Public Health & Preventive Medicine - Toronto Notes 2022

PH Public Health and Preventive Medicine
Glen Katsnelson and Caleb Tackey, chapter editors

Jacqui van Warmerdam and Ming Li, associate editors
Sarah House and Vrati Mehra, EBM editors
Dr. Onye Nnorom, Dr. Jason Pennington, and Dr. Lisa Richardson, staff editors
Acronyms..............................................................................PH2
Public Health Context...........................................................PH2
Public Health in Canada
Legislation and Public Health in Canada
Determinants of Health........................................................PH3
Concepts of Health
Groups Facing Systemic Barriers, Discrimination, and Structural
Violence
Indigenous Health in Canada
Disease Prevention
Measurements of Health and Disease in a Population....... PH13
Epidemiology...................................................................... PH14
Interpreting Test Results
Effectiveness of Interventions
Types of Study Design........................................................ PH17
Qualitative vs. Quantitative
Observational Study Designs
Experimental Study Designs
Summary Study Designs
Methods of Analysis.......................................................... PH20
Distributions
Data Analysis
Common Statistical Tests
Causation
Assessing Evidence
Health System Planning and Quality..................................PH23
Continuous Quality Improvement
Cost Analysis
Managing Disease Outbreaks............................................ PH25
Definitions
Steps to Control an Outbreak
Infection Control Targets
Environmental Health.........................................................PH27
Environmental Risk Assessment
Air
Water
Soil
Food
Environmental Racism
Occupational Health.......................................................... PH30
Taking an Occupational Health History
Occupational Hazards
Workplace Legislation
Workplace Health Promotion
Workplace Primary Prevention
Workplace Secondary Prevention
Workplace Tertiary Prevention
Appendix – Mandatory Reporting......................................PH32
Reportable Diseases
Other Reportable Conditions
Landmark Public Health and Preventive Medicine Trials....PH34
References..........................................................................PH34
PH1 Public Health and Preventive Medicine Toronto Notes 2022

Acronyms
ADLs activities of daily living FN false negatives NPV negative predictive value SARS severe acute respiratory
AR attributable risk FOBT fecal occult blood test OR odds ratio syndrome
CAS Children’s Aid Society IMR infant mortality ratio PFT pulmonary function test SDS safety data sheets
CBA cost benefit analysis ITT intention to treat analysis PHAC Public Health Agency of Canada SMR standardized mortality ratio
CEA cost effectiveness analysis LICO low income cut-off PP per protocol analysis TP true positives
CFR case fatality rate MERS Middle East respiratory PPV positive predictive value TN true negatives
CTFPHC
Canadian Task Force on syndrome PSA prostate screening antigen WHMIS Workplace Hazardous Materials
Preventive Health Care MHO Medical Health Officer PYLL potential years of life lost Information System
DALY disability adjusted life year MOH Medical Officer of Health QALY quality adjusted life year WHO World Health Organization
DDT dichlorodiphenyltrichloroethane MMR maternal mortality ratio QI quality improvement WSIB Workplace Safety and Insurance
EBM evidence-based medicine NNH number needed to harm RR relative risk Board
FP false positives NNT number needed to treat
Public Health Context

Preparing for the LMCC
The AFMC Primer on Population Health
• see Ethical, Legal, and Organizational Medicine, Overview of Canadian Healthcare System, ELOM2 is the core text for the LMCC and is
for the organization of health care in Canada including the legal foundation and historical context available as an online resource on the
AFMC website (http://phprimer.afmc.ca)
Definitions For the LMCC exam, it is recommended
• population health that you also read Chapter 15 in Shah CP.
Public health and preventive medicine in
■ refers to the health of defined groups of people, their health determinants, trends in health, and Canada, 5th ed. Toronto: Elsevier, 2003
health inequalities
■ influenced by: physical, biological, social, environmental, and economic factors; personal health
behaviours; health care services
■ broader scope compared to public health; accounts for socioeconomic, policy, and historical
Historical Perspective
issues Over the last century, the focus of public
• public health health has evolved:
■ an organized effort by society to promote, protect, improve, and when necessary, restore the • Infectious diseases: a prominent
health of individuals, specified groups, or the entire population issue in low- and middle-income
■ a combination of sciences, skills, and values that function through collective societal activities countries and higher income
countries alike; includes emergent
and involve programs, services, and institutions aimed at protecting and improving the health of diseases caused by unfamiliar or new
all people pathogens, inefficient or inappropriate
■ public health services in many provinces (e.g. Ontario) are administered, funded, and delivered antibiotic use, travel, global warming
entirely separately from healthcare services (e.g. HIV, drug-resistant TB, COVID-19),
• epidemiology and the manufactured conditions
of crisis and/or routine conditions
■ “study of the distribution […] of determinants of disease, health-related states, and events in of poverty imposed on Indigenous,
populations” Black, and other communities of
• public health and preventive medicine (formerly called community medicine) colour
■ the medical specialty that focuses on population rather than individuals’ health • Chronic diseases: have increased
■ works with diverse populations to improve population health, address social determinants of morbidity and mortality (e.g. heart
disease and cancer due to risk
health, and promote health equity factors and/or exposures) and
■ 5 yr Royal College training in medical skills and knowledge, epidemiology, statistics, social disproportionately affect Indigenous
sciences, public administration, policy development, program management, and leadership populations throughout the world
Sources: Shah, CP. Chapter 2 Measurement and Investigation. Public Health and Preventive Medicine in Canada, 5e. Toronto: Elsevier, 2003 • Social determinants of health:
Shah, CP. Chapter 15 Community Health Services. Public Health and Preventive Medicine in Canada, 5e. Toronto: Elsevier, 2003 driven by a growing body of evidence
since the 1980s that universal
Public Health in Canada access to health care services did
not ameliorate health inequalities,
and that significant improvements
The Public Health System in Canada is composed of various agencies at the federal (Public Health in health could only be achieved
Agency of Canada), provincial (Public Health Ontario), and municipal/local levels (local public health by going ‘upstream’ with action on
policies
units). The organization of the public health system in each province varies widely and is usually
separate from the health care system.
Mission of the Public Health Agency of Canada (federal only): to promote and protect the health of
Canadians through leadership, partnership, innovation, preparedness, and action in public health Example of a Municipal Health Unit:
• local public health units and services within regional health authorities (in most provinces except The Middlesex-London Health Unit
Ontario, where local public health units are either autonomous or within local government) provide • Serves 450000 people living,
programs and activities for health protection, promotion, and disease prevention at local and regional working, visiting, and studying in the
city of London and Middlesex county
levels • 275 full-time staff including MOHs
• catchment-area populations range widely (100s to 1000000s), covering areas of 15 km2 to 1.5 million (physicians), public health nurses,
km2 epidemiologists, health promotion
• the “core functions” of public health include six essential activities educators, dental hygiene managers,
(The Organization of Health Services in Canada. AFMC Primer on Population Health, Accessed: March 25 2016) etc.
1. health protection: measures taken to address potential risks to health at the population level • Services include infectious disease
through regulation and advising government (e.g. safe water and food supply) control, ensuring environmental
health standards, health promotion,
2. health surveillance: monitoring and predicting health outcomes and determinants with and providing family health programs
systematic, longitudinal data collection
3. disease and injury prevention: address infectious disease through preventive (e.g. vaccination,
droplet protection) and control (e.g. quarantine) measures; reduce morbidity through lifestyle
improvement
4. population health assessment: studying and engaging with a community to understand their
needs and improve policies and services
5. health promotion: advocate for improved health through broad community and government Chief Public Health Officer (CPHO) of
measures (e.g. policy, interventions, community organizations) Canada
6. emergency preparedness and response: developing protocols and infrastructure for natural (e.g. • Responsible for the Public Health
hurricane) and man-made (e.g. opioid crisis) disasters. In many types of health-related disasters, Agency of Canada (PHAC) and reports
public health leads the disaster response to the Minister of Health
Sources: Shah, CP. Chapter 15 Community Health Services. Public Health and Preventive Medicine in Canada, 5e. Toronto: Elsevier, 2003 • As the federal government’s lead
The Association of Faculties of Medicine of Canada Public Health Educators’ Network. The Organization of Health Services in Canada. AFMC Primer public health professional, provides
on Population Health advice to the Minister of Health
and Government of Canada and
collaborates with other governments,
Legislation and Public Health in Canada jurisdictions, agencies, organizations,
and countries on health matters
• Communicates public health
information to health professionals,
Table 1. Legislation and Public Health in Canada stakeholders, and the public
Federal Provincial Municipal (Ontario) • In an emergency, such as an outbreak
or natural disaster, directs PHAC
Health Canada Each province has its own Public Health Act Local public health units (e.g. Middlesex- staff, including medical professionals,
• Provides health services to the Canadian or equivalent (e.g. the Health Protection and London Health Unit) deliver programs scientists, and epidemiologists, to
military and veterans Promotion Act in Ontario) and agencies (e.g. mandated by provincial, municipal, or regional coordinate emergency response
• Provides non-insured health benefits Public Health Ontario) legislation and are responsible for the delivery Source: Public Health Agency of Canada. www.canada.
(NIHB) to status First Nations peoples and • Designates the creation of geographic of most public health services, such as: ca/en/public-health/corporate/organizational-structure/
Inuit, and is responsible for the funding of areas for the provision of public health • Infectious disease control, including canada-chief-public-health-officer/role-chief-public-
healthcare services on reserve services the follow-up of reported diseases and health-officer.html
• Approves new drugs and medical devices • Gives powers to the Chief Medical Officer management of local outbreaks
• Food Guide of Health to control public health hazards • Inspection of food premises including
Public Health Agency of Canada (main • Specifies diseases to be reported to public those in hospitals, nursing homes, and
Government of Canada agency responsible for health units by physicians, laboratories, restaurants
Medical Officer of Health (MOH)
public health) and hospitals (see Appendix, PH32) • Family health services including pre-
(Ontario)
• An independent body created post-SARS • Mandates programs that address public conception, preschool, school-aged, and
• May be called “Medical Health
to strengthen public health capacity and health issues, environmental health, and adult health programs
Officer” (MHO) in other provinces
response chronic disease prevention • Tobacco control legislation enforcement
• Appointed to each public health unit
• Focuses on preventing chronic diseases, • Assessment and management of local
by the board of health
preventing injuries, and responding to environmental health risks
• Position held by a Public Health
public health emergencies and infectious • Collection and dissemination of local
and Preventive Medicine specialist
disease outbreaks health status reports
physician
• Activities include CTFPHC guideline • Oral health
• Responsibilities include oversight of a
secretariat, knowledge brokers • By-laws may be approved by municipal
multidisciplinary team who:
• Oversees immigration screening, protects governments to facilitate public health
• Collect and analyze epidemiological
Canadian borders (e.g. airport health issues
data
inspection)
• Provide occupational and
• Liaises with the WHO on global health
environmental health surveillance
issues
• Implement health programs,
Canadian Food Inspection Agency
including tobacco use prevention
• Regulates food labeling
inspections (restaurants,
• Deals with animal-related infections
physician’s offices, tattoo parlors)
Canadian Institutes of Health Research
and prenatal courses
(CIHR)
• The MOH, by law, can require an
• Formed in 2000 to support research to
individual/premise/agency to take
improve health and the health care system
or refrain from any action due to
a public health hazard (Section 13
and 22 of the Health Protection and
Determinants of Health
Promotion Act)
Determinants of Health
Concepts of Health • Income and social status
• Employment and working conditions
• Education and literacy
• wellness: “state of dynamic physical, mental, social, and spiritual well-being that enables a person to • Childhood experiences
achieve full potential and have an enjoyable life” • Physical environments
• disease: “abnormal, medically-defined changes in the structure or function of the human body” • Social supports and coping skills
• illness: “an individual’s experience or subjective perception of a lack of physical or mental well-being • Healthy behaviours
and consequent inability to function normally in social roles” • Access to health services
• Biology and genetic endowment
• illness behaviour: an individual’s actions resulting from and responding to their illness, including • Gender
their interactions with, or avoidance of, the healthcare system • Culture
• sickness: views the individual and their society hold towards a health condition, affecting their • Exposure to colonization and
thoughts and actions racialized prejudice
• impairment: “any loss or abnormality of psychological, physiological, or anatomical structure or • Racism
Source: Public Health Agency of Canada. https://www.
function” canada.ca/en/public-health/services/health-promotion/
• disability: “any restriction or lack of ability to perform an activity within the range considered population-health/what-determines-health.html
normal for a human being”
• handicap: a disadvantage for an individual arising from impairment or disability
■ “limits or prevents the fulfillment of an individual’s normal role as determined by society and
depends on age, sex, social, and cultural factors”
• health equity: when all people have “the opportunity to attain their full health potential” and no
one is “disadvantaged from achieving this potential because of their social position or other socially
determined circumstance.” Health inequities are systematic differences in the health of individuals/ Definitions of Health
groups which are considered unjust • Multidimensional definition of health,
• health equality: defined as where populations have equal or similar health status. Health inequalities as defined by the WHO in 1948: “state
are systematic differences in the health of groups that do not necessarily carry a moral judgement of complete physical, mental and
Source: ACC Institute of Human Services, Special Needs Education. Impairment, Disability, and Handicap: What’s the Difference? [Internet]. Institute social well-being and not merely the
of Human Services; 2018 Nov 9 [cited 2020 Apr 28]. Available from: https://acc.edu.sg/en/impairment-disability-and-handicap-whats-the-difference/ absence of disease or infirmity”
• WHO updated the definition (socio-
Determinants of Health ecological definition) of health in
1986: “The ability to identify and to
• 1974: the Honourable Marc Lalonde, federal Minister of Health, publishes A New Perspective realize aspirations, to satisfy needs,
on the Health of Canadians which outlines four factors that determine health: “human biology, and to change or cope with the
environment, lifestyle, and health care organizations.” The idea of determinants of health has since environment. Health is therefore
been expanded and refined to include many additional factors a resource for everyday life, not
Sources: Shah, CP. Concepts, Determinants, and Promotion of Health. Public Health and Preventive Medicine in Canada, 5e. Toronto: Elsevier, 2003 the objective of living. Health is a
The Association of Faculties of Medicine of Canada Public Health Educators’ Network. Concepts of Health and Illness. AFMC Primer on Population positive concept emphasizing social
Health and personal resources, as well as
physical capacities” (Ottawa Charter
for Health Promotion)
• Other definitions of health have since
been proposed that incorporate other
Water and dimensions of health
sanitation Health care • “Health is a social, economic,
General Unemployment
socioeconomic, cultural,
services and political issue and above all a
Housing
and environmental fundamental human right” – The
Living and working
conditions People’s Charter for Health
conditions
Social and community • ”Health is the continuous and
Work environment networks harmonious interaction and balance
Individual lifestyle between the physical, emotional,
Education
factors spiritual, and mental/intellectual
realms“ - The National Aboriginal
Age, sex, and
Agriculture and hereditary factors
Health Organization
food production
© Cassandra Cetlin 2015
Figure 1. Population health model

