maintain well

Answer 216

- Arsenic (causes cancer) - Lead (neurocognitive effects in young children) - Total coliforms (indicator of well-functioning drinking water treatment system) - E. coli (indicates presence of fecal contamination) - Haloacetic acid (chlorine byproduct, causes liver cancer)

Answer 217

Safe Food for Canadians Act: Food safety oversight, authority to CFIA to take enforcement actions, licensing requirements, traceability Food and Drug Acts: Regulates any item sold as a food or drink that doesn't make a health claim, includes food labelling, advertising, packaging Health Canada is responsible for oversight of Food and Drugs Act CFIA is responsible for oversight of Safe Food for Canadians Act, and investigates foods responsible for foodborne illness outbreaks, and initiates food safety recalls PHAC does public health surveillance and coordination during cross-provincial foodborne illness outbreaks Provinces and Territories: Enact and enforce food safety laws within jurisdiction, including inspection programs, food handler requirements, etc.

Answer 218

Short: Salmonella (12-36 hours) Vibrio cholera (12 hours) Bacillus cereus toxin (1-16 hours) Clostridium perfringens toxin (6-24 hours) Clostridium botulinum toxin (12-72 hours) Norovirus (12-48 hours) Medium: Campylobacter (2-5 days) Shigella (1-4 days) Yersinia enterocolitica (3-7 days) Shiga toxin E. coli (1-4 days) Cryptosporidiosis, cyclosporiasis,and giardia (around 7 days) Long: Listeria (2-3 weeks)

Answer 219

Preparation: temperature (keep out of danger zone 4-60ºC), cooking kills heat-sensitive bacteria (in general target 74 C), pasteurization (mild heat to inactive pathogens) * Storage: refrigeration (slows most microbial growth except Listeria and Yersinia), freezing (reduces bacterial numbers but no effect on spores) * Preservation: canning (seal in sterile container), curing (using nitrites to prevent microbial growth in meats) * Irradiation: ionizing radiation to prevent microbial growth, done for flour, wheat * Sanitation: to keep surfaces and equipment clean * Other: employee training, pest control, food storage, recalls "Clean, Separate (Cross-Contaminate), Cook, Chill"

Answer 220

- Suspected or confirmed foodborne illness outbreak - Food test result - Food inspection finding - Complaints from consumers - Company-initiated recall - Recall in another country - CFIA assessment - Referral from other jurisdiction Step 1: Trigger Step 2: Food safety investigation (Food, lab, epi) Step 3: Health risk assessment (HI DR EARC, Hazard identification, Hazard characterization, Exposure Assessment, Risk Characterization) Step 4: Decision made and recall process Step 5: Follow-up

Answer 221

Incident Management System (IMS): organizational structure to coordinate response in an emergency (interoperable across jurisdictions) Key components include organizational chart (sections, units) and after-action report (documents incident response and recommends improvements) Key functions: -Commander (in charge), supported by safety, information (comms) and liaison officers -Finance and administration chief (pays) -Logistics chief (gets), includes human resourcing -Operations chief (implements) -Planning chief (prepares), monitors and surveils help guide response Single command is one jurisdiction, whereas Unified command is multijurisdictional but with one spokesperson. Incident Action Plan outlines objectives to be completed within the Operational Period which is usually less than 24 hours. The chiefs all meet following the operational period. Emergency Operations Centre (EOC): Facility where Incident Command is organized and coordinated

Answer 222

Urban heat island: area that is routinely hotter than surrounding areas as it generates and retains heat from buildings, human and industrial activities, and other factors. Due to black asphalt, decreased natural land coverage from vegetation, trapping of radiation by buildings, human activities that produce heat such as driving. Solutions include green roofs, ventilation corridors in cities, active transportation, greenhouse gas reduction.

Answer 223

Some communities in Canada and internationally are developing heat alert and response systems (HARS) to prepare for extreme heat events. These systems are made up of 5 parts: 1. Community mobilization and engagement - determines community needs, identifies an agency to coordinate the heat response as well as stakeholders to carry out the response actions 2. Alert protocol - Identifies weather conditions that could result in increased morbidity and mortality in the region. Trigger is usually a community-specific numerical value, reflecting local meteorological conditions (temperature, humidex, +/- air pollution, air masses), community needs, response capacities, and existing vulnerabilities 3. Community response plan - Includes mobilizing partners, individuals, and assisting vulnerable people (e.g. opening cooling centres, cancelling outdoor events 4. Communication plan - Increases awareness about heat health impacts, delivers messages to public about actions to take (e.g. "spend time indoors today", "check on your elderly neighbours", "reschedule your outdoor activities", "drink lots of cool water" 5. Evaluation plan - Assesses HARS activities and makes improvements. Process evaluation looks at whether the HARS was implemented as planned, and outcome evaluation looks at whether the program impacted morbidity and mortality and public awareness. Other preventive actions to reduce heat health risks: reduce urban heat island effect, promote healthy communities and individuals, modify transportation policies, improve social capital and social networks, build climate resiliency, assess heat-health vulnerability and reduce green-house gases.

