Test 3

Question 1

List the 5 components of the ‘multi-barrier approach’ to safe drinking water

Answer 1

1. source protection
2. treatment
3. securing distribution system
4. monitoring
5. responses to adverse conditions

Alternative

an integrated system of procedures, processes
and tools that collectively prevent or
reduce the contamination of drinking water from source to tap in order to reduce risks to public health.

Legislative and Policy frameworks
- who is responsible for each aspect of the drinking water system and their specific
responsibilities.

Research Science and Technology
- Research, disease surveillance, and associated science and technology development serve core functions in the multi-barrier approach.

Public Involvement and Awareness
- public be aware that they can report concerns to the appropriate authority.

Guidelines Standards and Objectives
- provide utility managers and system
owners with drinking water quality targets to strive to achieve within. These targets are closely linked to monitoring results

Monitoring
- qualified personnel to run the various aspects of the
system and plans in place to manage incidents and adverse events

Management
- Water quality monitoring takes place throughout the system for a number of reasons.

Source Water Protection
Drinking Water Treatment
Drinking Water Distribution System

Question 2

List three concerns related to cyanobacterial blooms

Answer 2

1. microcystins -> drinking water, potential liver toxicity
2. direct irritation
3. eutrophication and oxygen starvation of waterbody
4. animal illness (livestock, pets)
5. aesthetic

Question 3

What are three different types of disinfection methods for drinking water? List one limitation for each.

Answer 3

1. chlorination - limited effectiveness against protozoa
2. UV - no secondary residual
3. ozone - no secondary residual

Question 4

List 4 components of a Heat Response Plan

Answer 4

1. Suveillance and alert system
2. Communication plan - public and stakeholders
3. Response activities - cooling centres, access to water
4. Evaluation

Question 5

Which air pollutants are included in the AQHI?

Answer 5

PM 2.5, O3, NO2

Question 6

What is the air quality health index?

Answer 6

A tool for summarizing local air quality conditions for the purpose of health messaging.

Question 7

What are 4 limitations of the AQHI?

Answer 7

Doesn’t account for other pollutants (only PM2.5, O3, NO2)
Assumes additive effect
Unknown relationship with chronic exposure
Doesn’t account for importance of spatial location in exposure
Based on urban locations only
Limited evidence on benefits from messaging

Question 8

What are the 3 pollutants associated with Traffic related air pollution?

Answer 8

PM2.5
NO
NO2

Question 9

List and describe 3 federal acts related to food safety

Answer 9

Food and Drugs Act - establishes standards for food labeling for foods that are imported or transported between provinces,packaging, composition, advertising, additives, and pesticides
Safe Food for Canadians Act - streamlines existing food legislation (Fish Inspection Act, Meat Inspection Act, Canadian Agricultural Products Act) to safeguard against food tampering, strengthens regulations for imported foods, improves food traceability, prohibits the sale of recalled food,
Canadian Food Inspection Agency Act - established the CFIA, and provides powers to recall food

Question 10

List and describe 3 surveillance systems for monitoring food borne illness in Canada.

Answer 10

List and describe 3 surveillance systems for monitoring food borne illness in Canada.

FoodNet - monitors foodborne illness and pathogens from 4 sentinel sites, collecting data from human, retail food, farm, and water sources

PulseNet - monitors and connects genetic data on organisms that cause foodborne illness across Canada, via NML

NESP - National Enteric Surveillance Program. Weekly reporting for detection of emerging and priority enteric disease trends. Integrates national and international data on lab-confirmed foodborne illness

Question 11

List 5 principles that should be included in a food safety plan

Answer 11

List 5 principles that should be included in a food safety plan

HACCP:
Hazard analysis
Identifying critical control points
Establishing critical limits for each critical control point
Establishing monitoring procedures for critical control points
Establishing corrective actions
Record keeping
Establishing verification procedures

Question 12

List 5 limitations and challenges of cancer cluster investigations

Answer 12

Small samples
Forced case definitions
Unclear geographic boundary
Migration
Long latency period
Poor exposure data- Poorly characterized, heterogeneous, low in concentration
Recall bias

Question 13

What does CPS recommend as a population-based strategy to prevent ophthalmia neonatorum?

