Miscellaneous from 2021 Deck COPY

Question 1

You are the MOH of a large urban health unit. You have just been informed that an unknown contaminant was accidentally introduced into a batch of beers at a craft brewery. The batch of beers was shipped out two weeks ago. List steps that you would take to reduce the public risk.

Answer 1

Initiate a food safety investigation and recall process

CFIA process

1. Conduct a product safety investigation
2. Conduct a health risk assessment
3. Initiate a recall process
4. Implement the call process
5. Inform the public
6. Ongoing follow up
7. Work collaboratively with provincial and federal stakeholders including the Canadian food Inspection Agency
8. Conduct a health risk assessment of the contaminant
9. Issue a recall on the contaminated product if required
10. Conduct a safety investigation and ensure adequate steps take to prevent ongoing contamination / future contamination
11. Inform the public

Question 2

Describe the three classes of risk that can be assigned for a food recall

Answer 2

Class I (high risk): There is a high risk that eating or drinking the food product will lead to serious health problems or death.

Class II (moderate risk): Eating or drinking the food product will most likely lead to short-term or non-life threatening health problems. The chance of any serious health symptoms is low in healthy populations.

Class III (low and no risk): Eating or drinking the food product will not likely result in any undesirable health effects. This category can include food products that pose no health and safety risk, but do not comply with relevant laws (e.g. a product has more than the allowed level of an additive or preservative).

Question 3

What are 6 triggers for a food safety investigation?

Answer 3

• Outbreak of illness
• Food test result
• CFIA inspection finding
• Consumer complaint
• Company initiated
• Recall in other country

Question 4

You are a MHO. You have received a report of 3 children with bloody diarrhea who all attend the same boarding school. List 8 steps that you would take in the management of this report.

Answer 4

• Confirm outbreak and diagnosis
• Consider immediate control measures
• Assemble an outbreak response team
• Establish case definition - PPTLS (standard set of criteria for determining if a person should be classified as part of an outbreak, such as lab diagnosis, symptoms, person, place, and time; may be divided into confirmed, probable, and suspect/possible)
• Identify cases and contacts (line list), and obtain information

Organize data in terms of person, place, and time (descriptive epidemiology)

Define the population at risk

Develop and test hypotheses

Implement control measures: The chosen control strategies should take into account epidemiology, study findings, environmental sampling, and theory; practically, control strategies will also be influenced by jurisdictional authority, legal roles, political sensitivity, timeliness of outbreak detection, interpersonal issues, and available resources

Monitor the response

Summarize in a report

Question 5

List two types of study designs used in the investigation of food borne outbreaks, provide an example of when you would use each type, provide the measure of association you would calculate.

Answer 5

Retrospective cohort study. Useful when small, well-defined population, such as an outbreak of gastroenteritis among wedding guests for which a complete list of guests is available.

• the investigator calculates an attack rate for those exposed to (e.g., who ate) a particular item and an attack rate for those who were not exposed.

Case- control. Useful when attempting to determine cause of outbreak in large poorly defined population. For example, much larger number of salmonella cases observed in a health unit than normal for that time period.

Case-patients and a comparison group of persons without disease (“controls”) about their exposures.

Question 6

Your outbreak investigation identifies two plausible food exposures that may have resulted in the outbreak. What are three factors that suggest a particular food item is the source of an infection is a gastroenteritis outbreak?

Answer 6

The attack rate is high among those exposed to the item.

The attack rate is low among those not exposed, so the difference or ratio between attack rates is high.

Most of the case-patients were exposed to the item, so that the exposure could “explain” or account for most, if not all, of the cases.

Question 7

You are conducting an investigation of 14 members of the general public who have all developed Verotoxin producing e.coli. You have determined that you will do a case control study to identify a potential exposure. List three ways that you might identify controls.

Answer 7

• In a community outbreak, a random sample of the healthy population is the best control group

Alternative include
- Neighbours of case-patients

• Patients from the same physician practice or hospital who do not have the disease in question,
• Friends of case-patients who they have not recently seen

Question 8

What are 8 organisms that can be transmitted through meat?

Answer 8

1. Staph Aueus
2. Brucellosis
3. E.coli
4. Salmonella
5. Campylobacter
6. Trichella
7. Listeria
8. Toxoplasmosis

Question 9

What are 4 organisms that can be transmitted through unpasteurized milk?

Answer 9

Salmonella
E. coli
Listeria
Campylobacter
Brucellosis
Cryptosporidium

Question 10

What are four categories of hazards that can be found in food. list an example for each

Answer 10

Biological - presence of bacteria such as e.coli

Physical - presence of foreign bodies from food processing or contamination. Ex, small glass fragmenets

Chemical - mercury found in marine animals through bioaccumulation

Allergenic Hazards - contamination with an allergen containing food such as peanuts

Question 11

List 5 types of chemical hazards that can be present in food

Answer 11

Mycotoxins
Natural Toxins
Marine Toxins
Environmental Contaminants
Food Additives
Processing-induced chemicals
Pesticides/Agricultural Products and
Veterinary Drug Residues

Question 12

You are a MOH and are reviewing the annual budget for your health unit. List 4 steps you would take in preparing the budget for review by your board of health

Answer 12

gather information

understand each line item

predict the future (revenues and expenditures)

review the results

finish the budget

add assumptions

check numbers

present

Question 13

Describe three types of budgeting strategies?

Answer 13

1. Zero based budgeting (bottom up) - New budget is based on the justification of the expense, regardless of the amount budgeted in previous years (i.e., no base taken into account)
2. Incremental budgeting (historical) - New budget is the product of incremental, small changes to the previous budget
3. Marginal Analysis
   a) review and analyze budget for each program area
   b) identify programs that could cut funding without significant loss in function
   c) identify programs that could improve substantially with more funding
   d) allocate money from b to c

Question 14

What are three functions of a budget?

Answer 14

1. Transparency and accountability (Performance Monitoring)
2. Prioritization and planning (Decision Making)
3. Control and monitoring of spending (Accounting)

Question 15

Name 5 types of validity and describe them

Answer 15

Content Validity - did the study measure the right things? I.e. for depression did it capture all aspects of depression or just some?

Construct Validity - did the study accurately measure the things it wanted to study

Criterion Validity - how well does the test compare to an established measure or predict the desired outcome. E.g. does a score on this test accurately predict future smoking

Internal Validity - degree of confidence that the causal relationship being tested is trustworthy and not influenced by other factors or variables.

External Validity - extent to which results from a study can be applied (generalized) to other situations, groups or events.

Question 16

What organism is resistant to chlorine in water? What method can be used to remove this organism from water?

Answer 16

• Cryposporidium
• Filtration removes crypto oocysts

Question 17

List 2 ways or reducing exposure to trihalomethanes in water?

Answer 17

• At the source: reduce organic load in water before chlorine is added
• At the tap: charcoal filter

Question 18

What are the risks associated with recreational water? (ie. beaches, spas, pools)

Answer 18

Physical: injuries, drowning
Microbiological: enteric illness, pseudomonas, legionella
Chemical: skin and mucous membrane irritation due to chlorine

Question 19

What is the Tobacco Endgame? List 5 measures mentioned in the 2019 Tobacco Endgame report impact tobacco use.

Answer 19

-An initiative with a goal of reducing tobacco smoking prevalence to below 5% by year 2035.

• Increasing tobacco taxation
• Regulating tobacco prices (e.g. set minimum pricing)
• Raising legal age to 21
• Preventing contraband
• Plain and standardized packaging
• Enhancing package health warnings
• Banning flavours
• Expand and systematize tobacco cessation program across community, workplace, and clinic settings
• Tobacco retail reform by restricting tobacco sale to specialty stores
• Expanding smoke-free places (e.g. universities/colleges)

Question 20

What is the public health argument for vaping?

Answer 20

• Cession - For current smoker, vaping can be useful as a tobacco cessation tool.
• Harm-Reduction -Vaping is less harmful than tobacco smoking because vaping contains fewer number and lower level of harmful chemicals than found in tobacco and tobacco smoke except for nicotine.

Question 21

What are the public health arguments against vaping?

Answer 21

• Vaping may be a gate-way drug to future tobacco smoking
• Nicotine: Vaping with nicotine-containing liquid can lead to nicotine dependence and addiction, adversely affecting memory and concentration. Children and youth especially susceptible to harmful effect of nicotine as it can alter adolescent brain development (reduced impulse control, cognitive and behavioural problem)

Other chemicals:

• The long term health effects of inhaling chemicals used in vaping liquids such as vegetable glycerin, propylene glycol and chemicals for flavouring are unknown
• The heating process of vaping liquid may create new chemicals such as formaldehydes, which is harmful for health
• Some contaminants (e.g. nickel, tin, aluminum) might also get into the vaping products and then into the vapour.
• Long term health effects of inhaling second-hand vapour are unknown.

Question 22

What two federal regulations are in place for vaping products?

Answer 22

A) Tobacco and Vaping Products Act (TVPA) - setting minimum legal age to 18, banning sale of youth-appealing vaping products, giving federal gov’t ability to make rules on industry reporting/manufacturing standards/product & package labeling/vaping product promotion/restricting use of certain ingredients and flavours

B) The Food and Drug Act - applying to vaping products that make a health claim (help quit smoking). This includes products that contain nicotine or any other drugs as defined by the FDA. These products must receive an authorization from Health Canada before they can be commercially imported, sold or advertised in Canada.