Answer 224

- People living with HIV and Hep C - Indigenous - Gay and bisexual men who have sex with men - People who use drugs - Transgender persons - People who have been incarcerated - People who engage with sex work

Answer 225

- Skin breakdown - Immunocompromised or chronic conditions - Young children and older adults - Peripartum women - People who inject drugs - Postsurgical patients - Preceding varicella or influenza Contacts should self-monitor for 30 days.

Answer 226

Through FluWatch 1. Geographic spread of influenza like illness 2. Lab confirmed influenza detection 3. Syndromic surveillance 4. Outbreak surveillance 5. Severe outcome surveillance 6. Influenza strains and antiviral resistance 7. Influenza vaccine monitoring

Answer 227

"SCREEN IT" S – Safe C – Cost-effective (Low cost) R – Recognizable latent or early symptomatic stage E – Easy to perform (Simple) E – Effective (High sensitivity & specificity) N – Non-invasive (Acceptable to patients and clinicians) I – Intervention available (Treatable) T – Trustworthy results (High positive predictive value)

Answer 228

MISSUIFS Modular - Discrete related components Interoperable - Functions across jurisdictions Standardized - Shared structures and terminology Simple - Eliminate elements when no longer needed Unity of Command - Each person at every level reports to only one clearly designated supervisor Integrated Communication - Standardized way to communicate with stakeholder Flexible and Scalable - Can be expanded to address any size of incident

Answer 229

Health promotion is the process of enabling individuals to increase control over, and to improve, their health.

Answer 230

Risk factors: Lack of prenatal care, multiple partners, substance use disorder, homeless, incarcerated Presentations: -Fetal: miscarriage, stillbirth, prematurity, neonatal death -Neonatal: Skeletal malformations, anemia, jaundice, vision problems, hearing loss

Answer 231

Forever chemicals. Very long half-life, persist in environment and bioaccumulate in animals. Found in nonstock coating, firefighting foam, electronics, clothing, carpets. Ubiquitous in Canadian human blood samples. Possible carcinogen, liver damage, endocrine disruptor. May be related to prematurity, low birthweight in fetuses. Some PFAS are banned, MAC has been set for drinking water. Epidemiology: Levels are decreasing in the blood (through CHMS). Likely due to regulation and restrictions

Answer 232

Proximate causes: lightning (50%), drought, extreme heat, human activity Distal causes: climate change, biodiversity loss, development Health risk: physical and mental health, heat and smoke

Answer 233

-Lower life expectancy by up to 10 years -Increased infant mortality -Increased rates of tuberculosis -Increased rates of RSV -Increased rates of intimate partner violence * Vital statistics: lower life expectancy, large for gestational age * Communicable disease: higher RSV and TB * SDOH: higher unemployment, maternal smoking, food insecurity, low income

Answer 234

-Males -Age 30-39 -Indigenous -Homelessness -Low educational attainment -Trades occupation -Concurrent disorders

Answer 235

Household food insecurity, as this problem is measured and monitored in Canada, refers to the inadequate or insecure access to food due to financial constraints. Food security is on the rise, almost 1 in 5 households are food insecure. Food insecurity is a marker of material deprivation, and is tightly linked to low income. Black and Indigenous off-reserve were more likely to food insecure. Household food insecurity is one of the strongest predictors of poor health.

Answer 236

1. Canada must act now to be prepared for the next health emergency 2. Greater pan-Canadian coordination of research and science advice is required 3. A greater focus needs to be placed on equity and addressing social and structural determinants of health 4. Indigenous health expertise must be embedded in research coordination and science advice processes Key Recommendation: - Ensure surveillance systems work in real time -Improve external communication of advice from federal advisory bodies -Improve coordination of health emergency related research -Increase research investments to address needs of disadvantaged groups and Indigenous people -Meaningfully engage with Indigenous communities on health data strategies -Formalize the role of chief science advisor in legislation

Answer 237

Agent factors: - Length of exposure - Rate of release - Type of substance Host factors: - Population density - Vulnerability to hazard (LTC, schools, prisons) - Ability to evacuate (bedbound people in LTC) Environment factors: - Wind speed - Weather conditions - Temperature - Air exchange rate indoors, ability to seal off building from outdoors - Time of day Logistical factors: - Can evacuation occur before exposure (if so, evacuate) (aka is there time to evacuate) - Can population be adequately sheltered before exposure (if so, shelter-in-place) - PESTLE - Hazard vs outrage - Is situation stable or constantly changing Expertise: - Consult with local, provincial, and federal partners Situations favouring evacuation: -Flammable vapours -People are outdoors -Vapours will stay on the ground or are continuously being released -Only a few people to evacuate Situations favouring sheltering in place: -Vapours toxic and there will be exposure during evacuation -Buildings can be quickly sealed off from outdoors -People are already indoors -Too many people to evacuate with existing resources -Circumstances changing too quickly to evacuate safely

Answer 238

Health indicators are measures of health and of the factors that affect health. They are numbers and statistics that can provide a basis for comparison. CIHI Framework: -Health Status -Non–medical determinants of health -Health system performance -Community and health system characteristics

Answer 239

Structural measures: Structural measures give consumers a sense of a health care system's capacity. For example, number of physicians Process measures: Process measures indicate what a provider does to maintain or improve health. For example, percent of people receiving mammograms. Outcome measures: Outcome measures reflect the impact of the health care service or intervention on the health status of patients. For example, rate of nosocomial infections, or hospitalization mortality rate.