Answer 13

All pregnant women should be screened for N gonorrhoeae and C trachomatis infections at the first prenatal visit. note: universal AbX eye ointment proph no longer recommended

Question 14

You are giving advice to a family who will be traveling for an extended trip in Asia. What are 6 categories of topics that you will discuss regarding the prevention of disease.

Answer 14

Education about High Risk Activities e.g., safe sex Food and water Consumption and Precaution Pre-departure Immunization Prevention against vector borne illnesses Prophylactic medications (altitude sickness, malaria chemoprophylaxis) Travel Health kit Also Travel health Insurance (Not Prevention)

Question 15

You are giving advice to a family who will be traveling for an extended trip in Asia. When determining the travel advice and preventive services that you would recommend; list four factors that you would want to know about the trip and four factors that you would want to know about the people travelling

Answer 15

Trip Factors - Country AND location(s) in country - Duration – length of time in country - Planned activities - Accommodations Person Factors - Pregnant - Demographics - Immunization record - Medical Conditions and Immune Suppression

Question 16

You are giving advice to a family who will be traveling for an extended trip in Asia. List 4 specific vaccinations that you would consider giving and the indication

Answer 16

Japanese Encephalitis - individuals who will spend more than 30 days in an endemic region (Asia and Western pacific Region) Rabies - travellers who will have direct exposure to animals (cavers, vets) or individuals spending substantial time in rural areas where there are domestic dogs and rabies in endemic (endemic in Africa, Asia, and Central / South America) Hepatitis A - Nonimmune travelers to low income countries Yellow Fever- ONLY for South America and Africa Typhoid Fever - for individuals to South Asia Tick Borne Encephalitis - travellers to endemic areas who will be doing high risk activities (hiking or camping in forested areas)

Question 17

What is herd immunity and how do you calculate it?

Answer 17

-Herd immunity is a level of immunity in the population that protects the whole population from a communicable disease as the disease can no longer spread. -Vaccination coverage to reach herd immunity is based on vaccine effectiveness and the basic reproductive number of the specific disease. [(1 - 1/Ro) x 100%] /Vaccine Effectiveness x 100%

Question 18

What are the stages involved in getting a vaccine to the public?

Answer 18

There are 5 stages: -Preclinical stage where lab and animal studies done -Clinical Phase 1 where immunogenicity of the vaccine is studied (10-100 humans) -Clinical Phase 2 where safety of the vaccine is studied (50-500 humans) -Clinical Phase 3 where optimal dose and schedule, and rare adverse events are being studied (300-30,000 humans) -Clinical Phase 4 where post licensing surveillance is done.

Question 19

Which 3 federal or provincial bodies are involved in the getting a vaccine to the public? And what are their roles?

Answer 19

1) Biologic and Radiotherapeutics Directorate of Health Canada (approval and licensure) 2)National Advisory Committee on Immunization (NACI) (recommendations of vaccine for use in Canada to PHAC based on evidence) 3)Canadian Immunization Committee (CIC) takes NACI recommendations for further assessment on economic impact, feasibility, ethics of immunization programs and make recommendations on immunization program planning to provincial and territorial ministry of health through Public Health Network Council.

Question 20

What are the consequences of Underreporting diseases

Answer 20

• distorting trends observed in the incidence of disease
• distorting attributable risk estimates for disease acquisitions
• preventing accurate assessment of potential benefits or impact of control programs
• preventing timely identification of disease outbreaks
• distorting observed periods at risk and geographic distribution of cases and
• undermining the success of prevention and control programs for tuberculosis, sexually transmitted diseases, and other communicable diseases, such as immunization programs.