C) Canada Consumer Product Safety Act - applying to vaping products not making a health claim, regulating manufacturing, importation, advertisement and sale of these vaping products.

D) Non-smokers’ Health Act (NSHA) addresses the issue of second-hand smoke and vapour in federally regulated workplaces (e.g. federal gov’t offices, banks, commercial aircraft, ferries)

Question 23

What are 3 key observation regarding vaping in the Canadian Tobacco and Nicotine Survey 2019?

Answer 23

1) Vaping is far more prevalent among younger Canadians (aged 15 to 24 years old) with >1/3 of youths aged 15-19 and nearly 1/2 of young adults aged 20-24 surveyed ever trying vaping products.
2) Majoring of users of vaping products have used vaping liquids containing nicotine (~80%)
3) Younger Canadians (15-24 yo) are more likely to vape for recreational purposes with those 25+ much more like to cite tobacco cessation as the main reason for vaping
4) Perceptions of harm vary between users and non-users of vaping products with higher proportion of users perceiving vaping as less harmful than tobacco smoking.

Question 24

Define non-ionizing radiation and ionizing radiation. Electromagnetic fields are an example of which type?

Answer 24

Ionizing radiation- radiation with enough energy to remove an electron from an atom
Non-ionizing radiation- Electromagnetic wavelengths that are longer and less energetic than ionizing radiation

EMFs are an example of non-ionizing radiation

Question 25

What is Kaplan's criteria and when is it used?

Answer 25

Used when microbiological confirmation of a suspected norovirus outbreak is not possible, the Kaplan Criteria may be applied to determine the likelihood that the outbreak is of viral origin. These criteria are as follows: 1) a mean (or median) illness duration of 12 to 60 hours, 2) a mean (or median) incubation period of 24 to 48 hours, 3) more than 50% of people with vomiting, and 4) no bacterial agent found. When all four criteria are present, there is a high likelihood that the outbreak is attributable to norovirus.

Question 26

List 4 ways federal government excise its power in public health?

Answer 26

The Federal government derives its claims for jurisdiction in public health from its authority over: -International treaties (IHR 2005) -Criminal law -Power to quarantine at ports of entry under the Constitution Act -Tax/Spending power -“Peace, order, and good government” -Special population: Aboriginal/Military/Federal prisons/Refugees -Licensing powers (e.g. patents) -Charter of Rights and Freedoms

Question 27

List four requirements/ provisions from the international code of Marketing of Breastmilk Substitutes

Answer 27

The Code includes these ten important provisions: No advertising of products under the scope of the Code to the public. No free samples to mothers. No promotion of products in health care facilities, including the distribution of free or low cost supplies. No company representatives to advise mothers. No gifts or personal samples to health workers. No words or pictures idealizing artificial feeding, including pictures of infants on the labels of products. Information to health workers should be scientific and factual. All information on use of breastmilk substitutes, including the labels, should explain the benefits of breastfeeding and all costs and hazards associated with artificial feeding. Unsuitable products such as sweetened condensed milk should not be promoted for babies. Products should be of a high quality and take into account the climatic and storage conditions of the country where they are used.

Question 28

What is the goal of the baby friendly initiative?

Answer 28

Protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services.

Question 29

List three major changes between the original BFI steps and the new steps released in 2018.

Answer 29

1. Inclusion of compliant with the international code of marketing of breast milk supplements within the 10 steps 2. Responsibility of facility is now to facilitate discharge and linkage to community services rather than directly providing community services (breast feeding support groups) 3. Now advises counselling mothers on against the use of bottles, teats and pacifiers rather than prohibiting them

Question 30

What are four policy interventions that can be used to reduce obesity in Canada? Provide an example.

Answer 30

Education - regularly publish and promote information health eating and activity (Canada Food guide) Economic - modify the cost of food through subsidies so that healthy foods are less expensive and use taxes to make ultraprocessed food more expensive Service Delivery - improve food offering by governments (jails, schools, military) Laws - ban certain food types of activities (prohibit marketing of foods to children)

Question 31

List 6 steps in reproecessing of instruments

Answer 31

1. Pre-clean - remove visible soil and transport to reprocessing area 2. Disassembly and soaking - soak and pre-treat with enzymatic cleaner 3. Cleaning (mechanical) - mechanically remove soil with detergent, clean and flush lumens 4. Rinsing and drying 5. High-level disinfection or sterilization - if using high-level disinfectant document process parameters, if using steam sterilization document (time temperature pressure) 6. Store in transport in manner that avoid damage or contamination

Question 32

What are four ways that an IPAC lapse can occur in an office based setting?

Answer 32

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

Question 33

Due to a series of PH emergencies your health unit is coming in 3 percent over budget. Assuming that no additional revenue is available and there is 3 months left in your fiscal year what are 4 ways that you can have a balanced budget.

Answer 33

Ways to decrease expenditures - Salary gapping - Decrease material and supplies budget - Restructuring (letting individuals go) - capital asses sales (ex. buildings) - professional substitution (ex. LPN vs. RN) - technological efficiencies

Question 34

You have identified the need to fund a new program aimed at providing a service for an unmet community need. There is currently no dedicated funding in your budget to fund the program. What are three ways you can create room in a budget for a new expenditure?

Answer 34

Decrease costs in another program area One time Revenue Gain (sale of assets, draw from reserve funds) Increase regular program funding (apply for funding from funders, increase cost of provided services)

Question 35

List 4 sources of radiofrequency electromagnetic radiation.

Answer 35

cell phone towers, broadcasting towers, cell phones, microwaves, MRIs, high voltage powerlines, WiFi

Question 36

What is electromagnetic hypersensitivity syndrome?

Answer 36

Collection of non-specific symptoms experienced by individuals who believe it is a result of RF-EMF. -headache, dizziness, fatigue, myalgias, rashes, sleep disturbance. There is currently no evidence to confirm the existence of this syndrome as a medical condition.

Question 37

What are the steps of integrated pest management?

Answer 37

1. Identify and monitor for pests 2. Set action thresholds 3. Prevention measures 4. Control measures

Question 38

What are the six steps of a situational assessment

Answer 38

1. Determine Key Question - what is the situation, what is making it better/ worse, what actions can you take to address? 2. Develop Data Gathering Plan 3. Gather the data 4. Organize and Synthesize the data - SWOT analyses or force field analyses 5. Communicate the findings 6. Consider how to proceed with planning

Question 39

What is the purpose of a situational assessment?

Answer 39

Systematic process to gather analyze and communicate data to inform a planning decision Helps do the following - Learn about a population of interest - Anticipate trends and issues that may impact planning / implementation - Set priorities - Inform pending decisions

Question 40

Steps in a health equity assessment

Answer 40

Scoping Potential impacts Mitigation Monitoring Dissemination

Question 41

Steps in a health impact assessment

Answer 41

Screening - determining if an HIA is warranted/required Scoping - determining which impacts will be considered and the plan for the HIA Identification and assessment of impacts - determining the magnitude, nature, extent and likelihood of potential health impacts, using a variety of different methods and types of information Decision-making and recommendations - making explicit the trade-offs to be made in decision-making and formulating evidence-informed recommendations Evaluation, monitoring and follow-up - process and impact evaluation of the HIA and the monitoring and management of health impacts

Question 42

You receive a report of an individual with a 8mm TST. List 5 pieces of additional information you need to guide management?

Answer 42

HIV Status Contact of a active TB case in past two years? Organ transplant Prior hx of TB Immune suppressing medications (TNF-alpha) Child less than 5 years?

Question 43

You receive a report of a HCW who has a TST of 9mm a) When does TST conversion occur? b) Outline two criteria for TST conversion?

Answer 43

a TST seroconversion occurs within 8 weeks of exposure b 1) an exposed individual (or high risk) with a TST \>10 mm with a prior TST \<5 2) if an individual previously had a TST of 5-9mm and the TST increased by 6mm or more

Question 44

List 5 steps in the policy cycle

Answer 44

Agenda Setting Policy Formation Decision Making / Adoption Implementation Evaluation

Question 45

List 5 levels of public participation

Answer 45

Inform - we will keep you updated Consult - we will listen and acknowledge your ideas Involve - we will work with you to make sure your ideas are factored into our decision making Collaboration - we will work together to make decisions Empower - we will implement what you decide

Question 46

List Kotter’s 8 steps process for leading change:

Answer 46

Step 1: Create a sense of Urgency \* Examine market and competitive realities \* Identify and discuss crises, potential crises or major opportunities Step 2: Developing the Guiding Coalition \* Assemble a group with enough power to lead the change effort \* Encourage the group to work as a team Step 3: Developing a Change Vision \* Create a vision to help direct the change effort \* Develop strategies for achieving that vision Step 4: Communicating the Vision Buy-in \* Use every vehicle possible to communicate the new vision and strategies \* Teach new behaviors by the example of the Guiding Coalition Step 5: Empowering Broad-based Action \* Remove obstacles to change \* Change systems or structures that seriously undermine the vision \* Encourage the risk-taking and nontraditional ideas, activities, and actions Step 6: Generating Short-term Wins \* Plan for visible performance improvements \* Create those improvements \* Recognize and reward employees involved in the improvements Step 7: Don't Let Up \* Use increased credibility to change systems, structures and policies that don't fit the vision \* Hire, promote, and develop employees who can implement the vision \* Reinvigorate the process with new projects, themes, and change agents Step 8: Make Change Stick \* Articulate the connections between the new behaviors and organizational success • Develop the means to ensure leadership development and succession

Question 47

You are asked to Chair a provincial working group to reassess Ontario’s Flu vaccine program. a) What are the key tasks a Chair must do before, during and after a meeting?