Answer 240

- Focus on health and avoidance of corporatization - Preventing stigma through universal access - Ensuring cultural safety

Answer 241

- Prevention/mitigation: Public communication on human actions that increase wildfire, climate change mitigation and adaptation - Preparedness: Emergency response plan, stockpiling respirators - Response: IMS, provide advice to public on who is most at risk during fires, cancel outdoor events, decrease time outdoors, respirator masks to prevent PM2.5 inhalation for those who need to be outdoors, HEPA filters indoors - Recovery: After action repot, continue to survey for health impacts

Answer 242

Administrative controls: Policies and procedures that maintain information security Technological controls: Electronic algorithms that maintain information security (e.g. firewalls, passwords, encryption) Physical controls: Physical barriers that maintain information security (e.g. building access cards, security cameras)

Answer 243

1. Pandemic 2. Cybersecurity breach 3. Power outage 4. Labour disruption (strike) 5. Bioterrorism incident 6. Catastrophic natural event (earthquake, wildfire, flooding) COOP: Defines how organizational interests will be protected and essential operations will be sustained during an emergency - Identify time-critical public health services that must be delivered - Assign resources to maintain time-critical public health functions and identify dependencies and vulnerabilities to continued delivery - Develop recovery procedures to guide restoration of time-critical services

Answer 244

Confirm and contain: confirm the breach, ensure no ongoing risk Assess: What information was breached Notify: Privacy commissioner, Provincial public health authorities Investigate: Root cause analysis (fishbone diagram, 5 whys, pareto chart) Implement change: controls, discipline

Answer 245

SIN-RaSN-PE - Secure the scene - Hazard Identification: using knowledge of personnel, MSDS - Notify Partners: Should include ministry of environment, first responders, municipality. ministry of health - Rapid risk assessment: exposure assessment, context assessment, risk characterization - Spill management: managed by first responders - Community notification and education: includes evacuation or shelter in place orders if necessary -Patient transport and treatment -Evacuate or shelter in place (See Transport Canada Orange Emergency Response Guidebook)

Answer 246

Purpose: To achieve optimal health and well-being for all people living in Canada Aims: Enhance the health status of populations, protect against health emergencies and mitigate the impacts, achieve equitable health outcomes Essential public health functions: Health protection, health promotion, health surveillance, emergency preparedness and response, population health assessment, disease and injury prevention Building blocks: Policies and programs, research and evidence, medical and digital health technology, human resources, financing, governments/leadership

Answer 247

Trustworthy - accountable and transparent Evidence-informed and effective Population health approach Participatory - include community and citizen participation Equity-driven

Answer 248

International treaty whose goal is to keep global temperature increase to 2 C (or ideally 1.5 C).

Answer 249

- People experiencing homelessness - Populations that are racialized - People living with mental health conditions or substance use disorders - People with multiple and overlapping barriers to good health - Populations that experience social, economic, environmental, or health inequities, including those related to racism, discrimination and colonization - First Nations, Inuit, and Metis communities (specific to climate-related emergencies, such as wildfires/floods)

Answer 250

Hazard: An event, activity or agent that has the potential to cause damage or disruption Types of hazards: Meteorological - heat, cold, wildfire, hurricane, flood Biological - infectious diseases Geological - earthquake, landslide, tsunami, volcano Conflict - terror attack Technological - hazardous chemical, transport accident Social (not a formal emergency) - toxic drug crisis, mental health, racism Emergency: A serious event requiring immediate action to protect health and safety, and limit damage to property and environment Disaster: Critical event that causes widespread disruption to everyday life and essential functions

Answer 251

Differential exposure – when some populations or communities are more likely to experience a hazard than others e.g. living in area prone to flooding Differential vulnerability – how susceptible a population or community is to being impacted by a hazard e.g. individuals with pre-existing mental health conditions may be more likely to experience adverse mental health impacts after emergencies Differential capacity – unequal access to the power and resources needed to effectively react during an emergency e.g. people with disabilities may face accessibility barriers to evacuation or other response efforts

Answer 252

Community – Takes various forms including location-based communities and social connection communities based on relationships. Also includes groups or networks with shared experiences, identities, or professional backgrounds.