Question 21

A 77 year old recently immigrated from Pakistan to Canada. He is previously healthy and presents with 2 months of a new cough, hoarse voice, and weight loss. He has been diagnosed with TB. He has a positive sputum specimen by AFB smear, 2+, positive NAAT. Culture is still pending. CXR reveals small lesions in the left upper lobe, though no cavitary lesions. CT neck/chest reveals bilateral diffuse thickening of the vocal cords. He lives with 5 family members in a 3-bedroom house in a suburban neighborhood of a large multicultural city. He does not work.
1. List 4 factors that make this case highly infectious.
2. How should this individual be managed (4 items)?
3. You determine that close contacts should be followed up. List 6 factors that should be considered for contact investigations and management.
4. The WHO End TB strategy seeks to reduce the prevalence of TB to less than 10 per 100,000 globally by 2035. List 5 elements of TB elimination and control that can help Canada achieve this goal.

Answer 21

1. List 4 factors that make this case highly infectious.
   Smear positive
   NAAT positive
   Respiratory symptoms including a cough
   Upper lobe involvement seen on x-ray
   Laryngeal TB
2. How should this individual be managed (4 items)?
   Treatment with rifampin, isoniazid, pyrazinamide, ethambutol x 2 months, then isoniazid and rifampin for another 4 months
   Weekly sputum samples
   Home isolation until smear negative
   Monthly follow-up appointments with TB services
   Airborne precautions in healthcare settings
3. You determine that close contacts should be followed up. List 6 factors that should be considered for contact investigations and management.
   Age of the contact, specifically if 5 years or younger
   If they are immunocompromised, for example taking a TNF inhibitor
   If they have HIV
   History of BCG vaccination
   Any symptoms of active TB such as a new cough
   Duration of exposure
   Exposure setting, such as indoor versus outdoor, proximity to the case, and air quality or ventilation
4. The WHO End TB strategy seeks to reduce the prevalence of TB to less than 10 per 100,000 globally by 2035. List 5 elements of TB elimination and control that can help Canada achieve this goal.
   Primary prevention - improved access to adequate housing for Inuit, First Nations, and newcomer populations
   Secondary prevention - screening programs with chest x-ray for higher risk population such as immigrants
   Tertiary prevention - early diagnosis and treatment by improving access to primary care and specialist TB clinics, to reduce transmission to others
   Timely contact tracing and contact investigation/management
   Strengthening the Canadian TB Reporting System for ongoing surveillance
   Public education on the symptoms and risks of TB
   Improved adherence to treatment for active and latent TB through DOT or community-led initiatives

Other Categories for TB Control
- Prevention
- Diagnosis
- Treatment
- Contact Tracing
- Surveillance
- Targeted programs (CXR on IMEs)
- SDOH

Question 22

There is a new lab-confirmed hep B case
1. List 6 important elements to include in the case investigation
2. List 4 elements of case management
3. List 4 criteria for identifying close contacts

Answer 22

1. List 6 important elements to include in the case investigation
   Risk factors
   Was their mother hep B positive when pregnant with the case?
   Any hep B positive household contacts (acute or chronic carrier)
   Any unprotected sexual contact with someone who is hep B positive or multiple sexual partners?
   gbMSM?
   Injection drug use? Sharing needles or other supplies i.e. cookers, straws, pipes
   Current or past incarceration?
   Receipt of blood/tissue/organ donation?
   Invasive medical or dental procedure in an endemic country?
   Frequent recipient of blood products?
   Skin piercings, tattoos, or acupuncture with unsterile equipment or technique?
   Invasive medical or dental procedure? E.g. hemodialysis
   Immigration from or to a hep B endemic country (prevalence 8%)
   Determine co-infection with other blood borne infections
   Determine immunization history
   Determine pregnancy status
   Determine history of blood, tissue, or organ donation
   Determine occupation
2. List 4 elements of case management
   Education on signs and symptoms, modes of transmission, and ways to reduce risk of transmission
   Refer to hepatology or ID
   Routine IPC precautions for hospitalized cases
   Re-check HBsAg and anti-HBs in 6 months
3. List 4 criteria for identifying close contacts
   Living in the same household
   Sharing needles
   Sexual partners
   People who have shared personal care items (e.g. razors, toothbrushes)