Answer 47

Before Meeting (preparation) - Define purpose of meeting and who is attending - Create agenda and assign meeting roles - Logistics (time, place, background) During Meeting (facilitation) - Ensure discussion is clear, concise and respectful - Ensure start and end time are respected and meeting agenda met - may review past minutes Post Meeting (2 tasks Summary/ Delegation & evaluation and reporting) - Summarize and communicate decisions made, action items, and deadlines - Evaluate meeting - Potentially report on meeting results to other organizations or levels within own organization

Question 48

List 3 Protective Factors against suicide

Answer 48

- Socio-economic situation › Loving parent-child relationship › Having reasons for living › Social connectedness › Sense of belonging › Religion

Question 49

Calculate the population attributable fraction of hypertension to heart disease. prevalence of obesity = 25% RR = 2

Answer 49

PAF = (prevalence of exposure)\*(RR-1) / 1+numerator = (0.25)\*(2-1) / 1+numerator = 0.25 / 1+0.25 = 0.25 / 1.25 = 0.2 = 20%

Question 50

Three main elements of food security

Answer 50

- food utilization - nutritional value - social value - food safety - food availability - production - distribution - exchanges - food access - affordability - allocation - preference

Question 51

List 5 features of hazards that may lead to them being perceived as 'risky'

Answer 51

Hazard perceived as “risky” Coerced Industrial Exotic Memorable Dreaded Catastrophic Unknowable Controlled by others Unfair Morally relevant Untrustworthy sources Unresponsive process

Question 52

What are the 5 steps in the policy cycle

Answer 52

Agenda Setting Policy Formation Decision Making Implementation Evaluation

Question 53

What are the steps in the emergency preparedness cycle

Answer 53

prevention/ mitigation - Includes any activities that prevent an emergency, reduce the chance of an emergency happening, or reduce the damaging effects of unavoidable emergencies. preparedness - preparations made to save lives and to help response and rescue operations. response - save lives and prevent further property damage in an emergency situation recovery - includes actions taken to return to a normal or an even safer situation following an emergency.

Question 54

What is the goal of emergency preparedness

Answer 54

reduce or avoid the potential losses from hazards, assure prompt and appropriate assistance to damaged materials, and achieve rapid and effective recovery.

Question 55

What are three reasons that protazoa could still be present in a water system that has suffered a contamination event (e.g. a water main break resulting in sewage entering the water supply).

Answer 55

1. Protazoa are generally present in untreated sewage 2. Chlorine does not inactivate protozoa

Question 56

You have received a report of a 12 year old boy with a 13mm TST and a history of BCG vaccination. What information is required to determine if this represents a latent TB infection?

Answer 56

- When was the BCG vaccine given? - Has there been a known exposure to TB? - Is the individual at elevated risk of TB (migrant from high incidence country), Canadian born indigenous or inuit - what is the risk of disease progression (i.e. immune suppressed, HIV +ve) If BCG is given in first year of life only 1% have a TST \> 10mm 10 years later. A history of BCG vaccination can be ignored in all people 10+ if the TST is greater than 10mm If BCG is given after first year of life 42% have false positive TSTS \> 10 mm after 10 years.

Question 57

What steroid daily dose equivalent would suppress TB reactivity and make a TST unreliable?

Answer 57

2-4 weeks of 15mg or greater of prednisone

Question 58

You are interpreting the results of a case control study. a) What are three advantages of a case control study? b) What are three disadvantages?

Answer 58

a) 1) Allows you to examine multiple exposures (cohort studies can do this as well) 2) Good for looking at rare outcomes 3) Efficient studies in terms of time and cost 4) Good at looking at diseases with a long induction period (exposure to event takes a long time) as the event has occurred b) 1) cannot calculate measures of incidence or prevalence 2) information on exposure can be subject to recall or observation bias 3) controls can be subject to selection bias

Question 59

In the context of a case control study define recall bias related to exposure

Answer 59

The possibility that individuals in the case and control arms have the exact same exposure but might report exposures differently in a systematic way

Question 60

You are interpreting the results of a case control study. The study reports and odds ratio of 1.9 Interpret this finding

Answer 60

It tells us how much higher the odds of exposure is among cases of a disease compared with controls. Individuals with the disease had 1.9 times the odds of reporting the exposure of interest compared to individuals without the disease

Question 61

You are interpreting the results of a cohort study. a) What are three advantages of a cohort study? b) What are three disadvantages?

Answer 61

a) 1) Allows you to calculate the incidence of disease in different groups 2) Can examine multiple effects of a single exposure 3) Clarity of temporal sequences of exposure and outcome 4) Can study rare exposures - can ensure that you have sufficient numbers of individuals in your study with the exposure of interest b) 1) Not good for rare diseases 2) Can be very time consuming and expensive (especially for prospective studies and diseases with long latencies) 3) available data may be of low quality in retrospective studies 4) differential loss to follow up can bias results

Question 62

Define relative risk in a cohort study and interpret a RR of 3.4

Answer 62

It tells us how much more likely (or less likely) it is for people exposed to a factor to develop a disease compared to people not exposed to the factor. Individuals who were exposed to factor A where 3.4 more times likely to experience outcome X than individuals who were not exposed to factor A.

Question 63

List 7 of the bradford hill criteria

Answer 63

1. Temporal Association 2. Strength of association 3. Dose response relationshio 4. Experimental evidence 5. Biological plausibility 6. Coherance with established evidence 7. Specificity - one exposure one outcome

Question 64

List 6 ethical considerations from Canada influenza pandemic plan

Answer 64

Transparency / Trust - rationale for decisions should be available to public Proportionally / least coercive means -restrictions should be essential for risk management and proportionate to the risk Reciprocity -individuals who face disproportionate impacts (i.e. HCWs or quarantined) should be supported by society to minimize burdens Stewardship -decisions have been made to achieve the best patient and public health outcomes Equity and fairness - decisions should minimize health inequities

Question 65

List 3 reasons to support maintaining the autonomy of the chief public health officer of Canada

Answer 65

1. Provide evidence based advice - ability to provide science and evidence based advise to governments without political interference 2. Allow Direct Communication to Public: ability to speak directly to citizens on public health issues of concern and engage in advocacy 3. Protect Public Health Priorities - PH budget and staff to ensure prioritization and adequate funding.

Question 66

How can you protect the autonomy of a chief public health officer

Answer 66

1. Protected Budget to carry out activities 2. Ensure minimum qualifications for candidates 3. Create avenue for direct communication with the public 4. Protect position from dismissal without cause - consider having a fixed term 5. Report to an appropriate level of government or be independent 6. Mandatory information sharing / participation.

Question 67

Give four artifactual reasons why you might note a change in a reported health problem

Answer 67

Change in disease definition (different blood pressure cut off for hypertension) Change in screening recommendations or program delivery (prostate cancer screening) Increased public or care provider awareness (a case of active TB in a northern community) New more sensitive test for disease available (i.e. a new PCR test replaces an older culture based method) Decreased stigma of patient self reporting disease (i.e. cannabis use disorder post legalization) Decreased stigma of provider documenting disease (i.e. depression)

Question 68

List 6 recommendations related to detection and treatment of hypertension in Canada according to CHEP

Answer 68

The use of standardized measurement techniques and validated equipment is recommended for all blood pressure (BP) methods. BP should be assessed in all adult patients at all appropriate visits to determine cardiovascular risk and monitor antihypertensive treatment. Target Organ Damage (TOD) should be assessed in patients with hypertension. Presence of any of the following would put a patient into the moderate-to-high or high-risk categories for therapy. Individuals should be engaged in conversation about health behaviour changes and informed on how life style adjustments can help to lower their BP. In patients without a specific indication start individuals on first line treatments. Patient follow up every 3-6 months to monitor active modifications. For patients with BP not at target, visits every 1-2 months are recommended

Question 69

According to hypertension Canada what are the BP treatment targets for a high, medium and low risk patient

Answer 69

High \< 120 / NA DM2 \< 130 / 80 Low risk \< 140 / 90

Question 70

What are the major complications of measles and their probability of occurence?

Answer 70

- 1/5 individuals get hospitalized - 1/10 individuals develop pneumonia - 1 / 1000 develop encephalitis and can lead to permanent brain damage in children - 1-3/1000 children will die - Subacute sclerosing panencephalitis (1/10,000)

Question 71

You are the MOH of local health unit. You receive a call that batch of vaccine was exposed to temperature variation. What four pieces of information would you collect to determine the viability of the vaccine?