Answer 253

UNDRIP can provide road map for emergency management professionals when working with First Nations, Inuit and Metis communities. The following four theme represent the minimum standards for prosperity, dignity, and well-being of Indigenous Peoples: - The Right to Self-Determination (e,g, Assembly of First Nations advocacy for First Nations communities to assume control of their own emergency management including funding comparable to municipal services) - The Right to Cultural Identity - The Right to Free, Prior, and Informed Consent - Protection from Discrimination

Answer 254

-Decrease infectious disease morbidity and mortality -Ease strain on healthcare resources -Help strengthen health and social care infrastructure -Lessen the incidence of some chronic conditions -Preserve wellbeing and independence in older adulthood -Foster greater health equity -Mitigate the spread of antimicrobial resistance -Reduce costs to the healthcare system -Lower the number of work or school days missed due to illness -Protect population health through herd immunity -Provide early and ongoing connections with healthcare providers -Contribute to economic productivity

Answer 255

Misinformation is a broad term used to refer to many types of false or misleading information, some of which may exist without malicious intent. Disinformation is incorrect information that is created or spread specifically to deceive or mislead.

Answer 256

* Surveillance/epidemiology of communicable diseases of PH significance * Assessment of population health impacts * Population-based interventions * Public communication and education * Leadership and coordination for specific situations/emergencies * Community recovery * Continuity of operations planning (COOP) and execution

Answer 257

Exposure assessment: Measuring or estimating human exposure to an environmental agent  Source of contamination: point, disperse  Environmental media: air, water, food, soil, product  Location: home, work, recreation  Target/vulnerable population  Route: ingestion, inhalation, dermal contact, IV  Magnitude and duration of exposure o Methods  Indirect (estimation/modelling): questionnaires, imputation/models  Direct (measurement): continuous personal exposure monitoring, biomarkers

Answer 258

Organophosphates and carbamates: both cause muscarinic effects (MUDDLES): miosis, urination, diarrhea, diaphoresis, lacrimation, excitation, salivation

Answer 259

5 W's Who: Target audience/population, or population at risk What: What exactly is the issue Where: Location When: Time of day, weather conditions, wind conditions, temperature, incubation period, period of communicability, etc. Why: What is the cause of the issue, why does it exist, why is it important to address

Answer 260

PLEA for it to work out! 1. Preparation - Estimate costs of providing services, justify requests 2. Legislative consideration and approval (e.g. Board of Health) 3. Execution 4. Audit: internal (review compliance, processes finances), external (external auditor reviews financial statements) Components: - Budget to date if showing status of budget partway through year - Actual spending to date which should include anticipated spending - Variance (difference between budget and actual spending) - Projected position at year end - Comparison to prior year spending Highlights of areas of over or under spending - Divide into major categories e.g. by operating and capital expenditures, program-based

Answer 261

Balanced Scorecard for Public Health - Provides an organization’s management with an overarching view of risks and benefits of strategic and operational decisions - Knowledge gleaned from scorecard results can facilitate change and quality improvement, provide an accountability mechanism, and support planning - The following framework was proposed for the development of Ontario’s first balanced scorecard for public health to measure performance in four quadrants: Health determinants and status - Markers that gauge the overall health of the population, tend to change slowly over time and therefore it is not realistic to expect to see change within one year - Where there are positive changes in health status, it is hard to attribute the improvements to public health action, as other influencing factors must first be ruled out Community engagement * Outreach and advocacy have resulted in positive change as a result of efforts to raise awareness of important public health issues (community water fluoridation, infection prevention and control, and determinants of health) and to work with community partners to address these issues. Resources and services * Having staff specifically assigned to move initiatives forward contributes significantly to success in meeting identified outcomes.  Integration and responsiveness * Example integrating a Health Equity Impact Assessment into the Business Continuity Plan

Answer 262

Trust - The foundation of all relationships, whether between persons, persons and organisations, or citizens and government. Justice - Treating all persons and groups fairly and equitably, with equal concern and respect, in light of what is owed to them as members of society. Respect for persons, communities and human rights - Recognizing the inherent human rights, dignity, and unconditional worth of all persons, regardless of their human condition. Promoting well-being - Individuals, organizations and communities have a duty to contribute to the welfare of others. Minimising harm - Consider precautionary principle, reciprocity, proportionality, and effectiveness. Working together - Because individuals are part of a greater whole, whether an organization, a local community, a nation or the global community, collective action in the face of common threats is justified. PROCEDURAL FACTORS (RATIO) Responsiveness: decisions are revisited and revised as new information emerges; Accountability: decision makers are answerable to the public for the type and quality of decisions made or actions taken; inTersectionality: an intersectional lens is applied to deliberation and decision making. Inclusiveness: groups and individuals who are most likely to be affected by a decision are engaged in the decision-making and planning processes to the greatest extent possible; Openness and transparency: decisions are made in such a way that stakeholders know, in a full, accurate and timely manner, what decisions are being made, for which reasons, and what criteria were applied, and have the opportunity to provide input;