Adapted from Dahlgreen G, Whitehead M. European strategies for tackling social inequities in health: Leveling up Part 2. World Health Organization, State of the Art Review: Poverty and the
2006 Developing Brain
Pediatrics 2016;13(4):e20153075
Socioeconomic status (SES) plays an important
• cultural humility: an approach to health care based on humble acknowledgement of oneself as a role in paediatric brain development. Lower SES is
learner when it comes to understanding a person’s experience. This is a life-long process of learning associated with developmental delay, lower academic
and being self-reflexive achievement, and more behavioural and emotional
• cultural safety: problems. SES has been found to influence brain
■ developed by Dr. Irihapeti Ramsden, a Maori nurse scientist, in the 1980s and is “concerned with regions that support memory, emotion regulation,
higher-order cognitive functioning, and regions
the power relationships between nurses and those in their care. The recipients of nursing care are that support language and literacy. Some possible
empowered to decide what is culturally safe rather than complying passively with the authority of mechanisms underlying these changes include
nurses or other health professionals” - Cancer Australia epigenetics, material deprivation (e.g. cognitive
■ “an approach that considers how social and historical contexts, as well as structural and stimulation, nutrient deficiencies), stress (e.g.
interpersonal power imbalances, shape health and health care experiences. Practitioners are self- negative parenting behaviours), and environmental
toxins. There is a need for primary care providers to
reflective/self-aware with regards to their position of power and the impact of this role in relation build capacity to address poverty in their practice
to patients” - HeretoHelp British Columbia and facilitate referral to evidence based community
• cultural awareness: an attitude that includes awareness about differences between cultures intervention programs.
• cultural sensitivity: an attitude that recognizes the differences between cultures and that these
differences are important to acknowledge in health care
• cultural competency: an approach that focuses on practitioners’ attaining skills, knowledge, and
attitudes to work in more effective and respectful ways with Indigenous patients and people of Ottawa Charter for Health Promotion
different cultures (1986)
• Health promotion: the process of
enabling people to increase control
Groups Facing Systemic Barriers, Discrimination, and over, and improve their health
• Some health promotion can be
Structural Violence achieved through clinical interactions
with patients, but most health
promotion is done at the population
• certain groups are at greater risk for poorer health outcomes not due to their identity, but rather due level by public health professionals
to systemic barriers, discrimination, and structural violence (e.g. harmful policies, historic, and and agencies through engaging
contemporary factors). The readers are strongly cautioned against pathologizing entire groups and stakeholders, formulating policy, and
are encouraged to further read into the historical factors that have contributed to creating systemic influencing upstream factors
barriers which perpetuate inequities • The Ottawa Charter is a framework for
thinking about health promotion
• see Colonization and Healthcare, PH7; Ethical, Legal, and Organizational Medicine, Indigenous • The Ottawa Charter states that
Disproportionate Over-Representation of Biological, Psychological and Social Co-Morbidities, ELOM27; governments and health care
Indigenous Health, ELOM24 providers should be involved in
a health promotion process that
includes:
1. Building healthy public policy
2. Creating supportive environments
3. Strengthening community action
4. Developing personal skills
5. Re-orienting health services
Table 2. Equity-Seeking Groups Facing Systemic Barriers

Definition Physical Environmental Personal Risk Factors Population-Specific
Interventions
Indigenous Peoples Three distinct groups: First A history of surviving Limited overcrowded housing Lifestyle adaptation, loss Movements towards
Nations (status and non-status colonization and genocide in disrepair in community of traditional livelihood, decolonization and addressing
Indians as per the Indian Act), Systemic racism Homelessness off-reserve unemployment, and lack of the recommendations of
Métis, and Inuit Lower income Exposures to environmental facilities the Truth and Reconciliation
The original inhabitants of the Higher risk of experiencing toxins (poor drinking water) Obesity (higher BMI) secondary Commission
land now called Canada violence and unemployment due to land dispossession to poorer access to high quality Mental health awareness and
All Indigenous communities Homelessness and loss of environmental nutrition (food insecurity) increasing health literacy
and individuals experience stewardship Higher rates of smoking, Indigenous-specific chronic
the effects of colonization, but substance misuse, and suicide disease management including
sometimes in very different secondary to intergenerational DM
ways trauma Culturally appropriate and
interdisciplinary harm
reduction, substance use
treatment, and smoking
cessation programs
Cultural continuity
(language and cultural
programs are protective
against depression and
suicide)
Incorporation of Traditional
Medicine into the care
plan (wellness journey) for
Indigenous patients who want
this to be part of their care
Health practitioner training in
cultural humility and safety
Black Individuals and Sub-Saharan African Ancestry, Variable, depending on Anti-Black systemic racism Anti-Black systemic racism Culturally-specific and safe
Communities diverse cultures and histories socioeconomic status and in Canada (officially in Canada (officially practices
(people may self-identify immigrant status/history in acknowledged by the United acknowledged by the United Anti-racist approaches to care,
by geographic or ancestral Canada Nations, the Canadian Public Nations, the Canadian Public policy, and programming
regions (e.g. Caribbean, The Nova Scotian Black Health Association, and Health Association, and Movements to reallocate police
Ghanaian, Somali, African population has been in Canada several provincial and local several provincial and local funding to more appropriate
American, Black Canadian, for centuries; historically governments) has led to governments) has led to social services to curb police
etc.) but socially classified displaced into rural settings physical and mental health physical and mental health violence through transparency
by society based on hair/skin Newer immigrants tend to live inequities inequities and public oversight
phenotype as ‘Black’) in urban centres High BMI High BMI
3rd largest “visible minority” Higher risk DM and HTN Higher risk DM and HTN
group in Canada (poor data quality for (poor data quality for
43% Canadian-born identifying disparities identifying disparities
in Canada due to lack of in Canada due to lack of
collection of race-based data) collection of race-based data)
Isolated Seniors Individuals >65 yr Elder abuse Low hazard tolerance Inactivity Aging in place of choice
Lack of emotional support Higher rates of Polypharmacy Falls and injury prevention
Isolation institutionalization Medical comorbidities Mental health promotion
Mobility issues Preventing abuse and neglect
Individuals/Children in Based on LICOs Low income Housing availability Poor supervision Improvements in family income
Poverty Family dysfunction Unsafe housing Food insecurity most significant
LICO is an income threshold Lack of educational Lack of recreational space High-risk behaviours Access to early childhood
below which a family will likely opportunities education
devote a larger share of its Access to safe housing
income on the necessities of
food, shelter, and clothing than
the average family
People with Disabilities Includes impairments, activity Low income Institutionalization Substance misuse Transportation support
limitations, and participation Low education status Barriers to access Poor nutrition Multidisciplinary care
restrictions Discrimination Transportation challenges Inactivity Unique support for individuals
Stigma Dependency for ADLs with specific disabilities (e.g.
Trisomy 21)
New Immigrants Person born outside Access to community services Exposure to diseases and Barriers finding employment Women’s health
of Canada who has been Cultural perspectives conditions in country of origin, that matches skills and Mental health
granted the right to live in (including reliance on in current country of residence, qualifications Comprehensive medical exam
Canada permanently by alternative health practices) or during immigration process Exposure to cultural Dental and vision screening
immigration authorities Unstable or precarious housing (e.g. smoke from wood fires, discrimination and isolation Vaccinations
incidence of TB) which can impact health Cancer screening
English language learner Receive language and
Healthy immigrant effect employment training
(health worsens over time Support integrating into local
to match that of the general community
population) Benefit from culturally
Cultural or religious appropriate and culturally
expectations safe interventions, ideally
developed in collaboration
with the specific target
communities
Note: this chart delineates the major challenges faced by each group, but the issues listed are not unique to each population.
Sources: Shah, CP. The Health of Vulnerable Groups. Public Health and Preventive Medicine in Canada, 5e. Toronto: Elsevier, 2003.
Table 2. Equity-Seeking Groups Facing Systemic Barriers