Answer 71

1) Information on type and history of vaccine exposed (type, manufacturer, expiry date, prior cold chain breaches). 2) How long were the vaccines exposed to the temperature variation (date and time of breach)? 3) What was the temperature variation? (\<2 and \>8 degrees celcius generally problematic) 4) How certain is the data on the temperature breach (i.e. frequency of monitoring and method) 5. Cause of the breach? 6. Current temperature inside and outside the fridge 7. Volume of inventory exposed to brach 8. Point of breach (transport vs storage)

Question 72

You are the MOH of local health unit. You receive a call that batch of vaccine was exposed to temperature variation. Outline how you will approach this situation

Answer 72

1) Isolate the impacted vaccine and do not use until cleared to do so 2) Gather information including - date and time of breach - date and time breach was identified / reported - point of breach (i.e. transportation, storage) - Cause of breach - duration of breach - extend of breach (max / min temp) - quantity and type of inventory - current temperature 3) Risk assessment including consultation with relevant provincial body and manufacturer 4) identification and notification of patients exposed to breach if required for recall / revaccination

Question 73

List 4 interventions to reduce the harms related to gun violence.

Answer 73

Education - school based violence prevention programs Enforcement - registration and license requirements to purchase guns; ban on private handgun ownership Economics - pricing of guns and ammunition Engineering - gun safety technology (eg. locks)

Question 74

Name one Policy framework and describe its element

Answer 74

Kingdom's Multiple Stream Framework - Problem Stream where a problem needs solutions - Policy Stream where policies alternatives are debated by a policy community. - Political Stream, where power comes into play (three elements= national mood, interest groups, government) - When all three streams align, a policy window opens presenting an opportunity for a policy advocate to push their solution or raise awareness of their problem.

Question 75

What are key benefits / elements of a national immunization strategy

Answer 75

Automated reminders Provides proof of immunization Decreased repeat immunization (with concomitant reduction in immunization costs) Identify unimmunized individuals in the event of an outbreak Easy transfer of records to other regions Manage vaccine inventories more effectively Identify at-risk populations and develop targeted education programs  

Question 76

List 5 features of hazards that may lead to them being perceived as 'risky'

Answer 76

Hazard perceived as “risky” Coerced Industrial Exotic Memorable Dreaded Catastrophic Unknowable Controlled by others Unfair Morally relevant Untrustworthy sources Unresponsive process

Question 77

What is the goal of emergency preparedness

Answer 77

reduce or avoid the potential losses from hazards, assure prompt and appropriate assistance to damaged materials, and achieve rapid and effective recovery.

Question 78

List 4 interventions to reduce the harms related to gun violence.

Answer 78

Education - school based violence prevention programs Enforcement - registration and license requirements to purchase guns; ban on private handgun ownership Economics - pricing of guns and ammunition Engineering - gun safety technology (eg. locks)

Question 79

What are key benefits / elements of a national immunization strategy

Answer 79

Automated reminders Provides proof of immunization Decreased repeat immunization (with concomitant reduction in immunization costs) Identify unimmunized individuals in the event of an outbreak Easy transfer of records to other regions Manage vaccine inventories more effectively Identify at-risk populations and develop targeted education programs  

Question 80

Name one Policy framework and describe its element

Answer 80

Kingdom's Multiple Stream Framework - Problem Stream where a problem needs solutions - Policy Stream where policies alternatives are debated by a policy community. - Political Stream, where power comes into play (three elements= national mood, interest groups, government) - When all three streams align, a policy window opens presenting an opportunity for a policy advocate to push their solution or raise awareness of their problem.

Question 81

You are the MOH of local health unit. You receive a call that batch of vaccine was exposed to temperature variation. Outline how you will approach this situation

Answer 81

1) Isolate the impacted vaccine and do not use until cleared to do so 2) Gather information including - date and time of breach - date and time breach was identified / reported - point of breach (i.e. transportation, storage) - Cause of breach - duration of breach - extend of breach (max / min temp) - quantity and type of inventory - current temperature 3) Risk assessment including consultation with relevant provincial body and manufacturer 4) identification and notification of patients exposed to breach if required for recall / revaccination

Question 82

You are the MOH of local health unit. You receive a call that batch of vaccine was exposed to temperature variation. What four pieces of information would you collect to determine the viability of the vaccine?

Answer 82

1) Information on type and history of vaccine exposed (type, manufacturer, expiry date, prior cold chain breaches). 2) How long were the vaccines exposed to the temperature variation (date and time of breach)? 3) What was the temperature variation? (\<2 and \>8 degrees celcius generally problematic) 4) How certain is the data on the temperature breach (i.e. frequency of monitoring and method) 5. Cause of the breach? 6. Current temperature inside and outside the fridge 7. Volume of inventory exposed to brach 8. Point of breach (transport vs storage)

Question 83

What are the major complications of measles and their probability of occurence?

Answer 83

- 1/5 individuals get hospitalized - 1/10 individuals develop pneumonia - 1 / 1000 develop encephalitis and can lead to permanent brain damage in children - 1-3/1000 children will die - Subacute sclerosing panencephalitis (1/10,000)

Question 84

According to hypertension Canada what are the BP treatment targets for a high, medium and low risk patient

Answer 84

High \< 120 / NA DM2 \< 130 / 80 Low risk \< 140 / 90

Question 85

List 6 recommendations related to detection and treatment of hypertension in Canada according to CHEP

Answer 85

The use of standardized measurement techniques and validated equipment is recommended for all blood pressure (BP) methods. BP should be assessed in all adult patients at all appropriate visits to determine cardiovascular risk and monitor antihypertensive treatment. Target Organ Damage (TOD) should be assessed in patients with hypertension. Presence of any of the following would put a patient into the moderate-to-high or high-risk categories for therapy. Individuals should be engaged in conversation about health behaviour changes and informed on how life style adjustments can help to lower their BP. In patients without a specific indication start individuals on first line treatments. Patient follow up every 3-6 months to monitor active modifications. For patients with BP not at target, visits every 1-2 months are recommended

Question 86

Give four artifactual reasons why you might note a change in a reported health problem

Answer 86

Change in disease definition (different blood pressure cut off for hypertension) Change in screening recommendations or program delivery (prostate cancer screening) Increased public or care provider awareness (a case of active TB in a northern community) New more sensitive test for disease available (i.e. a new PCR test replaces an older culture based method) Decreased stigma of patient self reporting disease (i.e. cannabis use disorder post legalization) Decreased stigma of provider documenting disease (i.e. depression)

Question 87

How can you protect the autonomy of a chief public health officer

Answer 87

1. Protected Budget to carry out activities 2. Ensure minimum qualifications for candidates 3. Create avenue for direct communication with the public 4. Protect position from dismissal without cause - consider having a fixed term 5. Report to an appropriate level of government or be independent 6. Mandatory information sharing / participation.

Question 88

List 3 reasons to support maintaining the autonomy of the chief public health officer of Canada

Answer 88

1. Provide evidence based advice - ability to provide science and evidence based advise to governments without political interference 2. Allow Direct Communication to Public: ability to speak directly to citizens on public health issues of concern and engage in advocacy 3. Protect Public Health Priorities - PH budget and staff to ensure prioritization and adequate funding.

Question 89

List 6 ethical considerations from Canada influenza pandemic plan

Answer 89

Transparency / Trust - rationale for decisions should be available to public Proportionally / least coercive means -restrictions should be essential for risk management and proportionate to the risk Reciprocity -individuals who face disproportionate impacts (i.e. HCWs or quarantined) should be supported by society to minimize burdens Stewardship -decisions have been made to achieve the best patient and public health outcomes Equity and fairness - decisions should minimize health inequities

Question 90

List 7 of the bradford hill criteria

Answer 90

1. Temporal Association 2. Strength of association 3. Dose response relationshio 4. Experimental evidence 5. Biological plausibility 6. Coherance with established evidence 7. Specificity - one exposure one outcome

Question 91

Define relative risk in a cohort study and interpret a RR of 3.4

Answer 91

It tells us how much more likely (or less likely) it is for people exposed to a factor to develop a disease compared to people not exposed to the factor. Individuals who were exposed to factor A where 3.4 more times likely to experience outcome X than individuals who were not exposed to factor A.

Question 92

You are interpreting the results of a cohort study. a) What are three advantages of a cohort study? b) What are three disadvantages?

Answer 92

a) 1) Allows you to calculate the incidence of disease in different groups 2) Can examine multiple effects of a single exposure 3) Clarity of temporal sequences of exposure and outcome 4) Can study rare exposures - can ensure that you have sufficient numbers of individuals in your study with the exposure of interest b) 1) Not good for rare diseases 2) Can be very time consuming and expensive (especially for prospective studies and diseases with long latencies) 3) available data may be of low quality in retrospective studies 4) differential loss to follow up can bias results

Question 93

You are interpreting the results of a case control study. The study reports and odds ratio of 1.9 Interpret this finding

Answer 93

It tells us how much higher the odds of exposure is among cases of a disease compared with controls. Individuals with the disease had 1.9 times the odds of reporting the exposure of interest compared to individuals without the disease

Question 94

In the context of a case control study define recall bias related to exposure

Answer 94

The possibility that individuals in the case and control arms have the exact same exposure but might report exposures differently in a systematic way

Question 95

You are interpreting the results of a case control study. a) What are three advantages of a case control study? b) What are three disadvantages?

Answer 95

a) 1) Allows you to examine multiple exposures (cohort studies can do this as well) 2) Good for looking at rare outcomes 3) Efficient studies in terms of time and cost 4) Good at looking at diseases with a long induction period (exposure to event takes a long time) as the event has occurred b) 1) cannot calculate measures of incidence or prevalence 2) information on exposure can be subject to recall or observation bias 3) controls can be subject to selection bias

Question 96

What steroid daily dose equivalent would suppress TB reactivity and make a TST unreliable?