Answer 263

CRITICAL Equipment/Device - Enters sterile tissues, including the vascular system. Needs cleaning followed by Sterilization (autoclave). e.g. surgical instruments, biopsy instruments SEMICRITICAL Equipment/Device - Equipment/device that comes in contact with non-intact skin or mucous membranes but does not penetrate them. Needs cleaning followed by High- Level Disinfection (as a minimum), sterilization is preferred. e.g. Respiratory therapy equipment, anaesthesia equipment NONCRITICAL Equipment/Device - Touches only intact skin and not mucous membranes, or does not directly touch the client/patient/resident. Needs cleaning followed by Low- Level Disinfection (in some cases, cleaning alone is acceptable). E.g. ECG machines, oximeters, bedpans, urinals

Answer 264

Smog: Mixture of pollutants but the main two components are particulate matter and ozone. Leads to poor air quality and reduced visibility Acid rain: SO2 + NO + water -> sulphuric (SO4) and nitric acids (NO3) -> wet deposition (precipitation) and dry deposition (gases, particles). Acidifies lakes and streams making water unsuitable to some fish, and other plants and animals. Damages forest soils by stripping soil nutrients and increasing release of toxic chemicals such as aluminum.

Answer 265

o Substance use: The use of a psychoactive substance for various reasons including spiritual, medicinal, individual, and social. Can be beneficial, non-problematic, harmful, or substance use disorder o Substance abuse: Problematic use of a psychoactive substance (e.g. inability to fulfil responsibilities; dangerous use; legal, societal, or family problems) o Substance dependence: Physical, mental, and behavioural problems associated with use. Defined by tolerance, withdrawal, a desire to quit, and use despite consequences o Substance use disorder: Range of illnesses, based on the type of substance consumed, all of which are categorized by similar DSM-5 criteria. Range in severity from mild to severe and are characterized by significant distress and impaired functioning o Addiction: Problematic pattern of use leading to clinically significant impairment or distress. Manifested by craving, loss of control, compulsive use, use despite consequences o Harm reduction: Policies, programmes, and practices that aim to minimize negative health, social and legal impacts associated with drug use, drug policies and drug laws

Answer 266

Vaccine cold chain: Process used to maintain optimal conditions during the transport (including from manufacturer to distributor to depot to public health unit), storage, and handling of vaccines, within the safe temperature range of 2°C to 8°C, from manufacturer to patient including contingency plans for cooling failures Vaccine cold chain breach: Occurs when vaccine is exposed to a temperature outside the required temperature range of +2 °C to +8 °C for any period of time o Information to obtain during a cold chain breach: -vaccine name, lot number, expiry date -date and time of incident -issue (e.g., exposure to inappropriate temperature or exposure to light) -length of time vaccine may have been exposed to inappropriate conditions -whether any of the affected vaccines had been administered and if so, to whom -the room temperature where the vaccine storage unit is located -current temperature inside the vaccine storage unit (and freezer) -minimum and maximum temperature readings inside the vaccine storage unit (and freezer) -presence of water bottles in the refrigerator (storing filled water bottles on the lower shelf and the door of a refrigerator will help maintain an even, stable temperature inside the refrigerator) o Actions to take  Notify vaccine coordinator  Isolate and label vaccines with “Quarantine” and date of cold chain break  Store the vaccine at appropriate temperatures and monitor the storage unit conditions  Transfer vaccine to an alternative storage unit/cooler if storage unit has failed (breakdown, power outage, human error, etc.)  Identify the source of the failure (breakdown, power outage, human error)  Fill out appropriate forms according to jurisdictional/local guidelines  Contact jurisdictional/local public health office for further guidance

Answer 267

Role 1: Assess and report Assess and report on a) the existence and impact of health inequities, and b) effective strategies to reduce these inequities. Assess and report includes public health surveillance activities, specifically “the ongoing systematic collection, analysis, interpretation and dissemination of health data for the planning, implementation and evaluation of public health action” (Choi, 2012). It also includes assessing and reporting effective strategies to reduce inequities. Role 2: Modify and orient interventions Modify and orient interventions and services to help reduce inequities, with an understanding of the unique needs of populations that experience marginalization. It is essential for public health programs to reach populations that experience marginalization. Programs and services must be planned, implemented and evaluated with a consideration of equity. Role 3: Partner with other sectors Partner with other government and community organizations to identify ways to improve health outcomes for populations that experience marginalization. Because most of the social determinants of health lie outside of the health sector, working with multiple partners - including government, community organizations, communities, and specific populations - is an essential part of public health practice, especially considering that differences in our health are influenced by economic and societal factors. Role 4: Participate in policy development and advocacy Lead, support and participate with other organizations in policy analysis and development, and in advocacy for improvements in health determinants and inequities. Participating in policy development and advocacy is a key role for public health to improve health equity because policies that promote health improve conditions where people live, work and play.