Definition Physical Environmental Personal Risk Factors Population-Specific
Interventions
Persons with no Fixed An individual who lacks Low income A history of colonial Higher rates of adverse Housing First policies
Address permanent housing Food insecurity subjugation and land childhood events and Safe housing
Mental illness expropriation subsequent substance use Addictions support
Exposure to temperature Greater risk of experiencing Mental health
extremes violence due to lack of housing
Exposure to communicable and protection
diseases in shelters
Refugees Forced to flee country of origin Post-traumatic stress disorders Diseases and conditions in Employment Vaccinations
because of a well-founded Depression country of origin (e.g. malaria, English language learner Women’s health
fear of persecution and given Adjustment problems TB, onchocerciasis, etc.) Longstanding prior lack of Mental health
protection by the Government Partial health coverage Direct and indirect effects access to health care Comprehensive medical exam
of Canada via Interim Federal Health of war (chronically Dental and vision screening
Refugee claimant: arrive Program neglected problems) Political advocacy
in Canada and ask to be Cultural or religious Language training
considered refugee expectations Support for transitioning into
the workplace
Support integrating into local
community
Religious Minorities Religious minorities are Reduced employment options At risk of experiencing hate Poorer mental health If possible and when
those who do not practice the in Quebec due to laws banning crimes, especially those who Suboptimal health and care- requested, offer patients a
statistically dominant faith government workers such wear visible religious symbols seeking behaviours healthcare provider of the
It varies by country, but in as teachers, police officers, such as Muslim women, Sikh same gender
Canada, religious minorities publicly employed lawyers, men, and Jewish men Provide accessible multi-faith
are currently those who are not and court workers from spaces and chaplain services in
affiliated with one of the major wearing religious symbols like the hospital
Christian denominations hijabs, turbans, and kippahs Instill a culture of inclusion
Not all members of a minority beyond tolerance and provide
faith practice and degree religious accommodation
of identification varies by where possible
individual Proactively consult healthcare
workers if they require
alternative scheduling for
religious holidays or fasting
Collaborate with religious
leaders and chaplains in
supporting the health of their
respective communities
LGBTIQ2S Individuals Those who identify as lesbian Family violence Over-representation in youth Higher rates of depression, Apply an intersectional lens
(a homosexual woman), Lower income homeless population anxiety, obsessive-compulsive to understand LGBTIQ2S
gay (a homosexual person Identity documents lacking Violence, harassment, and and phobic disorders, populations (racialized,
irrespective of gender), correct name or sex discrimination when seeking suicidality, and self-harm gender-diverse, traditional/
bisexual (a person who is designations stable housing, employment, Increased risk of alcohol, cultural roles as in 2S)
attracted to both genders), Victims of hate crimes health, or social services tobacco, and other substance Gender-neutral language
trans (a person whose core motivated by sexual misuse and the avoidance of
gender identity and/or gender orientation and/or gender Double the risk for post- heteronormative assumptions
expression does not align with identity; higher prevalence of traumatic stress disorder than to invite patients to self-
the sex-assigned gender at hate crimes against racialized heterosexual people identify as gender or sexual
birth; the sexuality of trans communities with greater Greater participation in high- minorities
persons is independent of their fatality risk sexual practices related to Increased awareness of the
gender diversity), intersex HIV infection broader social, legal, and
(an umbrella term to describe Deterioration of mental medical context in which
bodies that fall outside the health due to multiple factors LGBTIQ2S individuals live
strict male/female binary), (internalized queerphobia, Improve recognition that
questioning (regarding one’s limited sociomedical individuals who belong
sexual or gender identity), infrastructure perpetuating/ to multiple marginalized
queer (a historically reclaimed instigating underlying communities may face
pejorative that is an umbrella comorbidities) additional barriers to
term to encompass all sexual maintaining good health
and gender diversities),
two-spirited (a pan-indigenous
term acknowledging gender
diversity in uniquely traditional
roles as distinct from western
gender diverse identities), and
asexual (a person who does not
experience sexual attraction
to others as distinct from
celibacy; asexual individuals
may still have sex
Note: this chart delineates the major challenges faced by each group, but the issues listed are not unique to each population.
Sources: Shah, CP. The Health of Vulnerable Groups. Public Health and Preventive Medicine in Canada, 5e. Toronto: Elsevier, 2003.
Screening for Poverty

• poverty is not always apparent despite being widespread (20% of families in Ontario live in poverty)
• poverty is a risk factor for many chronic diseases, cancer, and mental illness New Immigrants to Canada
• women, Indigenous peoples, new immigrants, and LGBTQ+ are some of the groups at highest risk of • Mandatory medical exams on entry
living in poverty to Canada by a designated medical
• primary healthcare providers should intervene practitioner
• Complete medical examination for
■ step 1: screen everyone for poverty by asking, “Do you ever have difficulty making ends meet at persons of all ages
the end of the month?” • Chest x-ray and report for persons
◆ for living below the poverty line, sensitivity 98% and specificity 40% ≥11 yr
■ step 2: ask everyone, “Have you filled out and sent in your tax forms?” • Urinalysis for persons ≥5 yr
◆ tax returns are required for accessing many income security benefits like GST/HST credit, • Syphilis serology for persons ≥15 yr
• HIV testing for applicants ≥15 yr, as
working income tax benefits, property tax credits, child benefits, etc. well as for those children who have
◆ connect your patients to a free community tax clinic to assist them received blood or blood products,
have a known HIV-positive mother, or
Indigenous Health in Canada have an identified risk. An ELISA HIV
screening test should be done for HIV
1 and HIV 2
Definitions • Serum creatinine for persons ≥15 yr,
and children with a history of HTN
• Indigenous peoples represent approximately 4.9% of the total population of Canada in 2016 and speak (resting BP >150/90 mmHg), DM,
over 70 Indigenous languages kidney disease, or signs of impaired
• 3 distinct groups of Indigenous peoples in Canada (per sec. 35 of the Constitution Act 1982): First renal function
Nations (status and non-status), Métis, and Inuit • Provide compassionate psychosocial
■ First Nations: includes over 600 diverse communities in Canada; status vs. non-status refers to assessment being aware of increased
prevalence of mental health issues
the registration of First Nations peoples under the Indian Act (1876), which, in addition to the (e.g. PTSD, depression, intimate
establishment of the Department of Indian Affairs, was originally established by the government partner violence)
to administer/manage Treaty commitments, and to remove self-governing and traditional • Assess immunization documents and
practice rights. The Indian Act affectsIndigenous life in many areas from birth to death. It has develop catch-up schedule
impacted every First Nations individual, family and community Source: Citizenship and Immigration Canada Handbook
https://www.canada.ca/en/immigration-refugees-
■ Métis: descendants of the First Nations and European settlers; nearly 2/3 residing in cities, citizenship/corporate/publications-manuals.html
greatest percentage in Ontario
■ Inuit: roughly 75% of this population of 70000 resides in the 4 Canadian Regions known as Inuit
Nunangat, the Inuit Homeland. These include: Nunavut, Nunavik (N. Quebec), Nunatsiavut
(Labrador), and Inuvialuit (Northwest Territories). The majority of Inuit live in Nunavut (30135),
followed by Nunavik (11800), Inuvialuit (3110), and Nunatsiavut (2285). Another 17690 Inuit
live outside of Inuit Nunangat, many in urban centres in southern Canada, including Ottawa, Traditional and Complementary Medicine Use
Edmonton, and Montréal Among Indigenous Cancer Patients in Australia,
Canada, New Zealand, and the United States: A
Systematic Review
Young and Growing Populations Integr Cancer Ther 2018;17(3): 568-581
• between 2006-2016 the Indigenous populations have increased by 42.5%, 4x that of non-Indigenous Purpose: To systematically review the use of
Canadian population growth traditional Indigenous and complementary medicines
• 32.1 is the average age of the Indigenous population, about 8 yr younger than the non-Indigenous among Indigenous cancer patients in Australia,
Canada, New Zealand, and the United States.
Canadian population Methods: Studies on the use of traditional Indigenous
• the aging Indigenous population is also growing, with anticipated doubling of >65 age group by 2036 and complementary medicines among Indigenous
cancer patients in Australia, Canada, New Zealand,
Colonization and Healthcare and the United States published between January
Colonizers have perpetrated specific acts throughout Canadian history that have greatly impacted the 2000 and October 2017 were eligible for inclusion.
Results: 21 articles based on 18 studies were
physical, mental, emotional, and spiritual health of Indigenous peoples. Physicians should therefore included. Traditional Indigenous and complementary
be aware of the historical (and current) underpinnings of Indigenous health disparities, and the medicines were used by between 19% to 57.7% of
way in which health care professionals, including physicians, have acted as agents of the colonial Indigenous patients. These modalities were most
agenda historically, which are discussed here, and their responsibility to redress previously damaged often used in combination with conventional cancer
healthcare relationships (see Ethical, Legal, and Organizational Medicine, Resources in Indigenous treatments to meet spiritual, emotional, and cultural
needs. These treatments had multiple perceived
Health, ELOM29). Despite institutionalized abuse and assimilation, Indigenous people have survived spiritual, emotional, and cultural benefits. Traditional
remarkable injustice and have built resilience through traditional knowledge and practices Indigenous and complementary medicine use
was influenced by a patient’s perceptions of their
Residential Schools (1870s-1996) healthcare practitioner’s attitudes towards these
The residential school era is well-known for its lasting and damaging effects on many generations modalities.
of Indigenous people. Many Indigenous students suffered from poor nutrition, hygiene, and living In Canada, many Indigenous healing practices include
conditions, as well as physical, sexual, and psychological abuse from teachers and others in power. drumming, singing, smudging, herbal teas, sweat
The intent of residential schools to assimilate Indigenous people also led to spiritual harms through lodges, and other ceremonies. Healthcare providers
significant loss of traditional language and culture. Residential school survivors report poorer general are encouraged to research and explore these options
and self-rated health as well as increased rates of chronic and infectious diseases, mental distress, as an additional therapeutic tool for Indigenous
patients requesting them. Not all Indigenous patients
depression, substance use, and suicide. Importantly, many of these outcomes extend to subsequent will request such treatments and so perhaps first ask
generations (i.e. intergenerational trauma) patients, “What do I need to know about you as a
person to give you the best care possible?”
The term “residential school syndrome” has been proposed to better characterize the traditional
DSM-V definition of post-traumatic stress disorder with additional criteria specific to residential
school survivors, such as tendency to misuse alcohol and drugs (often at a young age), loss of cultural
knowledge, violent or angry outbursts, and difficulty parenting. Treatment approaches must take into
account a holistic view of all these criteria, rather than simply focusing on one aspect, like substance
use, which often perpetuates negative stereotypes
The Truth and Reconciliation Commission (TRC) (2015) is a document jointly created by the Canadian
government and residential school survivors that preserves in writing the truth of residential schools
and delineates recommendations for reconciliation. Many TRC recommendations pertain directly to
health and healthcare providers. Unfortunately, seven years later they remain recommendations and
have not become Calls to Action
Nutrition Trials
From 1942 to 1952, nutritional scientists in conjunction with the Canadian government performed
unethical research on Indigenous people with the aim of “studying the state of nutrition of the Indian.”
The James Bay Survey is perhaps the most well-known of these studies conducted on the Attawapiskat
and Rupert’s House Cree First Nations, though many were conducted on residential school children
as well. One of the lead physician-scientists was Dr. Frederick Tisdall (inventor of Pablum), former
president of the Canadian Paediatric Society and paediatrician at the Hospital for Sick Children in
Toronto, Ontario. Some unethical and arguably criminal acts committed by researchers were:
• lack of informed consent from parents or children
• Indigenous children were kept malnourished over a two-year period to establish a baseline
• one group of children received a flour mix not yet approved for sale that caused them to develop
anemia, contributing to greater morbidity and mortality in this group with no therapeutic
intervention
• in an effort to control as many factors as possible, dental care was denied to observe the progression of
dental cavities and gingivitis in the setting of malnutrition
Impact of Sustained Caloric Restriction on Residential School Survivors and Other