Answer 96

2-4 weeks of 15mg or greater of prednisone

Question 97

You have received a report of a 12 year old boy with a 13mm TST and a history of BCG vaccination. What information is required to determine if this represents a latent TB infection?

Answer 97

- When was the BCG vaccine given? - Has there been a known exposure to TB? - Is the individual at elevated risk of TB (migrant from high incidence country), Canadian born indigenous or inuit - what is the risk of disease progression (i.e. immune suppressed, HIV +ve) If BCG is given in first year of life only 1% have a TST \> 10mm 10 years later. A history of BCG vaccination can be ignored in all people 10+ if the TST is greater than 10mm If BCG is given after first year of life 42% have false positive TSTS \> 10 mm after 10 years.

Question 98

What are three reasons that protazoa could still be present in a water system that has suffered a contamination event (e.g. a water main break resulting in sewage entering the water supply).

Answer 98

1. Protazoa are generally present in untreated sewage 2. Chlorine does not inactivate protozoa

Question 99

What are the steps in the emergency preparedness cycle

Answer 99

prevention/ mitigation - Includes any activities that prevent an emergency, reduce the chance of an emergency happening, or reduce the damaging effects of unavoidable emergencies. preparedness - preparations made to save lives and to help response and rescue operations. response - save lives and prevent further property damage in an emergency situation recovery - includes actions taken to return to a normal or an even safer situation following an emergency.

Question 100

What are the 5 steps in the policy cycle

Answer 100

Agenda Setting Policy Formation Decision Making Implementation Evaluation

Question 101

Three main elements of food security

Answer 101

- food utilization - nutritional value - social value - food safety - food availability - production - distribution - exchanges - food access - affordability - allocation - preference

Question 102

Calculate the population attributable fraction of hypertension to heart disease. prevalence of obesity = 25% RR = 2

Answer 102

PAF = (prevalence of exposure)\*(RR-1) / 1+numerator = (0.25)\*(2-1) / 1+numerator = 0.25 / 1+0.25 = 0.25 / 1.25 = 0.2 = 20%

Question 103

List 3 Protective Factors against suicide

Answer 103

- Socio-economic situation › Loving parent-child relationship › Having reasons for living › Social connectedness › Sense of belonging › Religion

Question 104

You are asked to Chair a provincial working group to reassess Ontario’s Flu vaccine program. a) What are the key tasks a Chair must do before, during and after a meeting?

Answer 104

Before Meeting (preparation) - Define purpose of meeting and who is attending - Create agenda and assign meeting roles - Logistics (time, place, background) During Meeting (facilitation) - Ensure discussion is clear, concise and respectful - Ensure start and end time are respected and meeting agenda met - may review past minutes Post Meeting (2 tasks Summary/ Delegation & evaluation and reporting) - Summarize and communicate decisions made, action items, and deadlines - Evaluate meeting - Potentially report on meeting results to other organizations or levels within own organization

Question 105

List Kotter’s 8 steps process for leading change:

Answer 105

Step 1: Create a sense of Urgency \* Examine market and competitive realities \* Identify and discuss crises, potential crises or major opportunities Step 2: Developing the Guiding Coalition \* Assemble a group with enough power to lead the change effort \* Encourage the group to work as a team Step 3: Developing a Change Vision \* Create a vision to help direct the change effort \* Develop strategies for achieving that vision Step 4: Communicating the Vision Buy-in \* Use every vehicle possible to communicate the new vision and strategies \* Teach new behaviors by the example of the Guiding Coalition Step 5: Empowering Broad-based Action \* Remove obstacles to change \* Change systems or structures that seriously undermine the vision \* Encourage the risk-taking and nontraditional ideas, activities, and actions Step 6: Generating Short-term Wins \* Plan for visible performance improvements \* Create those improvements \* Recognize and reward employees involved in the improvements Step 7: Don't Let Up \* Use increased credibility to change systems, structures and policies that don't fit the vision \* Hire, promote, and develop employees who can implement the vision \* Reinvigorate the process with new projects, themes, and change agents Step 8: Make Change Stick \* Articulate the connections between the new behaviors and organizational success • Develop the means to ensure leadership development and succession

Question 106

The incidence of disease in the exposed group is 50 per 1000 and the incidence in the unexposed group is 25 per 1000 Calculate and attributable risk percent Interpret this value

Answer 106

Two options a) (RR-1)/ RR \*100 or (Incidence exposed - incidence unexposed) / incidence exposed = 50% so 50% of the outcome in the group that had the exposure could be attributed to having had the exposure

Question 107

What can be the public health roles in addressing racial health inequity?

Answer 107

NCCDH, 2018 1) Building Capacity to analyze and take action on drivers that foster racial inequities 2) Create knowledge by assessing and reporting on the impact of racialization and racism including analyzing health outcomes utilizing an anti-racism lens, and measuring racism on both individual and structural levels 3) Re-orient/modify Health and social interventsion to eliminate racialized health inequities. 4) Develop Policies with an overt focus on tackling racism including implementing racial equity assessments 5) Develop partnerships with other sectors and communities

Question 108

Name one Policy framework and describe its element.

Answer 108

Kingdom's Multiple Stream Framework - Problem Stream where a problem needs solutions - Policy Stream where policies alternatives are debated by a policy community. - Political Stream, where power comes into play (three elements= national mood, interest groups, government) - When all three streams align, a policy window opens presenting an opportunity for a policy advocate to push their solution or raise awareness of their problem.

Question 109

A vaccine has been newly licensed for the disease, Cute Aggression caused by the Adorable Bunny Virus with a R0 of 3. In a RCT with 200,000 study participants, 50% had the vaccine administered and 50% had a placebo administered. In the vaccinated group, 5,000 participants developed the disease; in the unvaccinated group, 100,000 participants developed the disease. Please calculate the vaccine coverage required to achieve the herd immunity.

Answer 109

VE= (Incidence in unvaccinated - Incidence in vaccinated)/ Incidence in unvaccinated x 100% VE = (0.5 - 0.05)/0.5 x 100% VE = 0.45/0.5 x 100% VE = 0.9 x 100% VE = 90% This vaccine has 90% efficacy. Vaccine Coverage = (1- 1/R0) / VE Vc= (1-1/3)/0.9 = 0.666/0.9 = 0.74 You need at least 74% of the susceptible population administered to achieve herd immunity threshold.

Question 110

What are the four population health indicators (according to CIHI)

Answer 110

Health Status - deaths, health conditions, wellbeing Non-medical determinants of health - risk behaviours, living conditions, environment, personal resources (social supports) Health System performance - can the health system provide timely, accessible, safe and effective care Community and health system characteristics - demographic information (population, teen pregnancy rate) - health system demographics (doctors per capita, hospital beds per capita)

Question 111

List 8 measures and the associated data sources that you would use to assess the health of a population in a population health asesssment

Answer 111

Community and health system characteristics - Age and sex breakdown (census data) - Language spoken - Cultural background - Mortality, birth rate, infant mortality rate (vital statistics) Health Status Indicators - Immunization Status - Chronic Conditions (CCHS) - Mental Health Indicators - Health Measures - blood pressure, obesity (CHMS) - Screening received (i.e. cervical cancer, CRC) Non-medical Determinants of Health - Education - Income and finances - Personal Health Behaviors (smoking, alcohol, physical activity)

Question 112

a) Define Program Planning b) Outline steps in program planning

Answer 112

multi-step process that outlines the problem, proposed intervention, and evaluation plan. 1. Manage the planning process (engage stakeholders, timelines, resources) 2. Conduct a situational assessment 3. Identify goals, populations of interest, outcomes and outcome objectives 4. Identify strategies, activities, outputs process objectives and resources 5. Develop indicators Purpose: to develop a list of variables that can be tracked to assess the extent to which outcome and process objectives have been met 6. Review the program plan

Question 113

Outline six steps in program evaluation

Answer 113

Six Steps Engage Stakeholders Describe Program - Need (what does the program address)? - Expected effects (what does it accomplish to succeed?) - Activities (program logic / theory) - Resources (what inputs go in) Focus Evaluation Design Gather Credible Evidence Justify Conclusions Ensure use and share lessons

Question 114

What are three types of stakeholders that should be engaged during a program evaluation?

Answer 114

Three types of stakeholders - Those involved with the program - Those Served by the program - Users of the Evaluation (decision makers)

Question 115

What factors go into making a recommendation by the CTPFHC

Answer 115

1. Quality of evidence (GRADE Evidence - Strong, Moderate, Weak) 2. The balance between desirable and undesirable effects; 3. The variability or uncertainty in values and preferences of citizens; 4. Whether or not the intervention represents a wise use of resources.

Question 116

What are the three GRADE recommendations and what criteria is used to put evidence into these categories?

Answer 116

The quality of evidence is categorized as strong, moderate or weak Strong - a) many studies with no limitations, b) studies are consistent c) estimate of effect has narrow confidence interval Quality of evidence might be seen as strong when; there is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval. Quality of evidence might be seen as moderate when; there are only a few studies and some have limitations but not major flaws, there is some variation between studies, or the confidence interval of the summary estimate is wide. We judge evidence to be low or very low quality when the true effect may be substantially different from the estimate of the effect. For example, evidence might be judged as low quality if any of the following applies: the studies have major flaws, there is important variation between studies, or the confidence interval of the summary estimate is very wide.