Answer 268

1. Risk assessment a. Hazard/Risk identification; likelihood of exposure b. Surveillance 2. Risk control a. Routine precautions (PPE, hand hygiene, sharps disposal) b. Transmission based precautions (contact, droplet, airborne) c. Immunization d. Environmental cleaning; Sterilization 3. Education and training 4. Outbreak management 5. Evaluation

Answer 269

ROTER 1. Risk assessment a. Hazard/Risk identification; likelihood of exposure b. Surveillance 2. Risk control a. Routine precautions (PPE, hand hygiene, sharps disposal) b. Transmission based precautions (contact, droplet, airborne) c. Immunization d. Environmental cleaning; Sterilization 3. Training and education 4. Outbreak management 5. Evaluation

Answer 270

Reception: Presence of hand sanitizer, signage Environmental cleaning: Prompt cleaning and disinfecting when body fluids spill, including existing policies, routine cleaning of high touch surfaces, proper waste disposal Hand Hygiene: Following 4 moments of hand hygiene, availability of hand sanitizer, soap and water PPE: Gown, gloves, masks are available and used as appropriate Medical reprocessing: Spaulding's criteria followed Medication Room: Handwashing facilities, dedicated medication/vaccine fridge, clean area, single dose vials discarded after use, multidose vials use single use needles and syringes, and MDVs are never entered with a used needle or syringe Aseptic technique: Hand hygiene and alcohol prep pads are used before procedures Sharps safety: Sharps containers clearly labelled, not overfilled, policy in place to prevent and respond to needlestick injuries Specimen handling: policy for handling blood and body fluids, specimens stored separate from clean supplies, separate from vaccines/medications, separate from food/drinks Policies and Procedures: IPAC policies and procedures based on current best practices, scientific literature, and standards, they are written and regularly reviewed Education: Orientation and regular education on IPAC practices, process for reporting attendance and completion of education and training sessions Occ Health: Compliance with Ontario Occupational Health and Safety Act, policy for prevention of bloodborne illness and post exposure management, staff don't come to work when ill, staff immunized, hazardous materials labelled according to WHMIS, presence of eyewash station Vaccines: Cold chain maintained, fridge temperature monitored and kept between 2 and 8 C, fridge temperature alarm Indoor Air Quality: HVAC maintained

Answer 271

IPAC Framework Risk assessment including surveillance: o Maintain a surveillance system for animals and human illness in order to detect rabies and promptly implement prevention and control measures as required Risk control including immunization: o Encourage vaccination of domestic pets, livestock, and horses o Individuals who are at high risk of exposure such as veterinarians, wildlife and park personnel, or travellers to areas where rabies is endemic, should receive pre-exposure immunization o Wash animal bite wounds immediately with soap and clean running water and seek medical attention promptly o Post-exposure prophylaxis following high-risk exposure o Baiting program and trap-vaccinate-release programs Education and training: o Educate the public on ways to reduce exposures to wild animals including not feeding wildlife and ensuring homes are sealed from bats o Promote the reporting of aggressive animals, or animals that have bitten people, to the local board of health Outbreak management: o N/A Evaluation: o Regular evaluation of control programs and ongoing quality improvement Could also use 6 E's Framework (or One Health approach?)

Answer 272

Ensure you cover both positive AND negative. Think about the associated substance (e.g. gasoline well), the operations (e.g. industrial pollution, noise), the community context (e.g. vulnerable populations).

Answer 273

1. Money: Inadequate resources 2. Staff: Resistance to change 3. Culture: Inadequate consultation

Answer 274

Farm to Fork Approach: Key Stages and Food Safety Measures 1. Farm (Primary Production) Activities: Growing crops, raising livestock. Risks: Contaminated water, improper use of pesticides, infected animals. Safety Measures: -Use of clean irrigation water. -Responsible use of veterinary drugs and pesticides. -Proper manure handling and composting. -Animal health monitoring and vaccination. 2. Processing & Handling Activities: Slaughtering, packaging, processing (e.g., pasteurization, canning). Risks: Cross-contamination, microbial growth due to poor hygiene or temperature control. Safety Measures: -Hazard Analysis and Critical Control Points (HACCP) systems. -Clean equipment and surfaces. -Worker hygiene training. -Temperature control and sanitation protocols. 3. Distribution & Transport Activities: Transporting food to retailers, markets, or food service outlets. Risks: Temperature abuse, contamination during loading/unloading. Safety Measures: -Cold chain management (especially for perishables). -Clean, sealed containers and vehicles. -Regular inspection of transport systems. 4. Retail & Food Service Activities: Supermarkets, restaurants, cafeterias. Risks: Poor food handling, cross-contamination, unsafe storage. Safety Measures: -Staff training in food hygiene. -Safe food storage and labeling. -FIFO (First In, First Out) inventory system. 5. Consumer (Fork) Activities: Cooking, storing, and consuming food at home. Risks: Improper cooking, poor personal hygiene, inadequate refrigeration. Safety Measures: -Educating consumers on safe food practices. -Clear labeling with use-by dates and storage instructions. -Promoting proper handwashing, cooking temperatures, and food -storage. 🧬 Public Health Impact -Reduces foodborne illnesses (e.g., Salmonella, E. coli, Listeria). -Prevents outbreaks and ensures traceability during recalls. -Protects vulnerable populations (children, elderly, immunocompromised). -Enhances consumer confidence in food systems.