Generations
• sustained caloric restriction can cause height stunting, induce physiological changes to prioritize fat
over lean mass, and higher risk of developing type 2 diabetes
• stunting negatively impacts neurological, psychological and immune systems
• due to sustained starvation, “the child’s physiology is essentially ‘programmed’ by hunger to continue
the cycle of worsening effects, with their bodies displaying a rapid tendency for fat-mass accumulation
when nutritional resources become available”
• other generations are at risk of having a higher BMI and developing obesity
Tuberculosis, Tuberculosis Sanatoriums, and “Indian Hospitals”

European colonizers brought tuberculosis (TB) to Indigenous populations as early as the 1700s.
Indigenous communities, particularly the Inuit, already had risk factors predisposing the spread of
TB. For example, there was malnutrition from food scarcity and overcrowding on federally mandated
reserves after forced relocation from traditional territories. From 1930-1940, death rates from TB
in Inuit populations were roughly 700 per 100000, among the highest ever recorded in a human
population. For comparison, TB was the tenth leading cause of death globally in 2016 at a crude
death rate of 17 per 100000, while ischemic heart disease was the first at 126 per 100000. This led the
Canadian government to forcibly relocate many Indigenous people to TB sanatoriums and “Indian
hospitals,” often hundreds of kilometres away. The average length of stay at these institutions was 2.5 yr
and many patients never returned home
The TB health crisis persists today; in 2016, the average annual incidence rate of TB among the Inuit in
Canada was roughly 296 times higher than Canadian-born non-Indigenous people. In March 2018, the
national representational organization for Inuit people in Canada, called Inuit Tapiriit Kanatami (ITK),
and the Government of Canada committed to reduce TB rates across Inuit communities by 50% by 2025
and to eliminate TB by 2030 in a project called the Inuit Tuberculosis Elimination Framework
It is worth noting that “Indian hospitals” were initially welcomed by many First Nations who were under
the impression that reasonable healthcare was part of treaty terms. In reality, “Indian hospitals” were
crowded, underfunded, and poorly staffed, serving to segregate sick Indigenous people from the rest of
the population. They were also the site of the cycle of apprehension, coercive sterilization, chemical and
physical restraints, and scientific experimentation. When the Canadian government began closing these
hospitals in the 1960s, Indigenous people continued to fight for their right to healthcare, which was
finally recognized in the Indian Health Policy of 1979
Coerced Sterilizations
Throughout the twentieth century, eugenics programs existed across the country. In the 1920s-1930s,
both Alberta and British Columbia legalized eugenic policies in the Sexual Sterilization Acts which
were not repealed until the 1970s. To limit reproduction of “unfit” people in the eyes of the government,
Indigenous women were disproportionately targeted. This is referred to as forced or coerced sterilization
and, according to various accounts by Indigenous women across the country, involved any number of
the following:
• tubal ligations being performed without consent
• being falsely told that a procedure is reversible
• being pressured into signing consent forms while actively in labour or on operating tables
• being given an ultimatum to undergo a tubal ligation or risk child apprehension
It is important to note that many sterilizations also occurred outside legislation, in federally run
“Indian hospitals,” and some have been documented as recently as 2018. At least 100 Indigenous women
have come forward with accounts of coerced sterilization by physicians and nurses, spanning from the
1970s until 2018
Sixties Scoop and Indigenous Child Welfare

The “Sixties Scoop” (Johnson, 1983) (1951-1980s) refers to the government-mandated practice of
removing Indigenous children from their families without consent for placement in foster care or
adoption. As residential schools started to close, many children were transitioned to child welfare
facilities as the state deemed Indigenous parents unfit to care for their children – a legacy that persists
today. Similar to the Indian Residential School system, the goal was to assimilate Indigenous children
into a non-Indigenous family, rather than to directly provide child welfare to Indigenous communities.
Though Indigenous bands have increasingly been allowed to provide their own child welfare,
Indigenous children are still overrepresented in foster care. In 2016, Indigenous youth ages 0 to 4 made
up about half of all foster children in private households, despite being only 8% of total youth in this age
group in Canada. Youth with a history in government care may be at greater risk for substance misuse,
street involvement, and incarceration
To this day, Indigenous children are disproportionately represented in the child welfare system and are
often apprehended for reasons directly related to the routine conditions of poverty. The apprehensions
that continue today echo the practices of the Sixties Scoop and residential school eras; the displacement
of Indigenous children separates them from their language and culture and hinders the ability of
Indigenous families to build resilience. Importantly, many Indigenous mothers and families avoid
accessing healthcare services for fear of their children being apprehended
Indigenous Approaches to Health and Wellness