Question 117

Outline the differences between social marketing and commercial marketing

Answer 117

Social Marketing Ultimate Goal - improvement of individual health and societal wellbeing Proximate Goal - change in desired behaviour Target - population in need / willing to change Competition - current behaviour Commercial Marketing Ultimate Goal - Financial Gain Proximate Goal - selling product / services Target - population that will maximize sales Competition - other businesses offering similar services

Question 118

7 attributes of a effective surveillance system

Answer 118

PS-FARTS + SVQ (acronym credit: Laura Bourns) Positive predictive value: High proportion of positives are actually cases Sensitivity: Ability of the surveillance system to detect the health problem it was intended to detect\*\*\* Flexibility: Ability of the surveillance system to accommodate changes in the operating conditions Acceptability: To individuals and organizations who must participate Representativeness: Extent to which surveillance findings accurately portray the event\*\* Timeliness: Data available rapidly enough for public health authorities to take action\* Simplicity: Ease of operation Stability: Reliability of resources, personnel, and technology required to support the surveillance system Validity: Surveillance data are measuring what they are intended to measure Quality: Complete and valid data

Question 119

List 4 indicators of health system performance, and one example of each.

Answer 119

Accessibility - proportion of population with a family doctor. Acceptability - patient satisfaction scores. Safety - incidence of hospital acquired infections. Efficiency - wait times for diagnostic procedures.

Question 120

List 4 indicators of health status, and one example of each.

Answer 120

Mortality - all cause mortality rate. Health conditions - type 2 diabetes prevalence. Well-being - self reported health status. Function - disability adjusted life expectancy.

Question 121

What are some population level interventions to reduce obesity rates?

Answer 121

- Restriction on marketing and advertising of junk food. - Menu labeling. - Taxation of sugar sweetened beverages. - Nutrition policies in schools; availability of healthier food choices in cafeteria. - Increased access to active transport - bike lane infrastructure. - Subsidizing gym memberships.

Question 122

A cohort study compares rates of disease by subtracting the rate of disease in an unexposed group from the rate of disease in the exposed group. List all ways that this measure can be referred to How do you interpret this measure

Answer 122

Attributable Risk, Risk Difference, Excess Risk, Absolute Risk Reduction, Absolute Risk Subjects who had an exposure X had Y additional cases of outcome Z per 100 people compared to subjects who did not have exposure X.

Question 123

Define Selection Bias

Answer 123

selection of subjects into a study or their likelihood of being retained in the study leads to a result that is different from what you would have gotten if you had enrolled the entire target population

Question 124

What are three ways that selection bias can occur in a case-control study and provide an example

Answer 124

1. Control Selection Bias. Example - method of selecting controls into the study is more likely to recruit controls who have the exposure of interest than the general population. Problem because controls are used to estimate prevalence of exposure in source population of cases. 2. Self-Selection Bias - agreeing to participate in the study is related to the exposure of interest and the outcome. 3. Differential surveillance / diagnosis of cases and controls. Cases and controls may have been subjected to different levels of case finding.

Question 125

What are three ways that selection bias can occur in a cohort study

Answer 125

1. Differential loss to follow up. Individuals with the exposure are more likely to develop a secondary condition and drop out of the study than individuals without the exposure. 2. Subject Selection (retrospective only). Example, Individuals who had the outcome and exposure of interest are more likely to participate. 3. Healthy worker effect (special type of subject selection bias)

Question 126

What are the two general types of biases in a study that can occur and explain them.

Answer 126

Information bias: Systematic error in measurement, producing differential accuracy of information by level of exposure or outcome (e.g., recall, reporting, observer) Example recall bias: respondent does not remember things correctly Interviewer/observer bias: interviewer unintentionally influences subject's responses Example Selection bias: Subjects are selected such that the distribution of a characteristic among the subjects differs from the distribution of the characteristic in the target population (e.g., sampling, attribution, publication)

Question 127

Most common cancers in men and women

Answer 127

1. Prostate or Breast (Sex Specific Cancer) 2. Lung 3. Colorectal

Question 128

Top cause of cancer death in men and women

Answer 128

Women 1. Lung 2. Breast 3. CRC Men 1. Lung 2. CRC 3. Prostate

Question 129

THREE GENERAL POLICY RECOMMENDATIONS TO PREVENT OCCUPATIONAL CANCER IN CANADA

Answer 129

1. Strengthen occupational exposure limits across all Canadian jurisdictions. 2. Reduce or eliminate the use of cancer causing substances with toxic use reduction policies in workplaces. 3. Create registries of workplace exposures to occupational carcinogens that will facilitate the tracking of exposures over time.

Question 130

What are five commonly used indicators for water quality for municipal scale drink water systems?

Answer 130

Biological 1. Turbidity 2. Chlorine residual 3. Total Coliforms 4. E.coli 5. Cryptosporidum and giardia Chemicals 1. PH (acidity) 2. Trihalomethanes 3. Flouride level

Question 131

What does the presence of e.coli in drinking water (assume not false positive) indicate?

Answer 131

there has been fecal contamination of the water and the water should be considered unsafe to drink

Question 132

What does the presence of total coliforms in the water indicate?

Answer 132

Coliforms: These bacteria are often found in animal waste, sewage, as well as soil and vegetation. If they are in your drinking water, surface water may be entering your well.

Question 133

What four actions should immediately be undertaken when a municipal water system tests positive for e.coli

Answer 133

1. Check other operating parameters of system (high turbidity, loss of chlorine residuals, results from other samples) 2. Re-sample from test site and adjacent sites 3. Issue a BWA if more than 1 test is positive or any other indicators (loss of chlorine residual) 4. Communicate BWA to community and specific populations if issuing one (LTCF, Hospitals)

Question 134

Outline an overall approach (start to finish) related to a adverse event related to a municipal level water system

Answer 134

Water advisory steps: VGN-CDR Verify accuracy of indicator exceedance (retest) Gather other data (turbidity, chlorine residuals) Notify authorities (PHU, ministry of health/env) Corrective action (increase disinfection, flush lines) Decide on advisory, notify public Rescind advisory (Rescinded by LPHA)

Question 135

What toxin is associated with cyanobacteria. What level of cyanobacteria and associated toxin are permissible in recreational water?

Answer 135

Cyanobacteria Total cyanobacteria ≤ 100,000 cells/mL Cyanobacterial toxins Total Microcystins ≤ 20 μg/L (ppb)

Question 136

Outline 5 steps in wastewater treatment

Answer 136

Screening: Large pieces of debris (“chunks”) are removed and disposed of in a landfill Settling: Solids settle to the bottom of a tank; supernatant is removed Aeration: Supernatant is aerated (or filtered) to allow aerobic microorganisms to consume organic material Clarifier: Solids settle to the bottom of the tank (again) and are sent to sludge processing Sludge processing: Sludge from settling tank and clarifier is digested by microorganisms Disinfection: Aerated supernatant is disinfected (usually with chlorine) and then returned back to the water cycle (ie. to source water - lake) Sludge disposal: Processed sludge can be used in agriculture (fertilizer), biofuel (nitrogen, methane), incinerated, or sent to landfill

Question 137

What are 5 elements of the multi-barrier approach to drinking water with examples

Answer 137

Multi-barrier approach to safe drinking water: “Source to tap” 1. Source protection keeps the raw water as clean as possible to lower the risk that contaminants will get through or overwhelm the treatment system. 2. Treatment often uses more than one approach to removing or inactivating contaminants (e.g., filtration may be followed by chlorination, ozonation, or ultraviolet radiation). 3. Securing the distribution system against the intrusion of contaminants and ensuring an appropriate free chlorine residual throughout is highly likely to deliver safe water, even when some earlier part of the system breaks down. 4. Management: Standard operating procedures, operator certification, contingency procedures, communication procedures 5. Guidelines Standards and Objectives - water quality standards, source protection guidelines 6. Public involvement and awareness: All levels of government should be transparent and communicate regularly with stakeholders and the public regarding issues of water safety; owners of private drinking water systems are responsible for regularly testing their water 7. Monitoring programs, including equipment fitted with warning or automatic control devices, are critical in detecting contaminants that exist in concentrations beyond acceptable limits and returning systems to normal operation. 8. Legislative and policy frameworks: Outline who is responsible for which aspects of the drinking water system

Question 138

How do you calculate a DALY?

Answer 138

DALY = Years life lost + years lived with disability Take the difference between the age of death and average life expectancy for a person at the age of death (e.g. died at 50 and life expectancy for 50 year old in Canada is 84 - 34 years) and add the number of years they lived in a disease state multiplied by the disability weight value attributed to that state (5 years of being blind \* year of blindness = 0.5 "year being blind is considered to be half the value of a year being sighted"). The higher the disability weight value (closer to 1) the worse the disability.

Question 139

What are 5 psychological workplace factors?

Answer 139

Psychological workplace factors • balance • civility and respect • clear leadership and expectations • engagement • growth and development • involvement and influence • organizational culture • protection of physical safety • psychological competencies and demands • psychological protection • psychological and social support • recognition and reward • workload management https://www.guardingmindsatwork.ca/about/about-psychosocial-factors

Question 140

What are four components of a public health units heats response plan

Answer 140

Mitigate and/or Prevent o Environmental interventions to reduce heat islands, improve building design, etc. o Surveillance systems for detecting heat events and/or heat-related mortality Prepare o Development of protocols and procedures o Education and information for health workers Respond o Targeted outreach for at-risk groups o Cooling shelters Recover o Debrief and evaluate

Question 141

What are four key elements that should be included in a job description when being publically posted?