Question 23

1. List 5 elements of an animal exposure rabies risk assessment.
2. What is the regimen for rabies post-exposure prophylaxis from a high risk exposure? How does this change if the victim received an adequate pre-exposure prophylaxis series? For immunocompromised people?
3. List 4 possible interventions for a rabies control program in an area endemic for human and animal rabies

Answer 23

1. List 5 elements of an animal exposure rabies risk assessment.
   Date and time of exposure
   Location of exposure
   Type of animal
   Based on local epidemiology, is the type of animal a known reservoir for rabies?
   If not a known reservoir, could the animal have come into contact with a rapid animal?
   Was the attack provoked?
   Did the animal have clinical signs of rabies i.e. encephalopathy, self-mutilation, coma
   Is the animal available for observation?
   Has the victim previously received rabies vaccine?
   Do we know the victim’s RFFIT titre (greater than 0.5 IU/mL?)?
2. What is the regimen for rabies post-exposure prophylaxis from a high risk exposure? How does this change if the victim received an adequate pre-exposure prophylaxis series? For immunocompromised people?
   4-dose regimen for immunocompetent unvaccinated patient: vaccine 1.0mL IM on days 0,3,7,and 14
   2-dose regimen if previously vaccinated on days 0 and 3, then check titres
   5-dose regimen if immunocompromised on days 0,3,7,14, and 28
   Note: PrEP regime is 3 doses on days 0,7,and 28
3. List 4 possible interventions for a rabies control program in an area endemic for human and animal rabies
   Public education campaigns on animal safety and management for animal bites
   Pre-exposure vaccination
   Post-exposure vaccination
   Animal vaccination
   Timely access to healthcare following an animal bite
   Surveillance for rabies cases

Question 24

1. Your local influenza surveillance systems indicate that seasonal influenza cases are much higher this year compared to average cases in previous years. List 4 possible reasons for this.
2. List 3 types of influenza surveillance used in Canada and give an example of each

Answer 24

1. Your local influenza surveillance systems indicate that seasonal influenza cases are much higher this year compared to average cases in previous years. List 4 possible reasons for this.
   Agent - Mismatch between the circulation strain and vaccine strain
   Host - Lower vaccination compared to previous years
   Physical Environment - Unseasonably cold weather leading to respiratory viruses surviving longer on surfaces and people spending more time together indoors
   Social Environment - Mass gatherings or holidays with many social gatherings
   Increased testing
   Change in test sensitivity
   Increased surveillance
   Change in case definition
2. List 3 types of influenza surveillance used in Canada and give an example of each
   Syndromic - FluWatch, school absenteeism, LTC respiratory illness monitoring
   Passive - lab reporting
   Sentinel - FluWatch, Sentinel Practitioner Surveillance Network for vaccine effectiveness, Tarrant (AB)

Question 25

A lab-confirmed case of measles has been identified in a 30 year old male. 1. List 5 steps of your case investigation. 2. What are your next steps for case management (3) 3. What are the criteria for a susceptible contact? (6) 4. Household contacts have been identified: (i) case’s 30 year old wife who is 16 weeks pregnant and received all childhood vaccines in Canada , (ii) a 2 year old child who is unvaccinated, (iii) a 6 year old child who received 1 measles containing vaccine at age 14 months, (iv) and the case’s 58 year old mother who has a diagnosis of hypertension but otherwise healthy with childhood vaccination is unknown. What type of post-exposure prophylaxis do you offer each contact? 5. What criteria do you consider for exclusion orders for contacts? 6. What variables do you need to know to calculate critical vaccination coverage against measles? (2)