• it is important to recognize the significant diversity amongst Indigenous nations in the land now
known as Canada. Even within the same nation or language group, there will be variability in
practices. Despite this diversity, there are some ideas that recur across many nations
• restoring balance in the four realms of spiritual, emotional, mental, and physical health of a person
acting as an individual, as well as a member of a family, community, and nation
■ ideas represented by the medicine wheel of First Nations peoples, the Learning Blanket of Inuit
peoples, and the Métis tree model all share a worldview based on holistic lifelong learning and
wellness
■ Indigenous medicines may take many forms (song, dance, smudge, ceremonies, plant medicines,
etc.)
■ practiced by experts who have decades of apprenticeship
■ while allopathic medicine often focuses on treating illness (like HTN or DM), Indigenous
medicine may understand the cause of a condition and the approach to healing in a different way
than a biomedical guideline might
■ cultural humility
◆ cultural humility is a respectful, person-centered way of bringing curiosity and compassion
when a patient is willing to come for support
◆ it takes courage to be humble enough to admit that we do not know what we do not know
◆ Indigenous medicine is thousands of years old and eludes randomized controlled trials
◆ Traditional Medicine is unlikely to interfere with Western Therapies
◆ Latin root of “curiosity” is “cura,” which means “to care.” Caring about someone’s healing
and their beliefs about what may help them heal is a powerful act of witnessing and
honouring. Beginning with the belief that a person has wisdom about themselves that no
one else does and that we can be supporters of their healing, if they consent, can be a way to
honour the inherent wholeness of a person seeking care
■ before assuming that an Indigenous person is interested in using traditional medicine, it is
important to begin with questions and curiosity. Dr. Chantal Perrot speaks about the Patient
Dignity Questionnaire which advises healthcare workers to first ask patients, “What do I need to
know about you as a person to give you the best care possible?”
■ National Indigenous Health Organization (NIHO) offers 8 guidelines on practicing culturally
safe health care for Indigenous patients including the need to allow Indigenous patients to access
ceremony, song, and prayer; the need for information and for family support; guidelines for the
appropriate disposal of body parts and for handling death
Disease Prevention
Natural History of Disease Passive Prevention
Measures that operate without the
• course of a disease from onset to resolution person’s active involvement (e.g. airbags
1. pathological onset in cars) are more effective than active
2. presymptomatic stage: from onset to first appearance of symptoms/signs prevention, measures that a person must
3. clinical manifestation of disease: may regress spontaneously, be subject to remissions and relapses, do on their own (e.g. wearing a seatbelt)
or progress to death
Surveillance
• the continuous, systematic collection, analysis, and interpretation of health-related data needed for Example of Primary Prevention
HPV 9-Valent Vaccine and Its Efficacy in
the planning, implementation, and evaluation of public health practice the Prevention of Cervical Cancer
Sources: World Health Organization. Public Health Surveillance. Accessed from: https://www.who.int/topics/public_health_surveillance/en/. 2019
• This is a nonavalent HPV vaccine
• types of surveillance covering strains 6, 11, 16, 18, 31, 33,
■ passive surveillance: reporting of disease data by all institutions that see patients, relying solely 45, 52, and 58
on the cooperation of health-care providers (laboratories, hospitals, health facilities, and private • The efficacy of this vaccine was
practitioners) studied in 4 randomized, double-
◆ most common, least expensive, but difficult to ensure completeness and timeliness of data blind, placebo-controlled trials on
females between 11 and 26 yr and
■ active surveillance: regular visits to health facilities for reviewing medical records to identify was found to prevent nearly 100% of
suspected cases of disease under surveillance, or active testing of a population for the presence of precancerous cervical changes for up
a disease to 4 yr after vaccination
◆ resource-intensive, used when a disease is targeted for eradication where every possible case
must be investigated, or for outbreak investigations
■ sentinel surveillance: selective reporting of disease data from a limited network of carefully
selected reporting sites with a high probability of seeing cases in question, Does Evidence Support Supervised
◆ well-designed system can be used to signal trends, identify outbreaks, and monitor the Injection Sites?
burden of disease in a community in a timely and cost-effective manner compared to other Can Fam Physician 2017;63(11):866
• Clinical question: Do supervised
kinds of surveillance injection sites (SISs) reduce mortality,
◆ may not be as effective in identifying rare diseases, or diseases that occur outside the hospitalizations, ambulance calls, or
catchment area of sentinel sites disease transmission?
Sources: World Health Organization. Public Health Surveillance. Accessed from: https://www.who.int/immunization/monitoring_surveillance/burden/ • Bottom line: The best evidence
vpd/surveillance_type/passive/en/; https://www.who.int/immunization/monitoring_surveillance/burden/vpd/surveillance_type/active/en/; https:// from cohort and modelling studies
www.who.int/immunization/monitoring_surveillance/burden/vpd/surveillance_type/sentinel/en/
suggests that SISs are associated with
lower overdose mortality (88 fewer
Disease Prevention Strategies overdose deaths per 100000 person-
• measures aimed at preventing the occurrence, interrupting through early detection and treatment, or years (PYs)), 67% fewer ambulance
slowing the progression of disease/mitigating the sequelae calls for treating overdoses, and a
decrease in HIV infections. Effects on
hospitalizations are unknown
Table 3. Levels of Disease Prevention
Level of Prevention Goal Examples
Primordial Preventing the development of risk factors Education that begins in childhood about
behaviour that can harm health Smoking Cessation: Vaping Compared with
Programs that encourage physical activity Traditional Nicotine Replacement Therapies: a
Primary Protect health and prevent disease onset Immunization programs (e.g. measles, Systematic Review and Meta-analysis
Reducing exposure to risk factors diphtheria, pertussis, tetanus, polio, see BMJ Open 2021;11:e044222
Paediatrics, P5) Pooled results from six randomized controlled
Smoking cessation trials identified no difference in smoking cessation,
Seatbelt use the proportion of participants reducing smoking
See Landmark Public Health and Preventive consumption, mean reduction in cigarettes smoked
Medicine Trials, PH34 for more information on per day, or harms, between e-cigarettes and
VAXICOL, which details the impact of influenza traditional nicotine replacement therapy. Most
vaccination of nursing home staff on mortality studies were judged to have a high risk of bias,
of residents resulting in the overall quality of evidence as low.
More research is necessary prior to establishing
Secondary Early detection of (subclinical) disease to Mammography recommendations related to e-cigarettes as smoking
minimize morbidity and mortality Routine Pap smears cessation tools.
Tertiary Treatment and rehabilitation of disease to DM monitoring with HbA1c, eye exams, foot
prevent progression, permanent disability, and exams
future disease Medication
Source: Basic Concepts in Prevention, Surveillance, and Health Promotion. AFMC Primer on Population Health. http://phprimer.afmc.ca/Part1-
TheoryThinkingAboutHealth Chapter4BasicConceptsInPreventionSurveillanceAndHealthPromotion/Thestagesofprevention
Screening (Secondary Prevention)

• “screening is a strategy used in a population to identify the possible presence of an as-yet-
undiagnosed disease in individuals without signs or symptoms”
■ screening vs. case finding: screening tests are not diagnostic tests
■ the primary purpose of screening tests is to detect early disease or risk factors for disease in
large numbers of apparently healthy individuals. The purpose of a diagnostic test is to establish
the presence (or absence) of disease as a basis for treatment decisions in symptomatic or screen
positive individuals (confirmatory test). Both screening and case finding seek to risk stratify for
further investigation
■ to minimize biases and harms, and maximize benefits, screening is best done at the population
level, not the individual clinical level, as part of a screening program (e.g. provincial breast
cancer screening program vs. screening by primary care/family physicians)
• types of screening
■ universal screening: screening all members of a population for a disease (e.g. phenylketonuria
(PKU) and hypothyroidism in all newborns) A Snapshot of the Opioid Crisis in
■ selective screening: screening of targeted subgroups of the population at risk for a disease (e.g. Canada
mammography in women >50 yr) Canada is experiencing a crisis of opioid-
■ multiphasic screening: the use of many measurements and investigations to look for many related overdose and death. Between
January 2016 and September 2019,
disease entities (e.g. periodic health exam) there were more than 14700 deaths in
• types of bias in screening Canada related to opioids. There were
■ lead-time bias: overestimation of survival time ‘from diagnosis’ when the estimate is made from also 19490 hospitalizations and 17000
the time of screening, instead of the later time when the disease would have been diagnosed emergency services. Individuals 25-34
without screening y/o are at the greatest risk of overdose
death (1 in 6 deaths), but rates have
■ length-time bias: overestimation of the survival time due to screening at one time point increased for all adult ages. Deaths are
including more stable cases than aggressive cases of disease, which may have shorter survival most commonly unintentional. Heroin,
times fentanyl, and hydromorphone are most
commonly involved. The highest rates of
Overt opioid-related overdose and death are
Occult
Disease found in British Columbia. An estimated
Disease
Onset of Disease Death from Disease 300 per million British Columbians
died in relation to opioid use in 2017.
Lead Time More died from opioids than homicide,
motor vehicle accidents, and suicide
Screen Detected Clinically Detected combined. In 2017, deaths from opioids
in Ontario ~1250, deaths from motor
Figure 2. Lead-time bias vehicle accidents ~450. Fentanyl or a
fentanyl analogue were involved in more
Table 4. Ideal Criteria for Screening Tests than 70% of cases, increased from 55%
in 2016.
Disease Test Health Care System Sources: J Addict Med. Measuring the Burden of Opioid-
related Mortality in Ontario, Canada. Latest Trends in
Causes significant suffering and/or death High sensitivity Adequate capacity for reporting, follow-up, Opioid-Related Deaths in Ontario: 1991 to 2015, Toronto:
Natural history must be understood Safe, rapid, easy, relatively inexpensive and treatment of positive screens Ontario Drug Policy Research Network. Health Canada.
Must have an asymptomatic stage that can be Acceptable to providers and the population Cost effective March 2018. Opioid-related harms in Canada. Health
detected by a test Continuously utilized Sustainable program Canada. March 2020
Early detection and intervention must result in Clear policy guidelines on who to treat
improved outcomes
Adapted from: Shah CP. Public Health and Preventive Medicine in Canada, 5th ed. Toronto: Elsevier, 2003
Health Promotion Strategies See Landmark Public Health and Preventive Medicine
Trials table for more information on the Swedish Two-
County Trial, which details the long-term effect of
Table 5. Disease Prevention vs. Health Promotion Approach mammographic screening on breast cancer mortality.
Disease Prevention Health Promotion
Health = absence of disease Health = positive and multidimensional concept
Medical model (passive role) Participatory model of health
Aimed mainly at high-risk groups in the population Aimed at the population in its total environment
One-shot strategy aimed at a specific pathology Diverse and complementary strategies aimed at a network of issues/
determinants
Directive and persuasive strategies enforced in target groups Facilitating and enabling approaches by incentives offered to the
population
Focused mostly on individuals Focused on a person’s health status and environment
Led by professional groups from health disciplines Led by non-professional organizations, civic groups, local, municipal,
regional, and national governments
Source: Shah CP. Public Health and Preventive Medicine in Canada, 5th ed. Toronto: Elsevier, 2003
Healthy Public Policy

• purpose: to create a supportive environment to enable people to lead healthy lives, thereby making
healthy choices easier for citizens
• governments and non-governmental agencies need to consider the cost and acceptability of proposed
public health interventions (i.e. more invasive or costly measures should be justified by the extent of
beneficial impacts on people’s lives)
• the Nuffield Intervention Ladder provides one way of ranking the level of intrusion and hence a need
for proportionate benefit of health promotion interventions at a population level
• methods
■ fiscal: imposing additional costs (e.g. taxes on tobacco and alcohol)
■ legislative: implementing legal deterrents (e.g. smoking bans, legal alcohol drinking age)
■ social: improving health beyond providing universally funded health care (e.g. providing
affordable housing)
Source: International Conference on Health Promotion, Adelaide, South Australia (1998)
Behaviour Change
• behaviour is a result of three factors
1. predisposing factors: knowledge, attitude, beliefs, values, intentions
2. enabling factors: skills, supports
3. reinforcing factors: health care professionals and the social context of family and community
• health education serves to: increase knowledge and skills and promote healthy behaviours
Health Belief Model (1975)