Answer 141

1. Job Title (PHN), Type (Casual, permanent) and Desired start date 2. Desired qualifications / pre-requisites 3. Job details - salary, location 4. Job expectations / responsibilities 5. Details on how to apply / required documents

Question 142

PHO 10-steps for program evaluation

Answer 142

1. clarify what is to be evaluated 2. engage stakeholders 3. assess resources and evaluability 4. determine evaluation questions 5. determine appropriate methods of measurement 6. develop evaluation plan 7. collect data 8. process data 9. interpret and disseminate results 10. apply evaluation findings

Question 143

What are the steps in a surveillance system

Answer 143

Data Collection - case definition, sampling, Analysis - time, person, place Interpretation - evaluation, trends, comparisons Dissemination - reports, alerts, publication Action

Question 144

Differentiate between population attributable risk and attributable risk / risk difference Explain what a PAR of 0.009 is compared to a RD of 0.009

Answer 144

Population attributable risk is the amount of the excess risk in the population due to the exposure of interest. It account for the excess risk of the exposure and its prevalence in the population. Attributable risk tells you the excess risk among the exposed compared to the unexposed. It does not account for the prevalence of an exposure. a PAR of 0.009 means that the exposure is responsible for an 9 excess cases per 1000 people in the population a RD of 0.009 means that for every 1000 people who experience the exposure you would expect 9 additional cases compared to if no one was exposed

Question 145

What can be the public health roles in addressing racial health inequity?

Answer 145

NCCDH, 2018 1) Building Capacity to analyze and take action on drivers that foster racial inequities 2) Create knowledge by assessing and reporting on the impact of racialization and racism including analyzing health outcomes utilizing an anti-racism lens, and measuring racism on both individual and structural levels 3) Re-orient/modify Health and social interventsion to eliminate racialized health inequities. 4) Develop Policies with an overt focus on tackling racism including implementing racial equity assessments 5) Develop partnerships with other sectors and communities

Question 146

The incidence of disease in the exposed group is 50 per 1000 and the incidence in the unexposed group is 25 per 1000 Calculate and attributable risk percent Interpret this value

Answer 146

Two options a) (RR-1)/ RR \*100 or (Incidence exposed - incidence unexposed) / incidence exposed = 50% so 50% of the outcome in the group that had the exposure could be attributed to having had the exposure

Question 147

Differentiate between population attributable risk and attributable risk / risk difference Explain what a PAR of 0.009 is compared to a RD of 0.009

Answer 147

Population attributable risk is the amount of the excess risk in the population due to the exposure of interest. It account for the excess risk of the exposure and its prevalence in the population. Attributable risk tells you the excess risk among the exposed compared to the unexposed. It does not account for the prevalence of an exposure. a PAR of 0.009 means that the exposure is responsible for an 9 excess cases per 1000 people in the population a RD of 0.009 means that for every 1000 people who experience the exposure you would expect 9 additional cases compared to if no one was exposed

Question 148

What are the steps in a surveillance system

Answer 148

Data Collection - case definition, sampling, Analysis - time, person, place Interpretation - evaluation, trends, comparisons Dissemination - reports, alerts, publication Action

Question 149

PHO 10-steps for program evaluation

Answer 149

1. clarify what is to be evaluated 2. engage stakeholders 3. assess resources and evaluability 4. determine evaluation questions 5. determine appropriate methods of measurement 6. develop evaluation plan 7. collect data 8. process data 9. interpret and disseminate results 10. apply evaluation findings

Question 150

What are four key elements that should be included in a job description when being publically posted?

Answer 150

1. Job Title (PHN), Type (Casual, permanent) and Desired start date 2. Desired qualifications / pre-requisites 3. Job details - salary, location 4. Job expectations / responsibilities 5. Details on how to apply / required documents

Question 151

What are four components of a public health units heats response plan

Answer 151

Mitigate and/or Prevent o Environmental interventions to reduce heat islands, improve building design, etc. o Surveillance systems for detecting heat events and/or heat-related mortality Prepare o Development of protocols and procedures o Education and information for health workers Respond o Targeted outreach for at-risk groups o Cooling shelters Recover o Debrief and evaluate

Question 152

What are 5 psychological workplace factors?

Answer 152

Psychological workplace factors • balance • civility and respect • clear leadership and expectations • engagement • growth and development • involvement and influence • organizational culture • protection of physical safety • psychological competencies and demands • psychological protection • psychological and social support • recognition and reward • workload management https://www.guardingmindsatwork.ca/about/about-psychosocial-factors

Question 153

How do you calculate a DALY?

Answer 153

DALY = Years life lost + years lived with disability Take the difference between the age of death and average life expectancy for a person at the age of death (e.g. died at 50 and life expectancy for 50 year old in Canada is 84 - 34 years) and add the number of years they lived in a disease state multiplied by the disability weight value attributed to that state (5 years of being blind \* year of blindness = 0.5 "year being blind is considered to be half the value of a year being sighted"). The higher the disability weight value (closer to 1) the worse the disability.

Question 154

What are 5 elements of the multi-barrier approach to drinking water with examples

Answer 154

Multi-barrier approach to safe drinking water: “Source to tap” 1. Source protection keeps the raw water as clean as possible to lower the risk that contaminants will get through or overwhelm the treatment system. 2. Treatment often uses more than one approach to removing or inactivating contaminants (e.g., filtration may be followed by chlorination, ozonation, or ultraviolet radiation). 3. Securing the distribution system against the intrusion of contaminants and ensuring an appropriate free chlorine residual throughout is highly likely to deliver safe water, even when some earlier part of the system breaks down. 4. Management: Standard operating procedures, operator certification, contingency procedures, communication procedures 5. Guidelines Standards and Objectives - water quality standards, source protection guidelines 6. Public involvement and awareness: All levels of government should be transparent and communicate regularly with stakeholders and the public regarding issues of water safety; owners of private drinking water systems are responsible for regularly testing their water 7. Monitoring programs, including equipment fitted with warning or automatic control devices, are critical in detecting contaminants that exist in concentrations beyond acceptable limits and returning systems to normal operation. 8. Legislative and policy frameworks: Outline who is responsible for which aspects of the drinking water system

Question 155

Outline 5 steps in wastewater treatment

Answer 155

Screening: Large pieces of debris (“chunks”) are removed and disposed of in a landfill Settling: Solids settle to the bottom of a tank; supernatant is removed Aeration: Supernatant is aerated (or filtered) to allow aerobic microorganisms to consume organic material Clarifier: Solids settle to the bottom of the tank (again) and are sent to sludge processing Sludge processing: Sludge from settling tank and clarifier is digested by microorganisms Disinfection: Aerated supernatant is disinfected (usually with chlorine) and then returned back to the water cycle (ie. to source water - lake) Sludge disposal: Processed sludge can be used in agriculture (fertilizer), biofuel (nitrogen, methane), incinerated, or sent to landfill

Question 156

What toxin is associated with cyanobacteria. What level of cyanobacteria and associated toxin are permissible in recreational water?

Answer 156

Cyanobacteria Total cyanobacteria ≤ 100,000 cells/mL Cyanobacterial toxins Total Microcystins ≤ 20 μg/L (ppb)

Question 157

Outline an overall approach (start to finish) related to a adverse event related to a municipal level water system

Answer 157

Water advisory steps: VGN-CDR Verify accuracy of indicator exceedance (retest) Gather other data (turbidity, chlorine residuals) Notify authorities (PHU, ministry of health/env) Corrective action (increase disinfection, flush lines) Decide on advisory, notify public Rescind advisory (Rescinded by LPHA)

Question 158

What four actions should immediately be undertaken when a municipal water system tests positive for e.coli

Answer 158

1. Check other operating parameters of system (high turbidity, loss of chlorine residuals, results from other samples) 2. Re-sample from test site and adjacent sites 3. Issue a BWA if more than 1 test is positive or any other indicators (loss of chlorine residual) 4. Communicate BWA to community and specific populations if issuing one (LTCF, Hospitals)

Question 159

What does the presence of total coliforms in the water indicate?

Answer 159

Coliforms: These bacteria are often found in animal waste, sewage, as well as soil and vegetation. If they are in your drinking water, surface water may be entering your well.

Question 160

What does the presence of e.coli in drinking water (assume not false positive) indicate?

Answer 160

there has been fecal contamination of the water and the water should be considered unsafe to drink

Question 161

What are five commonly used indicators for water quality for municipal scale drink water systems?

Answer 161

Biological 1. Turbidity 2. Chlorine residual 3. Total Coliforms 4. E.coli 5. Cryptosporidum and giardia Chemicals 1. PH (acidity) 2. Trihalomethanes 3. Flouride level

Question 162

THREE GENERAL POLICY RECOMMENDATIONS TO PREVENT OCCUPATIONAL CANCER IN CANADA

Answer 162

1. Strengthen occupational exposure limits across all Canadian jurisdictions. 2. Reduce or eliminate the use of cancer causing substances with toxic use reduction policies in workplaces. 3. Create registries of workplace exposures to occupational carcinogens that will facilitate the tracking of exposures over time.