Answer 25

1. List 5 steps of your case investigation. Are there clinical symptoms consistent with measles such as fever, maculopapular rash on the head that spreads inferiorly, cough, conjunctivitis, coryza, Koplik spots? Are there signs or symptoms of severe illness such as encephalitis or seizure? Any travel during the incubation period (21 days prior to onset of fever) What is the case’s occupation? Any contact with a known or probable case of measles? Has the case previously received any measles-containing vaccines? Did the case attend any healthcare settings during the period of communicability (4 days prior to rash until 4 days after rash onset)? 2. What are your next steps for case management (3) Isolation until 4 days after the rash appeared If hospitalized or seeking healthcare, ensure airborne, droplet IPC precautions are used Initiate contact tracing 3. What are the criteria for a susceptible contact? (6) Shared airspace for any length of time with the case, including 2 hours after the case left the airspace and No measles-containing vaccines Less than 2 doses of measles-containing vaccine for adults who are healthcare workers, military personnel, or students Less than 2 valid doses of measles-vaccine for children and adolescents ages 1-17 (2 doses administered after 12 months old at least 4 weeks apart (MMR) or 6 weeks apart (MMRV) No history of lab-confirmed measles No prior serologic evidence of immunity (IgG >200 U/mL) 4. Household contacts have been identified: (i) case’s 30 year old wife who is 16 weeks pregnant and received all childhood vaccines in Canada , (ii) a 2 year old child who is unvaccinated, (iii) a 6 year old child who received 1 measles containing vaccine at age 14 months, (iv) and the case’s 58 year old mother who has a diagnosis of hypertension but otherwise healthy with childhood vaccination is unknown. What type of post-exposure prophylaxis do you offer each contact? Wife who is 16w pregnant - Ig up to 6 days after initial exposure 2 year old child unvaccinated - 1 dose MMR(V) at anytime, Ig up to 6 days after initial exposure 6 year old child 1 vaccine - 1 dose MMR(V) at anytime 58 year old mother with hypertension assumed to not have received a measles containing vaccine previously - 1 dose MMR(V) anytime, Ig up to 6 days after initial exposure 5. What criteria do you consider for exclusion orders? Consider exclusion orders for contacts who do not receive PEP for the duration of 5 days after first exposure to 21 days after last exposure or until immunization with measles-containing vaccine, administration of immunoglobulin, or documented lab-confirmed immunity Exclude any healthcare workers exposed who only have 1 dose of measles-containing vaccine until there is lab-confirmed immunity and administer 1 dose of measles-containing vaccine immediately 6. What variables do you need to know to calculate critical vaccination coverage against measles? (2) R0 (15-17) Vaccine effectiveness (99% with 2 doses) * Critical vaccine coverage = (Herd immunity threshold)/(Vaccine effectiveness) = [1-(1/R0)]/VE

Question 26

There is a vaccine shortage; list 3 methods for pivoting a vaccine program to deal with this resource scarcity

Answer 26

There is a vaccine shortage; list 3 methods for pivoting a vaccine program to deal with this resource scarcity Eligibility - restrict to the highest risk populations (risk of exposure and risk of severe illness) Scheduling - increase the time interval between doses or provide an incomplete series to a large number of people in the the target population before offering complete series (i.e. mpox 1 dose as PrEP) Dosing - offer dose-sparing regimens via alternate routes of administration (e.g. lower volumes are usually administered when IM vaccines are given ID, for example mpx, rabies) Eliminate waste/ manage clinic flow - create plans for unused doses that remain in multidose vials at the end of a clinic due to no-shows or incompletely booked clinics (e.g. offer to workers, call clients from a waitlist, outreach)

Question 27

List 5 elements of a possible syphilis control strategy and give an example for each element.

Answer 27

Pan-Canadian STBBI Framework for Action 4 pillars Prevention - sex education in schools, low barrier access to condoms (i.e. free distribution in public spaces), public awareness campaigns including banners on dating/hook up apps and websites Testing - increase lab capacity for higher volumes of syphilis tests; collaborate with primary care providers, emergency departments, STI clinics, and prenatal care providers to increase routine and opportunistic syphilis screening; change screening guidelines to be more inclusive (additional prenatal screening, newborn screening, youth and young adults); upscale point of care test and treat clinics and dried blood spot testing for areas that do not have resources to support phlebotomy or swabbing Initiation of Care and Treatment - encourage point-of-care test and treat programs to reduce the potential for loss to follow-up; create care environments that are culturally safe and gender affirming; reduce the barriers to testing and treatment in emergency departments by creating a standardized order set and stocking benzathine penicillin kits in emerg with instructions; increase capacity for complex case management and partner notification Ongoing Care and Support - Find ways of building trust and encouraging an ongoing care relationship with clients/patients (e.g. peer support workers, collaborate with outreach programs or community-based organizations, incentive programs such as gift cards, communicating via text or social media instead of phone calls) On a foundation of enabling environment, research and surveillance, knowledge mobilization, and monitoring and evaluation (e.g. reflex lab reporting to Public Health; required reporting from point-of-care testing)