• a psychological model adapted over time to explain and predict individual short- and long-term
health behaviours based on one’s beliefs and attitudes Transtheoretical Model Stages of Change for
• based on the assumption that one will adopt a beneficial health behaviour if 3 beliefs are present: Dietary and Physical Exercise Modification in
■ the negative health outcome is avoidable Weight Loss Management for Overweight and
Obese Adults
■ expects that the health outcome can be prevented if the recommended health behaviour is Cochrane DB Syst Rev 2014:CD008066
adopted Purpose: To explore the efficacy of dietary
■ the individual can be successful in adopting the health behaviour and physical activity interventions based in the
• six concepts: transtheoretical model of change for sustained
■ four concepts influencing one’s “readiness to act” – perceived susceptibility, perceived severity, weight loss after one yr in overweight or obese
adults.
perceived benefits, perceived barriers Methods: RCTs comparing the use of weight loss
■ cues to action: stimuli that can trigger health action or physical activity intervention grounded in the
■ self-efficacy: confidence in one’s ability to take a health action transtheoretical model of change to usual care for
weight loss in adults who were overweight or obese
Stages of Change Model were eligible for inclusion. Interventions had to be
carried out by healthcare professionals or trained lay
• provides a framework in which the Health Belief Model is applied to facilitating behaviour change people. Weight loss or change in BMI was required as
(e.g. quitting smoking) an outcome measure.
1. Precontemplation: the individual is not seriously considering change Results: Three studies including a total of
(for various reasons) and is not interested in any kind of intervention 2971 participants were included in this review.
Interventions grounded in this model did have positive
2. Contemplation: the individual begins to seriously consider making effects on physical activity and dietary habits that
the change within the foreseeable future (often defined as six included increased exercise duration and frequency,
months) reduced fat intake, and increased fruit and vegetable
consumption. The evidence for sustained weight loss
Relapse:
3. Preparation: the individual begins experimenting, making at one yr was inconclusive (mean difference in favour
possible
small changes; he or she resolves to make a serious attempt of the transtheoretical model was between 2.1 kg and
at any
in the future (usually defined as 30 days) 0.2 kg at 24 mo).
stage
4. Action: the individual is actively involved in making

the change, using different techniques
5. Maintenance: the individual must learn to

successfully cope with temptations to return
to the previous behaviour pattern Principles of Standardization
• When comparing a health measure
Figure 3. Stages of change model (e.g. mortality) between two
Source: Prochaska JO, DiClemente CC, and Norcross JC. In Search of How People Change. Applications to Addictive Behaviours. Am Psychol populations (or the same population
1992;47:1102-1114 at different time points) that differ in
characteristics known to influence that
Risk Reduction Strategies outcome (e.g. age), standardization
is used to control for the effect of
• risk reduction: lower the risk to health without eliminating it (e.g. avoiding sun to lower risk of skin that factor
cancer) • Standardization is either direct or
• harm reduction: a set of strategies aimed to reduce the negative consequences of drug use and other indirect
risky behaviours (e.g. needle exchange programs) • Indirect standardization is expressed
Source: Shah, CP. Concepts, Determinants, and Promotion of Health. Public Health and Preventive Medicine in Canada, 5e. Toronto: Elsevier, 2003 as standardized outcome ratio. For
example, Standardized Mortality Ratio
Community Needs Assessment (SMR) is calculated using age specific
rates for a reference population, as
• a community needs assessment studies a community’s health gaps and pairs identification of that well as age structure and total cases
community’s existing resources and strengths to find solutions to address those gaps. This assessment for a sample/known population. (e.g.
strongly values interviewing community members to gather their concerns and proposed solutions. an SMR of 100 signifies that deaths
Steps include: are at the expected level, a SMR of 110
1. define the community and understand its history and demographic characteristics to formulate indicates a death rate 10% higher than
expected)
context for subsequent data collection • Direct standardization is expressed as
2. understand what matters to community stakeholders (e.g. interviews, surveys, focus groups) a rate (i.e. using age specific rates in
3. using evidence (e.g. mortality rate, feasibility), prioritize each concern a known/sample population against a
4. identify barriers that may prevent a concern from being addressed and propose solutions using standard population)
resources available to the community
Measurements of Health and Disease in a

Population
MEASURES OF DISEASE OCCURRENCE
Rates, Ratios, and Proportions

• a rate measures the frequency of an event in a defined population over a specific period of time (e.g.
number of opioid overdoses in Canada in one year)
• a ratio compares the magnitude of one quantity to another (e.g. ratio of women to men with lupus)
• a proportion is a ratio where the numerator is a part of the denominator (e.g. proportion of deliveries
complicated by placental abruption)
Incidence Rate
• number of new cases in a population over a specific period of time
Prevalence
• total number of cases in a population over a defined period of time
• two forms of prevalence
■ point prevalence: assessed at one point in time
■ period prevalence: assessed over a period of time, therefore including new cases and excluding
cases that terminate (cure or death)
• a function of the incidence rate and disease duration from onset to termination
• favours the inclusion of chronic over acute cases and may underestimate disease burden if those with
short disease duration are missed
• prevalence estimates are useful for measuring disease burden and therefore help in the planning of
facilities and services
Age-Standardized Rate
• adjustment of the crude rate of a health-related event using a “standard” population
• standard population is one with a known number of persons in each age and sex group
• standardization prevents bias that can occur when crude rates from two dissimilar populations are
compared (e.g. crude death rates over a number of decades are not comparable as the population age
distribution has changed with time)
• this allows for the calculation of a Standardized Mortality Ratio (SMR), where SMR = (observed
number of deaths)/(expected number of deaths)
MEASURES OF MORTALITY
Life Expectancy
• the expected number of years to be lived by a newborn based on age-specific mortality rates at a
selected time
Crude Death Rate

• mortality from all causes of death per 1000 in the population
Infant Mortality Rate (IMR)

• number of reported deaths among children <1 yr of age during a given time period divided by the
number of reported live births during the same time period and expressed as per 1000 live births per
year
Maternal Mortality Rate (MMR)

• “number of deaths of women during pregnancy and due to puerperal causes […] per 1000 live births
in the same year”
Top 10 Causes of DALYs in Canada,
2019
MEASURES OF DISEASE BURDEN 1. Neoplasms
2. Cardiovascular diseases
3. Musculoskeletal disorders
Potential Years of Life Lost (PYLL) 4. Neurological disorders
• calculated for a population using the difference between the actual age at death and a standard/ 5. Mental disorders
expected age at death 6. Other non-communicable diseases
• increased weighting of mortality at a younger age 7. Unintentional injuries
8. Chronic respiratory diseases
9. Diabetes and kidney diseases
Disability Adjusted Life Year (DALY) 10. Substance use disorders
• life expectancy weighted by amount of disability experienced, where 0 = perfect health and 1 = death Source: Global Burden of Disease Compare | Viz Hub
[Internet]. Seattle (WA): University of Washington,
• both premature death and time spent with disability accounted for; these disabilities can be physical Institute for Health Metrics and Evaluation (IHME); 2021
or mental [cited 2021 Mar 28]. Available from: https://vizhub.
• used to assess burden of diseases in a population healthdata.org/gbd-compare/
Quality Adjusted Life Year (QALY)

• years of life weighted by quality (utility is a proxy for quality), ranging from 0 (= death) to 1 (= perfect
health). Weights are assigned based on large studies that assessed the effect of various conditions on
quality of life (e.g. blindness = 0.3)
• it is possible to have “states worse than death” (e.g. QALY <0 for extremely serious conditions)
• usually used as an economic measure to assess the value for money of medical interventions
For additional rate calculations see Steps to Control an Outbreak, PH25

Consult the Public Health Agency of Canada for examples and latest statistics
http://www.phac-aspc.gc.ca/cphorsphc-respcacsp/2008/fr-rc/cphorsphc-respcacsp06b-eng.php
Sources: Shah, CP. Health Indicators and Data Sources. Public Health and Preventive Medicine in Canada, 5e. Toronto: Elsevier, 2003
The Association of Faculties of Medicine of Canada Public Health Educators’ Network. Methods: Measuring Health. AFMC Primer on Population
Health
Epidemiology
Population
• a defined collection of individuals/regions/institutions/etc. (e.g. individuals defined by geographic
region, sex, age)
Sample SPIN: use a SPecific test to rule IN a

hypothesis. Note that specific tests have
• a selection of individuals from a population very few false positives. If you get a
• types positive test, it is likely a true positive
■ random: all members are equally likely to be selected SNOUT: use a SENsitive test to rule OUT
■ systematic: an algorithm is used to select a subset a hypothesis. Note that sensitive tests
■ stratified: population is divided into subgroups that are each sampled have very few false negatives. If you get
a negative test, it is likely a true negative
■ cluster: grouped in space/time to reduce costs
■ convenience: non-random inclusion, for populations that are difficult to reach (e.g. people with
precarious living conditions)
Sample Size
• increasing the sample size increases the statistical precision of the observed estimate, resulting in
more narrow confidence intervals
• increasing the sample size decreases the probability of type I and type II errors
• increasing sample size does not alter the risk of bias/confounding
Bias
• systematic error leading to an incorrect estimate of the true association between exposure and
outcome
• can occur at several points in study execution (e.g. collection, analysis, interpretation, publication, or
review of data)
■ selection bias: a systematic error in the recruitment or retention of study participants
• Berkson’s bias occurs in a case-control study using hospitalized controls, as they may not be a
representative sample of the population due to the complexity that led to their hospital admission
• non-response bias occurs when participants differ from non-participants in a study, in that those
who volunteer may be healthier
• loss to follow-up bias occurs when dropout rates differ between study groups and patients who
dropped out are different from those who did not
■ information bias: the way in which information is collected about study participants is
inadequate
• recall bias occurs when individuals with disease may be more likely to incorrectly recall/believe they
were exposed to a possible risk factor than those who are free of disease
• interviewer bias occurs when interviewers are unblinded to outcome status and this knowledge
biases their behaviour
• observer bias occurs when knowledge of exposure status (e.g. race, gender) biases the observer
towards a diagnosis; this occurs more commonly with subjective diagnoses like those found in
psychiatry
Confounder
• a variable that is related to both the exposure and outcome but is not a mediator in the exposure-
outcome relationship
• distorts the estimated effect of an exposure if not accounted for in the study design/analysis (e.g.
late maternal age could be a confounder in an investigation of birth order >4 and risk of developing
Trisomy 21)
• randomization, stratification, matching, and regression modelling can help minimize confounding
effects
Source: The Association of Faculties of Medicine of Canada Public Health Educators’ Network. Assessing Evidence and Information. AFMC Primer on
Population Health
Interpreting Test Results Figure 5. Understanding sensitivity

and specificity
Source: Loong TW. Understanding sensitivity and
TP = True positive TN = True negative FP = False positive FN = False negative specificity with the right side of the brain. BMJ
2003;327:716-719
Disease
Present Negative
Test Result Positive TP FP
Negative FN TN
Sensitivity = TP/(TP+FN)
Specificity = TN/(TN+FP)
Likelihood Ratio (LR)
• Likelihood that a given test result would be expected in a patient with disease compared with the likelihood
that the same result would be expected in a patient without disease — well person
— person with disease
• LR+ indicates how much the probability of disease increases if the test is positive
• LR- indicates how much the probability of disease decreases if the test is negative
Figure 5a. Hypothetical population
LR+ = Sensitivity = [TP/TP+FN)] LR– = 1 - Sensitivity = [FN/(TP+FN)]
1 - Specificity [FP/(TN+FP)] Specificity [TN/(TN+FP)]
Positive Predictive Value (PPV)

• Proportion of people with a positive test who have the disease
PPV = TP
TP + FP
Negative Predictive Value (NPV)