Question 163

Top cause of cancer death in men and women

Answer 163

Women 1. Lung 2. Breast 3. CRC Men 1. Lung 2. CRC 3. Prostate

Question 164

Most common cancers in men and women

Answer 164

1. Prostate or Breast (Sex Specific Cancer) 2. Lung 3. Colorectal

Question 165

What are the two general types of biases in a study that can occur and explain them.

Answer 165

Information bias: Systematic error in measurement, producing differential accuracy of information by level of exposure or outcome (e.g., recall, reporting, observer) Example recall bias: respondent does not remember things correctly Interviewer/observer bias: interviewer unintentionally influences subject's responses Example Selection bias: Subjects are selected such that the distribution of a characteristic among the subjects differs from the distribution of the characteristic in the target population (e.g., sampling, attribution, publication)

Question 166

What are three ways that selection bias can occur in a cohort study

Answer 166

1. Differential loss to follow up. Individuals with the exposure are more likely to develop a secondary condition and drop out of the study than individuals without the exposure. 2. Subject Selection (retrospective only). Example, Individuals who had the outcome and exposure of interest are more likely to participate. 3. Healthy worker effect (special type of subject selection bias)

Question 167

What are three ways that selection bias can occur in a case-control study and provide an example

Answer 167

1. Control Selection Bias. Example - method of selecting controls into the study is more likely to recruit controls who have the exposure of interest than the general population. Problem because controls are used to estimate prevalence of exposure in source population of cases. 2. Self-Selection Bias - agreeing to participate in the study is related to the exposure of interest and the outcome. 3. Differential surveillance / diagnosis of cases and controls. Cases and controls may have been subjected to different levels of case finding.

Question 168

Define Selection Bias

Answer 168

selection of subjects into a study or their likelihood of being retained in the study leads to a result that is different from what you would have gotten if you had enrolled the entire target population

Question 169

A cohort study compares rates of disease by subtracting the rate of disease in an unexposed group from the rate of disease in the exposed group. List all ways that this measure can be referred to How do you interpret this measure

Answer 169

Attributable Risk, Risk Difference, Excess Risk, Absolute Risk Reduction, Absolute Risk Subjects who had an exposure X had Y additional cases of outcome Z per 100 people compared to subjects who did not have exposure X.

Question 170

What are some population level interventions to reduce obesity rates?

Answer 170

- Restriction on marketing and advertising of junk food. - Menu labeling. - Taxation of sugar sweetened beverages. - Nutrition policies in schools; availability of healthier food choices in cafeteria. - Increased access to active transport - bike lane infrastructure. - Subsidizing gym memberships.

Question 171

List 4 indicators of health status, and one example of each.

Answer 171

Mortality - all cause mortality rate. Health conditions - type 2 diabetes prevalence. Well-being - self reported health status. Function - disability adjusted life expectancy.

Question 172

List 4 indicators of health system performance, and one example of each.

Answer 172

Accessibility - proportion of population with a family doctor. Acceptability - patient satisfaction scores. Safety - incidence of hospital acquired infections. Efficiency - wait times for diagnostic procedures.

Question 173

7 attributes of a effective surveillance system

Answer 173

PS-FARTS + SVQ (acronym credit: Laura Bourns) Positive predictive value: High proportion of positives are actually cases Sensitivity: Ability of the surveillance system to detect the health problem it was intended to detect\*\*\* Flexibility: Ability of the surveillance system to accommodate changes in the operating conditions Acceptability: To individuals and organizations who must participate Representativeness: Extent to which surveillance findings accurately portray the event\*\* Timeliness: Data available rapidly enough for public health authorities to take action\* Simplicity: Ease of operation Stability: Reliability of resources, personnel, and technology required to support the surveillance system Validity: Surveillance data are measuring what they are intended to measure Quality: Complete and valid data

Question 174

Outline the differences between social marketing and commercial marketing

Answer 174

Social Marketing Ultimate Goal - improvement of individual health and societal wellbeing Proximate Goal - change in desired behaviour Target - population in need / willing to change Competition - current behaviour Commercial Marketing Ultimate Goal - Financial Gain Proximate Goal - selling product / services Target - population that will maximize sales Competition - other businesses offering similar services

Question 175

What are the three GRADE recommendations and what criteria is used to put evidence into these categories?

Answer 175

The quality of evidence is categorized as strong, moderate or weak Strong - a) many studies with no limitations, b) studies are consistent c) estimate of effect has narrow confidence interval Quality of evidence might be seen as strong when; there is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval. Quality of evidence might be seen as moderate when; there are only a few studies and some have limitations but not major flaws, there is some variation between studies, or the confidence interval of the summary estimate is wide. We judge evidence to be low or very low quality when the true effect may be substantially different from the estimate of the effect. For example, evidence might be judged as low quality if any of the following applies: the studies have major flaws, there is important variation between studies, or the confidence interval of the summary estimate is very wide.

Question 176

What factors go into making a recommendation by the CTPFHC

Answer 176

1. Quality of evidence (GRADE Evidence - Strong, Moderate, Weak) 2. The balance between desirable and undesirable effects; 3. The variability or uncertainty in values and preferences of citizens; 4. Whether or not the intervention represents a wise use of resources.

Question 177

What are three types of stakeholders that should be engaged during a program evaluation?

Answer 177

Three types of stakeholders - Those involved with the program - Those Served by the program - Users of the Evaluation (decision makers)

Question 178

Outline six steps in program evaluation

Answer 178

Six Steps Engage Stakeholders Describe Program - Need (what does the program address)? - Expected effects (what does it accomplish to succeed?) - Activities (program logic / theory) - Resources (what inputs go in) Focus Evaluation Design Gather Credible Evidence Justify Conclusions Ensure use and share lessons

Question 179

a) Define Program Planning b) Outline steps in program planning

Answer 179

multi-step process that outlines the problem, proposed intervention, and evaluation plan. 1. Manage the planning process (engage stakeholders, timelines, resources) 2. Conduct a situational assessment 3. Identify goals, populations of interest, outcomes and outcome objectives 4. Identify strategies, activities, outputs process objectives and resources 5. Develop indicators Purpose: to develop a list of variables that can be tracked to assess the extent to which outcome and process objectives have been met 6. Review the program plan

Question 180

List 8 measures and the associated data sources that you would use to assess the health of a population in a population health asesssment

Answer 180

Community and health system characteristics - Age and sex breakdown (census data) - Language spoken - Cultural background - Mortality, birth rate, infant mortality rate (vital statistics) Health Status Indicators - Immunization Status - Chronic Conditions (CCHS) - Mental Health Indicators - Health Measures - blood pressure, obesity (CHMS) - Screening received (i.e. cervical cancer, CRC) Non-medical Determinants of Health - Education - Income and finances - Personal Health Behaviors (smoking, alcohol, physical activity)

Question 181

What are the four population health indicators (according to CIHI)

Answer 181

Health Status - deaths, health conditions, wellbeing Non-medical determinants of health - risk behaviours, living conditions, environment, personal resources (social supports) Health System performance - can the health system provide timely, accessible, safe and effective care Community and health system characteristics - demographic information (population, teen pregnancy rate) - health system demographics (doctors per capita, hospital beds per capita)

Question 182

A vaccine has been newly licensed for the disease, Cute Aggression caused by the Adorable Bunny Virus with a R0 of 3. In a RCT with 200,000 study participants, 50% had the vaccine administered and 50% had a placebo administered. In the vaccinated group, 5,000 participants developed the disease; in the unvaccinated group, 100,000 participants developed the disease. Please calculate the vaccine coverage required to achieve the herd immunity.

Answer 182

VE= (Incidence in unvaccinated - Incidence in vaccinated)/ Incidence in unvaccinated x 100% VE = (0.5 - 0.05)/0.5 x 100% VE = 0.45/0.5 x 100% VE = 0.9 x 100% VE = 90% This vaccine has 90% efficacy. Vaccine Coverage = (1- 1/R0) / VE Vc= (1-1/3)/0.9 = 0.666/0.9 = 0.74 You need at least 74% of the susceptible population administered to achieve herd immunity threshold.

Question 183

Name one Policy framework and describe its element.

Answer 183

Kingdom's Multiple Stream Framework - Problem Stream where a problem needs solutions - Policy Stream where policies alternatives are debated by a policy community. - Political Stream, where power comes into play (three elements= national mood, interest groups, government) - When all three streams align, a policy window opens presenting an opportunity for a policy advocate to push their solution or raise awareness of their problem.

Question 184

What can be the public health roles in addressing racial health inequity?

Answer 184

NCCDH, 2018 1) Building Capacity to analyze and take action on drivers that foster racial inequities 2) Create knowledge by assessing and reporting on the impact of racialization and racism including analyzing health outcomes utilizing an anti-racism lens, and measuring racism on both individual and structural levels 3) Re-orient/modify Health and social interventsion to eliminate racialized health inequities. 4) Develop Policies with an overt focus on tackling racism including implementing racial equity assessments 5) Develop partnerships with other sectors and communities

Question 185

The incidence of disease in the exposed group is 50 per 1000 and the incidence in the unexposed group is 25 per 1000 Calculate and attributable risk percent Interpret this value

Answer 185

Two options a) (RR-1)/ RR \*100 or (Incidence exposed - incidence unexposed) / incidence exposed = 50% so 50% of the outcome in the group that had the exposure could be attributed to having had the exposure