Question 28

List 8 of the 13 criteria of the Erikson-De Wals framework for deciding if a vaccine should be incorporated into a publicly funded program.

Answer 28

Disease factors Does the burden of disease justify a control program? Vaccine factors Is the vaccine safe and effective? Is the vaccine licensed for the proposed use, or will it be off-label? Are there important research questions that have not been answered? E.g. how long does the vaccine confer immunity? Program factors What is the goal? What is the delivery strategy? E.g universal, targeted Can it be evaluated? Is it cost effective? Legal Ethical Feasibility Societal factors Acceptability Equity Conformity - is the program implemented elsewhere? Political landscape - is there political gain or risk from implementing the program?

Question 29

List 5 categories of vaccine components and their purpose

Answer 29

Antigen - induces immune response against the pathogen of interest Adjuvant - improves immunogenicity and duration of protection e.g aluminum hydroxide Antibiotics - prevent bacterial contamination during manufacturing Preservative - prevents microbial contamination in multidose vials e.g. thimerosal, formaldehyde Stabilizers - improve stability and the delivery of the antigen e.g. lactose, gelatin, albumin

Question 30

List 8 factors that contribute to AMR

Answer 30

Overuse of antibiotics Misuse of antibiotics (e.g. for viral infections) Prescribing before sensitivity is tested Stopping before treatment is complete (e.g. TB) Medical conditions requiring recurrent of chronic antibiotic use (e.g. indwelling catheter leading to recurrent UTIs, CF, chronic wounds) Prolonged hospitalization and nosocomial infections Globalization of trade and travel Use of antibiotics in animal agriculture

Question 31

List and give an example of 4 levels in the hierarchy of controls

Answer 31

Elimination - enhanced cleaning and disinfection, staff screening Substitution - replace reusable equipment with disposable Engineering controls - physical distancing, cohorting, improved ventilation, auto-retracting needles Administrative controls - IPC education for staff, single-site orders PPE - continuous masking and eye protection

Question 32

List 5 things that comprise a strategic plan.

Answer 32

Vision: image of the desired future; "what we want to be" Mission: statement of the purpose of the organization; "why we exist"; "what we do, for whom and why" Values how an organization will carry out its mission; "how we behave" Strategic directions: broad strategies or objectives that will contribute to achieving the vision and mission Goals: concrete, medium-term outcome statements(~5 yrs) that fit within the strategic directions; specifically tied to objectives that are SMART

Question 33

What is social marketing?

Answer 33

"the application of commercial marketing technologies to the analysis, planning, execution, and evaluation of programs designed to influence voluntary behavior of target audiences in order to improve their personal welfare and that of society. product, people, place, price, promotion

Question 34

benefits of centralization and local public health unit

Answer 34

Benefits of local of Public health units Flexibility to adapt to local context Relationships with organizations within jurisdictions Better understanding of local context Higher creativity Faster decision making Self-sufficient leaders Happier managers/team members Benefits of centralization of Public Health Powerful data sharing Coordinated response/ more standardization More resources to respond Less expensive (decreased admin costs, more efficient use of money/less wasting/duplication of efforts) Improved collaboration across jurisdiction

Question 35

Public Health Roles for reducing Inequities.

Answer 35

* Assess and report. – may include surveillance, epidemiological analysis, literature review or primary research * Modify and orient interventions – Various tools, resources and approaches can be used to modify interventions to meet the unique needs of populations and reduce inequities.eg HEIA tool * Partner with other sectors – mobilize partnerships with govt, community or other organizations to improve health inequity * Participate in policy development- support the development of legislation, regulations or policies that consider the determinants of health and reduce inequities.