Answer 275

💧 Source to Tap Approach: Key Stages and Water Safety Measures 1. Water Source Protection Sources: Rivers, lakes, reservoirs, groundwater. Risks: Agricultural runoff, industrial pollution, human/animal waste. Safety Measures: -Watershed protection (e.g., restricting land use near sources). -Monitoring for pollutants (e.g., nitrates, pathogens, heavy metals). -Buffer zones and reforestation to reduce erosion and runoff. 2. Water Collection Activities: Drawing water from natural sources for treatment. Risks: Intake of contaminated water or debris. Safety Measures: -Controlled intake locations and filtration barriers. -Regular water quality testing at abstraction points. -Seasonal adjustment of intake to avoid high contamination periods. 3. Water Treatment Activities: Removing contaminants to make water safe to drink. Risks: Inadequate treatment, equipment failure, chemical overdosing. Safety Measures: -Multi-barrier treatment (coagulation, filtration, disinfection). -Use of safe and approved chemicals (e.g., chlorine, ozone, UV). -Monitoring and maintenance of treatment facilities. 4. Storage & Distribution Activities: Transporting treated water to homes via pipes and tanks. Risks: Pipe leaks, biofilm growth, backflow contamination. Safety Measures: -Pressurized and sealed distribution systems. -Regular inspection and maintenance of pipes and reservoirs. -Protection from cross-connections with wastewater systems. 5. Consumer Tap Activities: Water use in homes, schools, and businesses. Risks: Contamination from plumbing materials, stagnation in pipes. Safety Measures: -Use of certified plumbing materials. -Flushing of stagnant water (especially in unused buildings). -Public education on safe water storage and usage. 🩺 Public Health Impact -Prevents waterborne diseases (e.g., cholera, typhoid, cryptosporidiosis). -Protects vulnerable communities with limited immunity. -Supports hygiene, sanitation, and food safety. -Promotes trust in municipal water systems and emergency preparedness.

Answer 276

-Changes in local reporting procedures or policies (e.g., a change from passive to active surveillance). -Changes in case definition (e.g., AIDS in 1993). -Increased health-seeking behavior (e.g., media publicity prompts persons with symptoms to seek medical care). -Increase in diagnosis. -New laboratory test or diagnostic procedure. -Increased physician awareness of the condition, or a new physician is in town. -Increase in reporting (i.e., improved awareness of requirement to report). -Outbreak of similar disease, misdiagnosed as disease of interest. -Laboratory error. -Batch reporting in which reports from previous periods are held and reported all at once during another reporting period (e.g., reporting all cases received during December and the first week of January during the second week of January). -Increase in population size -Improved diagnostic procedures -Enhanced reporting -Duplicate reporting.

Answer 277

The alcohol harm paradox notes that lower income groups suffer from higher rates of alcohol related harm compared with higher income groups. Canadians with the lowest incomes report less heavy drinking but are more than twice as likely to be hospitalized for conditions entirely caused by alcohol. Possible reasons for this are higher stress levels, limited social supports, and poor diet and physical inactivity.

Answer 278

1. Administrative controls: Policies and procedures that maintain information security (e.g., record retention policies) 2. Technological controls: Electronic algorithms that maintain information security (e.g., firewalls) 3. Physical controls: Physical barriers that maintain information security (e.g., building access cards)

Answer 279

Host: Increased number of partners, decreased condom use, increased substance use, increased awareness of testing Agent: Antimicrobial resistance, synergistic interactions Environment: Change in case definitions, change to clinical guidelines, new treatments such as PrEP, social media and dating apps, changes to testing, more sensitive tests

Answer 280

o Toxin: toxic substance made by living organisms such as animals or microorganisms (e.g. snake venom, bacterial toxins) o Toxicant: toxic substances that are man-made or result from anthropogenic activity: * Toxicodynamics: dose-response effects of xenobiotics on an individual (i.e. what a drug does to your body) * Toxicokinetics: what the body does to the drug (ADME) o Absorption: ability to pass into the body o Distribution: transport throughout the body o Metabolism: activation vs. detoxication o Excretion: elimination from the body

Answer 281

-Warmer temperatures -Runoff from agricultural fertilizers -Excess nitrogen and phosprorous Other -Release cyanotoxins that build up in water and marine life -Includes saxitoxin which can cause paralytic shellfish poisoning (red tide) -IARC 2B for cancer -Symptoms - GI (N/V), Skin (irritation), Neuro (headache weakness, paralysis) -MAC 0.0015 mg/L -Cannot be boiled out -Ultrafiltration, oxidation and activated charcoal can treat cyanotoxin-contaminated water

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-Incidence -Duration of disease -Increase in case fatality -Differential migration of people with/without disease -Changes in diagnosis -Changes in case definition -Changes in reporting -Changes in case finding