• Proportion of people with a negative test who are free of disease
NPV= TN
Dark grey — positive test result
TN + FN Light grey — negative test result
0.239
LR+ = = 3.85
Advanced Neoplasia 1 - 0.938 Figure 5b. Results of diagnostic test
Present Negative 1 - 0.239 on hypothetical population
LR– = = 0.81
Test Result 0.938
Positive 68 147
Negative 216 2234 PPV = 68 = 31.6%
(68 + 147)
Total 284 2381
Sensitivity = 68/284 = 23.9% NPV = 2234

= 91.2% Figure 5c. Sensitivity of test
Specificity = 2234/2381 = 93.8% (2234 + 216)
(e.g. 24/30 = 80% sensitive)
Figure 4. Interpreting test results: practical example using FOBT testing in advanced colon cancer
Source: Collins J, Lieberman D, Durbin T, et al. Accuracy of screening for fecal occult blood on a single stool sample obtained by digital rectal
examination: a comparison with recommended sampling practice. Ann Intern Med 2005;142:81-85
Sensitivity
• proportion of people with disease who have a positive test
Specificity
• proportion of people without disease who have a negative test
Figure 5d. Specificity of test
(e.g. 56/70 = 80% specific)
Pre-Test Probability
• probability that a particular patient has a given disease before a test/assessment results are known
Post-Test Probability
• a revision of the probability of disease after a patient has been interviewed/examined/tested • Sensitivity and specificity are
• calculation process can be explicit using results from epidemiologic studies, knowledge of the characteristics of the test
accuracy of tests, and a nomogram/Bayes’ theorem • LR depends on the test characteristics,
• the post-test probability from clinical examination is the basis of consideration when ordering not the prevalence
diagnostic tests or imaging studies • PPV and NPV depend on the
prevalence of the disease in the
■ after each iteration, the resultant post-test probability becomes the pre-test probability when population
considering new investigations
Effectiveness of Interventions PRE - TEST POST - TEST

PROBABILITY PROBABILITY
Effectiveness, Efficacy, Efficiency 0.001 0.999
• three measurements indicating the relative value (beneficial effects vs. harmful effects) of an
0.002 0.998
intervention
0.003 LIKELIHOOD 0.997
■ efficacy: the extent to which a specific intervention produces a beneficial result under ideal
0.005 RATIO 0.995
conditions (e.g. RCT) 0.993
0.007
◆ ideal conditions include adherence, close monitoring, access to health resources, etc. 0.01 0.99
■ effectiveness: measures the benefit of an intervention under usual conditions of clinical care
◆ considers both the efficacy of an intervention and its actual impact on the real world, 0.02 0.98
taking into account access to the intervention, whether it is offered to those who can benefit 0.03 1000 0.97
from it, its proper administration, acceptance of intervention, and degree of adherence to 0.05 500 0.95
0.07 0.93
intervention 200
0.1 100 0.9
■ efficiency: a measure of economy of an intervention with known effectiveness 50
◆ considers the optimal use of resources (e.g. money, time, personnel, equipment) 0.2 20 0.8
10 PSA
Disease (e.g. lung cancer) 0.3 =20 0.7
5
0.4 0.6
2
Present Absent Total 0.5 1 0.5
0.6 0.5 PSA 0.4
Present A B A+B =4
0.7 0.2 0.3
Exposure 0.8 0.1 0.2
(e.g. smoking) Absent C D C+D 0.05
0.02
0.9 0.01 0.1
Total A+C B+D A+B+C+D 0.93 PSA 0.07
0.005 =3
0.95 0.05
0.003
Case-Control Study 0.97 0.001 0.03
A B A×D 0.98 0.02
odds ratio (OR)* = ÷ =
C D B×C
Cohort Study 0.99 0.01
0.993 PSA 0.007
A = incidence rate of health outcome in exposed C = incidence rate of health outcome in non-exposed 0.995 =0.5 0.005
A+B C+D
0.997 0.003
relative risk = A ÷ C attributable risk = A C 0.998 0.002
(RR)** A+B C+D (AR)*** A+B C+D
0.999 0.001
*Ratio of the odds in favour of the health outcome among the exposed to the odds in favour among the unexposed
**Ratio of the risk of a health outcome among exposed to the risk among the unexposed ©Naveen Devasagayam 2016
***Rate of health outcome in exposed individuals that can be attributed to the exposure
Figure 7. Fagan’s likelihood ratio
Figure 6. Measures of effect by study type
nomogram: practical example using
PSA levels to calculate post-test
Number Needed to Treat (NNT) probability of prostate cancer
• number of patients who need to be treated to achieve one additional favourable outcome Modified from source: Holmstrom B, Johansson M,
• only one of many factors that should be taken into account in clinical or health system decision Bergh A, et al. Prostate specific antigen for early
detection of prostate cancer: longitudinal study.
making (e.g. must take into account cost, ease, feasibility of intervention) BMJ 2009;339:b3537
■ a condition with death as a potential outcome can have a higher NNT (and be acceptable), as
compared to an intervention to prevent an outcome with low morbidity, in which a low NNT
would be necessary
Equations to Assess Effectiveness
Number Needed to Harm (NNH) CER = control group event rate
• number of patients who, if they received the experimental treatment, would lead to one additional EER = experimental group event rate
ARR = absolute risk reduction
patient being harmed, compared with patients who received the control treatment RR = relative risk
NNT = number needed to treat
Adherence (formerly compliance) RR = EER/CER
• degree to which a patient’s behaviour and lifestyle concords with the recommendations of healthcare ARR = CER – EER
providers (e.g. the extent to which a patient takes medications as directed) NNT = 1/ARR
Coverage
• extent to which the services rendered cover the potential need for these services in a community
Sources: Shah, CP. Health Indicators and Data Sources. Public Health and Preventive Medicine in Canada, 5e. Toronto: Elsevier, 2003 Beware
The Association of Faculties of Medicine of Canada Public Health Educators’ Network. Assessing Evidence and Information. AFMC Primer on Do not be swayed by a large RR or
Population Health odds ratio, as it may appear to be large
if event rate is small to begin with. In
these cases AR is more important (e.g.
a drug which lowers an event which
occurs in 0.1% of a population to 0.05%
can boast a RR of 50%, and yet the AR
is only 0.05%, which is not nearly as
impressive)
NNT
Consult http://www.thennt.com for quick
summaries of evidence-based medicine
(includes NNT, LR, and risk assessments
Types of Study Design

Formulating a Research Question
PICO
Qualitative vs. Quantitative Population/Patient characteristics
Intervention/exposure of interest
Comparison group or control group
Outcome that you are trying to prevent
Table 6. Qualitative vs. Quantitative Study Designs or achieve
Qualitative Quantitative
Often used to generate hypotheses (Why? What does it mean?) Often tests hypotheses (What? How much/many?)
“Bottom-up” approach “Top-down” approach
Observation → pattern → tentative hypothesis → theory Theory → hypothesis → observation → confirmation
Sampling approach to obtain representative coverage of ideas, Sampling approach to obtain representative coverage of people in the
concepts, or experiences population
Narrative: rich, contextual, and detailed information from a small Numeric: frequency, severity, and associations from a large number of
number of participants participants
Source: Adapted from http://phprimer.afmc.ca
Source: The Association of Faculties of Medicine of Canada Public Health Educators’ Network. Assessing Evidence and Information. AFMC Primer
on Population Health
Quantitative Research Methods
Were exposures assigned by the investigator?
Yes No
Experimental Study Observational Study
Random allocation to groups? Testing a hypothesis?
Yes No Yes No
Randomized Non- Analytical Study Descriptive

Controlled Randomized Study
Trial Designs
Sampling based on
Exposure Outcome Neither
Cohort Case-Control Cross-Sectional

Study Study Study
Figure 8. Quantitative study designs

Source: Adapted from http://phprimer.afmc.ca
Observational Study Designs

• observational studies involve neither the manipulation of the exposure of interest nor randomization
of the study participants
• there are two main subtypes of observational studies: descriptive and analytic studies
An ecological fallacy is an erroneous
Descriptive Studies conclusion made when extrapolating
• describe the events and rates of disease with respect to person, place, and time; estimates disease population level data to explain
frequency and time trends phenomena occurring in individuals. An
• includes case reports, on one person or event, or a case series, which assesses exposures and outcomes example of an ecological fallacy would
be concluding that red wine drinking
• can be used to generate an etiologic hypothesis and for policy planning leads to lower risk of death from CVS
disease based on an ecological study
Analytic Studies showing that countries with a higher rate
• observational studies used to test a specific hypothesis of red wine consumption have a lower
• includes ecological studies, cohort studies, case-control studies, and cross-sectional studies rate of death from CVS causes
Table 7. Observational Study Designs

Type of Study Ecological Cross-Sectional Case-Control Cohort
Definition Units of analysis are Use individual data on Samples a group of people Subjects are sampled and,
populations or groups exposures and outcomes who already have a as a group, classified on the
of people, rather than gathered at the same time particular outcome (cases) basis of presence or absence
individuals and compares them to of exposure to a particular
a similar sample group risk factor
without that outcome
(controls)
Subjects Aggregated groups (e.g. Sample of a population Two or more samples One or more cohorts
cities) of individuals with and Cohort: group of people with
without the outcome(s) common characteristics
of interest (i.e. cases and (e.g. year of birth, region of
controls) residence)
Divided into measured
exposed vs. unexposed
groups
Methods Descriptions of the average Collect information Select sample of cases of Collect information on factors
exposure or risk of disease from each person at one a specific disease during a from all persons at the
for a population particular time specific time frame beginning of the study
Can use regression models Tabulate the numbers in Representative of Subjects are followed for
to test associations groups (e.g. by presence or spectrum of clinical a specific period of time to
between area-level absence of disease/factor disease determine development of
predictors and aggregate of interest) Select control(s) disease in each exposure
outcomes Make tables and compare Represent the general group
groups population Prospective: measuring from
Estimate prevalence To minimize risk of bias, the exposure at present to the
Use regression models to may select more than one future outcomes
test associations between control group and/or match Retrospective: measuring
predictors and outcomes controls to cases (e.g. age, forward in time from
of interest gender) exposures in the past to later
Assess past exposures outcomes
(e.g. EMR, questionnaire) Use statistical models to
Association can be test associations between
concluded between the exposures and disease or
risk factor and the disease other measured outcomes
(odds ratio) Provides estimates of
incidence, relative risk,
attributable risk
Advantages Quick, easy to do Determines association Often used when disease Shows an association
Uses readily available data between variables in population is rare (less between risk factor(s) and
Generates hypothesis Quick and uses fewer than 10% of population) outcome(s)
resources due to increased efficiency Stronger evidence for
Surveys with validated or when time to develop causation
questions allows disease is long Can consider a variety of
comparison between Less costly and time exposures and outcomes
studies consuming
Disadvantages Poor generalizability to Does not allow for Recall bias Confounding may occur due
individual level (not direct assessment of temporal (see Bias, PH14) to individuals self-selecting
assessment of causal relationship or offer strong Confounding the exposure, or unknown/
relationship) evidence for causation Selection bias for cases unmeasured factors are
Ecological fallacy: an between variables and controls associated with the measured
incorrect inference from Confounding Only one outcome can be exposure and outcome
groups to individuals Selection bias measured Cost and duration of time
Confounding Recall bias needed to follow cohort
(see Bias, PH14) Selection bias
Examples A study looking at the A study that examines the A famous case control A famous cohort study is the
association between distribution of BMI by age study published by Sir Framingham Heart Study,
smoking rates and lung in Ontario at a particular Richard Doll demonstrated which assessed the long-term
cancer rates in different point in time the link between tobacco cardiovascular risks of diet,
countries at the population smoking exposure and exercise, and medications
level without individual lung cancer cases at the such as ASA, etc.
data on both factors individual level
Sources: Shah, CP. Measurement and Investigation. Public Health and Preventive Medicine in Canada, 5e. Toronto: Elsevier, 2003
The Association of Faculties of Medicine of Canada Public Health Educators’ Network. Assessing Evidence and Information. AFMC Primer on
Population Health
Rothman KJ, Greenland SG, Lash TL. Modern Epidemiology, 3e. Philadelphia: Wolters Kluwer, 2012
Experimental Study Designs