Question 36

Describe the 4 pillars of the National Seniors Strategy

Answer 36

1. Independent, productive, and engaged citizens 2. Healthy and active lives 3. Care closer to home 4. Support for unpaid caregivers

Question 37

Define a cross sectional study design

Answer 37

An observational study where exposure and outcomes are assessed at a single point in time.

Question 38

List 3 strengths and 3 weaknesses of cross sectional study design

Answer 38

Strengths: - Inexpensive - Quick - Can assess multiple exposures and outcomes - Can calculate prevalence Weaknesses: - Cannot assess time trends - Cannot assess causation - Difficult to assess rare outcomes

Question 39

What is the key difference between a cohort and case control study

Answer 39

In a case control study the outcome is known and the exposure status between cases and non cases is investigated, in a cohort study the exposure is known and the outcomes in the exposed and non exposed groups are investigated

Question 40

When can an odds ratio be considered equivalent to a relative risk

Answer 40

When the outcome is relative rare in the investigation (\<20%) If the odds ratio is interpreted as a relative risk it will always overstate any effect size: the odds ratio is smaller than the relative risk for odds ratios of less than one, and bigger than the relative risk for odds ratios of greater than one

Question 41

A recent study examined the association between avoidable mortality and neighbourhood marginalization. The study took neighbourhood marginalization (a continuous variable) and divided it into quintiles. What are 3 limitations and 3 benefits of this approach

Answer 41

Limitations - reduces ability to compare results between studies in different settings as quintiles may not represent the same exposure in different regions (analagous to comparing two studies on the association between poverty and health, when poverty was defined as an annual income of $22,000 in one and $47,000 in the other) - increases liklihood of false positive due to multiple testing - assumption that risk is homegenous within each category (i.e. within lowest quintile bottom 5 percent might be very different than next 15 percent) Advantages - Facilitates communication to the lay public and decision makers - Can be easily used to divide groups into levels of risk with a relative risk for each group - facilitates interpretation of statistical interaction (effect measure modification) tests (interactions between continuous variables are difficult to interpret)

Question 42

What is the difference between direct and indirect standardization? What data do you need to do direct standardization? What data do you need to do indirect standardization?

Answer 42

Direct Standardization - Uses the age structure of a reference population and the known event rates by age or sex in two populations to create standardized rates - need the number of events and the number of individuals in the population for multiple age ranges in two separate populations Indirect Standardization - Uses the known age specific rates of a reference population to calculate the expected overall number of cases in the population of interest - need to age specific reference rates and the observed number of cases / number of individuals in a population for 1 population

Question 43

You have been asked to plan for a process, short-term, and long-term outcome evaluation of an intensive 12-week group intervention program designed to increase physical activity among men aged 40-64 in your region who are at high risk of progression to T2DM and developing IHD. A) Apart from reduced risk of T2DM and IHD, list 4 health benefits of physical activity B) List 4 potential process indicators C) List 4 potential short-term outcome indicators D) List 4 potential medium-to-long-term outcome indicators

Answer 43

**A) Health benefits** 1. Decreased risk of certain cancers 2. Decresed blood pressure/risk of hypertension 3. Decreased risk of adverse blood lipid profile 4. Decreased risk of dementia **B) Process indicators** 1. Number of participants who took part in group sessions 2. Number of group sessions delivered 3. Proportion of target population in region that participated 4. Number of individuals referred to the program **C) Short-term outcome indicators** 1. Proportion of participants meeting 150 minutes of moderate-vigorous physical activity upon completion of program 2. Mean % change in weekly minutes of physical activity reported by participants before and after program 3. Mean % change in weight of participants before and after program 4. Mean % change in HDL, LDL and triglycerides before and after program **D) Medium-Long-term outcome indicators** 1. Proportion of participants meeting 150 minutes of moderate-vigorous physical activity 1 year after completion of program 2. Proportion of participants who develop T2DM in 1-5 years 3. Proportion of participants who are diagnosed with an MI in 1-5 years 4. Mean % change in weight 1 year after program