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o Social support: can decrease the risk for premature death and poor health by promoting healthy behaviours and helping people deal with difficult situations o Social isolation: can increase risk of depression, poor sleep, difficulties paying attention, impaired decision making, problem solving and memory, cognitive decline, poor cardiovascular function, poor immune function and stress o Community belonging: those with a strong sense of community belonging are more likely to report having excellent or very good health o Stress: chronic stress can increase the risk of early death and poor physical/mental health. Neighbourhood features linked to increase stress and poor mental health include hazards, noise, trash, poor quality housing, lack of services, low walkability, and lack of green space. Long commute times can be a source of stress o Social interactions: neighbourhoods can affect social interactions by increasing the probability of meeting others and by providing places to gather

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o Reduce the risk of premature death o Cardiovascular: decreased coronary heart disease, stroke, hypertension, o Cancer: decreased colon cancer, breast cancer o Deceased type 2 diabetes o Improve muscular and cardiorespiratory fitness o Improve bone and functional health (decrease osteoporosis) o Reduce risk of falls as well as hip or vertebral fractures o Fundamental to energy balance and weight control o Improved cognitive function and indicators of mental health

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o Background: context in which the individual or committee will work o General: describe the membership, the chair, agenda process, minute process, frequency of meetings, whether or not delegation is permitted, quorum requirements o Decision making process: consensus, voting, etc. o Function of the committee/position: describe the responsibilities o Role of the committee/position: list the tasks that the committee will complete, describe the role of chair o Frequency at which the Terms of Reference will be reviewed (e.g. annually)

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- N: nutrition label standards and regulations - O: offer healthy food in public institutions - U: use economic tools for food affordability - R: restrict food advertising - I: improve nutritional quality - S: set incentives for healthy food environment - H: harness food supply chain - I: inform people about food and nutrition - N: nutrition advice and counselling - G: give nutrition education and skills

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Decreased Premature death Decreased CVD, stroke, hypertension Decreased colon cancer, breast cancer Decreased obesity, diabetes Increased bone strength, decreased falls Increased cognitive function, Improved mental health

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Particulate matter (2.5 worst) - Lung function impairment, cardiovascular disease, intrauterine growth restriction, IARC Group 1 for lung cancer, mortality Nitrogen dioxide - Lung function impairment, ↑ respiratory infections, ↑ allergic airway inflammation Sulfur dioxide - Lung function impairment, cardiovascular disease Ozone - Lung function impairment, COPD exacerbations Carbon monoxide - Fatigue, dizziness, headache, neurological damage, exacerbate CVD

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SINCE - Security of benefits: employee is paid when they sustain an injury at work - Independent administration: administrator is separate from a government entity - No fault compensation: no matter who is at fault (employee or employer), benefits are paid to injured employee - Collective liability: all employers contribute to system - Exclusive jurisdiction: only insurers that are workplace compensation organizations can provide worker’s compensation insurance

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Ecological fallacy - incorrectly applying group-level data to individual relationships Atomistic fallacy - incorrectly applying individual-level data to group relationships

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Budgeting: estimation of revenue and expenditure over a set period of time * Balance sheet: snapshot in time to examine financial assets and liabilities * Income statement: revenues and expenses over a certain time period, typically one year * Cash flow statement: cash over a certain time period, typically one year (operating activities, capital activities, investing activities)

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- Extremes of age (infants, young children, and older adults - People with chronic illnesses or who are physically impaired - People taking certain medications that affect heat or cold sensitivity by interfering with the body’s cooling functions or water/salt retention (e.g., antihypertensives, antidepressants, antipsychotics, anti-Parkinson’s) (beta-blockers for cold) - Newcomers to Canada and transient populations (e.g., tourists) - Certain occupational groups (e.g., farmers, construction workers, miners, tree planters), particularly outdoor workers - Those who are physically active (for heat) - Socially isolated, those who lack air conditioning - Winter sport enthusiasts (for cold) - Homeless persons and those lacking shelter or proper clothing

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ST. PPP System: Change in case definition or reporting requirements, change in guidelines Test: Change in sensitivity or threshold for positive diagnosis Patient: Change in awareness, change in access Provider: Change in awareness, misdiagnosis Population: Change in denominator, change in demographics

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Gather information: 5 W's Assemble team: PHIs, managers, comms, legal Investigate: Disclose to operator and then do an inspection - Inspection should include looking at device reprocessing including through Spaulding's criteria Confirm whether there has been a breach Notification: Professional regulatory body, ministry of health, provincial CDC, communications department, legal team Risk assessment to determine what is the health risk (Q's to answer: what is the actual health risk, prevalence of disease in exposed pop'n, vulnerable pop'n, how long has this been going on, how big of an issue is this, what other lapses were discovered, how likely is operator to be cooperative, length of risk, number of people affected, multiple locations involved) Interventions Education, mandatory corrective action, order for closure Public Notification: Done by health unit vs operator vs public notice (if doing public notice involve MOH, lab system, primary care) -Considerations: cooperativeness of operator, capacity of operator/health unit, timeliness needed for response, completeness of records kept -If operator is notifying will need to follow up to ensure this happens

Key PHPM Concepts to Review Flashcards

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