Question 44

You are performing an HIA related to the proposed construction of a new sports complex in your area. You have identified that there is likely to be a significant impact related to noise on residents in neighbouring areas during the construction phase. A) List 4 adverse health impacts associated with noise B) List 4 potential mitigating measures you could recommend to reduce the adverse health impacts of noise on the residents. C) List 4 potential indicators you could use to assess the impact of noise on residents once construction has commenced

Answer 44

A) 1. Noise induced hearing loss 2. Impaired speech comprehension 3. Increased sleep disturbance 4. Increased stress & annoyance B) 1. Erect a sound barrier around construction site 2. Alter routes of construction vehicles into area to reduce need for reversing alarms 3. Use machinery with improved technological effiiciency to reduce noise production 4. Alter orientation and design of construction site to maximize physical distance between construction and residents 5. Reduce the maximum blast noise produced in exchange for increased number of blasts (evidence-based) C) 1. Noise complaints made by residents to local council about construction noise 2. % of residents reporting sleep disturbance pre and post construction commencement 3. % of residents reporting extreme annoyance pre and post construction commencement 4. % change in background noise levels in decibals before and after construction commencement

Question 45

You are an MOH in a regional health authority and have been advised there is a large (~500) arrival of Somali refugees expected to be relocated to your region in the coming months. Your CMOH has asked you to perform a health needs assessment for the incoming refugees. A) List 4 health conditions that are likely to be more prevalent in the incoming refugees than your existing typical regional Canadian population B) List 4 potential recommendations you would make to prepare various health services to provide care for the incoming refugees

Answer 45

A) 1. TB 2. Psychological distress (e.g. PTSD if coming from refugee camps) 3. Malaria 4. HIV 5. Schistosomiasis 6. Strongyloides B) Recommendations 1. Appropriate interpreter services are available in the necessary languages and dialects of the incoming refugees 2. Healthcare providers to undergo andy specific cultural competency training related to this specific population 3. Health information materials and resources are translated into the appropriate languages 4. Providing training to healthcare workers related to diagnosis and treatment of specific conditions they may encounter in the refugee population that they are unfamiliar with e.g. schistosomiasis 5. Making a contact network among relevant healthcare and social service providers to enable better continuity of care

Question 46

Describe the steps of a COOP with regards to a contingency strike?

Answer 46

Case study: Contingency strike Strike contingency planning (using TAGOPIE) **Team** – planning team (usually management) **Assessment** *Identify and prioritize critical functions of the organization *Identify the minimum number of staff and the minimum skill set required to maintain the critical functions (can these functions be temporarily filled by management? contractors?) **Goal/Objective** *Determine how the organization will proceed with non-critical functions during a strike (e.g., temporarily cease the function, reduce function) **Planning** *Develop strategies to reduce the impact of the strike on critical functions (e.g., alternative work locations, site closures) *Develop strategies to address the following critical functions during the strike:  Security (e.g., how will you ensure safety of staff who continue to come to work?)  Staff redeployment  Replacement workers/contractors  Picket line monitoring  Communication (external and internal)  IT (e.g., can striking staff access their voicemail, e-mail, etc.?)  Payroll  Human resources **Implement** *Based on the previous steps, write the strike contingency implementation plan (concepts of operations - ConOps) *Train management staff to deploy the strike contingency plan e.g table-top exercises **Evaluate** *Ensure the process in place will work by reviewing training and tabletop exercises to improve on what needs to be improved.

Question 47

List 3 cognitive bias a leader or manager may be prone to.

Answer 47

Anchoring: to first impressions even when there is new evidence Confirming evidence: seeking evidence that supports a preferred option Overconfidence: assuming you understand all the possible options Framing: asking questions a certain way to get a certain response (ie. leading Qs) Sunk cost: pursuing an option bc it has already been paid for Status quo: failing to consider options other than the current one Prudence: being overly cautious Recallability: assuming current situation is the same at the last worst case scenario