• not discussed here are non-randomized controlled trials (e.g. allocation by clinic or other non-random
basis – performed when randomization is not possible)
RANDOMIZED CONTROLLED TRIAL (RCT)
Definition
• participants are assigned by random allocation to two or more groups, one of which is the control
group, the other group(s) receive(s) an intervention
Participants
© Emilie Wiens 2016 after Laura Greenlee 2014

• individuals are selected using explicit inclusion/exclusion criteria and recruitment targets are guided Study begins by sampling
by sample size calculations subjects based on outcome
Disease No Disease
Methods (cases) (controls)
• random allocation of individuals into two or more treatment groups through a centralized concealed
Review records
process
• method of assessment to reduce bias
■ single-blind: participant does not know group assignment (intervention or placebo)
■ double-blind: participant and observer both unaware of group assignment
■ triple-blind: participant, observer, and analyst unaware of group assignment
• control group receives standard of care or placebo if no standard of care exists
• one or more group(s) receive(s) the intervention(s) under study
• baseline covariate(s) and outcome(s) are measured and the groups are compared
• all other conditions are kept the same between groups Exposed Unexposed Exposed Unexposed
Advantages Classify Exposure

• “gold standard” of studies, upon which the practice of EBM is founded
Figure 9. Case-control study
• provides the strongest evidence for effectiveness of intervention Adapted from http://phprimer.afmc.ca
• threats to validity are minimized with sufficient sample size and appropriate randomization
• randomization is one of few methods that can eliminate confounding (including unmeasured
Study begins
© Emilie Wiens 2016 after Laura Greenlee 2014

confounders) and self-selection bias
• allows prospective assessment of the effects of intervention Exposed group Unexposed group
Disadvantages
• some exposures are not amenable to randomization (e.g. cannot randomize participants to poverty/
wealth or to harmful exposures such as smoking) due to ethical or feasibility concerns
time
• can be difficult to randomly allocate groups (e.g. communities, neighbourhoods)
• difficult to study rare events, since RCTs require extremely large sample sizes
• contamination, co-intervention, and loss to follow-up can all limit causal inferences
• can have poor generalizability (e.g. when trial participants are healthier than the average patient
population)
• costly Disease No disease Disease No disease
Sources: Shah, CP. Measurement and Investigation. Public Health and Preventive Medicine in Canada, 5e. Toronto: Elsevier, 2003
The Association of Faculties of Medicine of Canada Public Health Educators’ Network. Assessing Evidence and Information. AFMC Primer on Figure 10. Cohort study
Population Health Outcomes
Adapted from http://phprimer.afmc.ca
Summary Study Designs

META-ANALYSIS Analysis
Per-Protocol Analysis (PP)
Strategy of analysis in which only
Definition patients who complete the entire study
• a form of statistical analysis that aggregates all relevant studies addressing the same research question are counted towards the results
in order to increase statistical precision
Intention-to-Treat Analysis (ITT)
When groups are analyzed exactly as
Participants they existed upon randomization (i.e.
• all the studies identified through a systematic literature review using data from all patients, including
those who did not complete the study)
Methods
• selection of relevant studies from the published literature which meet quality criteria
• statistical models used to combine the results of each independent study
• provides a summary statistic of overall results as well as graphic representation of included studies An example of an RCT is the SPARCL
(forest plot) trial, which demonstrated intense
lipid-lowering with atorvastatin reduces
the risk of cerebro- and cardiovascular
Advantages events in patients with and without
• attempts to overcome the problem of reduced power due to small sample sizes of individual studies carotid stenosis when compared to
• can address questions (e.g. subgroup analyses) that the original studies were not powered to answer placebo
Disadvantages
• studies may be heterogeneous and therefore inappropriate to combine (e.g. different patient
populations, exposure classification/measurement, outcome assessment) An example of a meta-analysis is one
• reliance on published studies may increase the potential conclusion of an effect as it can be difficult to that compares the effects of ACEIs,
publish studies that show no significant results (publication bias) calcium channel blockers, and other
Sources: Shah, CP. Measurement and Investigation. Public Health and Preventive Medicine in Canada, 5e. Toronto: Elsevier, 2003 antihypertensive agents on mortality
The Association of Faculties of Medicine of Canada Public Health Educators’ Network. Assessing Evidence and Information. AFMC Primer on and major cardiovascular events by
Population Health compiling and analyzing data from a full
set of reported RCTs
Methods of Analysis
Distributions
• a distribution describes the frequency at which each value (or category) occurs in a study population
Consult the Cochrane Library of
• distributions can take characteristic shapes. i.e. normal (Gaussian) or non-normal (binomial, gamma, Systematic Reviews (http://www.
skewed, etc.) cochranelibrary.com) for high-quality
• characteristics of the normal distribution systematic reviews and meta-analyses
■ mean = median = mode
■ 68% of observations fall within one standard deviation of the mean
■ 95% of observations fall within two standard deviations of the mean
• measures of central tendency Example Calculation
■ mean: sum of each observation’s data (e.g. ages) divided by total number of observations Data set: 17, 14, 17, 10, 7
■ median: value of the 50th percentile; a better reflection of the central tendency for a skewed Mean = (17 + 14 + 17 + 10 + 7)
distribution ÷ 5 = 13
Median (write the list in order, median is
■ mode: most frequently observed value in a series the number in the middle)
• measures of dispersion = 7, 10, 14, 17, 17 = 14
■ range: the largest value minus the smallest value Mode (number repeated most often) = 17
■ variance: a measure of the spread of data Range = 17 – 7 = 10
■ standard deviation: the average distance of data points from the mean (the positive square root of Variance = [(17 – 13)2 + (14 – 13)2
+ (17 – 13)2 + (10 – 13)2
variance) + (7 – 13)2] ÷ 5 = 19.5
• given the mean and standard deviation of a normal or binomial distribution curve, a description of Standard Deviation = √variance = √19.5
the entire distribution of data is obtained = 4.42
Data Analysis
Mean=Median=Mode
# values
Statistical Hypotheses
• null (Ho)
■ the default hypothesis; often states there is no relationship between two variables
Normal Distribution
• alternative (H1)
■ the hypothesis that we are interested in; often states there is a relationship between two variables
■ we can find evidence against Ho but we can never ‘prove’ H1 Mode
Median
Type I Error (α Error) Mean
• the null hypothesis is falsely rejected (i.e. concluding an intervention X is effective when it is not, or
declaring an observed difference to be real rather than by chance) Negatively Skewed
• the probability of this error is denoted by the p-value Figure 11. Distribution curves
• studies tend to be designed to minimize this type of error, since a type I error can have larger clinical
significance than a type II error
• i.e. in a study exploring a drug’s effectiveness on lowering blood pressure, the data may indicate the
drug is effective and therefore lowers blood pressure, when in reality the drug is ineffective Type I (α) Error
“There Is An Effect” where in reality
Type II Error (β Error) there is none
• the null hypothesis is falsely accepted (i.e. stating intervention X is not effective when it is, or
declaring an observed difference/effect to have occurred by chance when it is present)
• by convention a higher level of error is often accepted for most studies
• can also be used to calculate statistical power
• i.e. in a study exploring the effectiveness of a COVID-19 vaccine, the data suggests the vaccine is
ineffective and therefore does not protect against COVID-19 infection, when in reality it does
Power
• probability of correctly rejecting a null hypothesis when it is, in fact, false (i.e. the probability of
finding a specified difference to be statistically significant at a given p-value)
• power increases with an increase in sample size
• power = 1 – β, and is therefore equal to the probability of a true positive result
Statistical Significance
• the probability that the statistical association found between variables is due to random chance alone
(i.e. there is no association)
• the preset probability is set sufficiently low that one would act on the result; frequently p<0.05
• when statistical tests result in a probability less than the preset limit, the results are said to be
statistically significant (denoted by the α-value)
Clinical Significance
• measure of clinical usefulness (e.g. 1 mmHg BP reduction may be statistically significant, but may not
be clinically significant)
• depends on factors such as cost, availability, patient adherence, and side effects in addition to
statistical significance
Confidence Interval (CI)

• provides a range of values within which the true population result (e.g. the mean) lies, bounded by the
upper and lower confidence limits A wider confidence interval implies
• frequently reported as 95% CI (i.e. if this study were repeated 100 times, estimates would fall within more variance than a tighter confidence
the 95% CI 95 out of 100 times) interval given the same critical value
Data
• there are 2 types of quantitative data
■ continuous data (e.g. height in cm)
■ discrete data (e.g. number of patients in the ICU)
• information collected from a sample of a population
©Wendy Gu 2016
• there are 4 overall levels of measurement for quantitative data Good reliability Poor reliability
■ categorical (e.g. blood type, marital status) Good validity Good validity
■ ordinal (e.g. low, medium, high)
■ interval (e.g. °C, time of day)
■ ratio (e.g. serum cholesterol, hemoglobin, age)
Validity/Accuracy (of a measurement tool)

• how closely a measurement reflects the entity it claims to measure Good reliability Poor reliability
Poor validity Poor validity
Reliability/Precision Figure 12. Validity vs. reliability
• how consistent multiple measurements are when the underlying subject of measurement has not
changed
• may be assessed by different observers at the same time (inter-rater reliability) or by the same
observer under different conditions (test-retest reliability)
Internal Validity What’s the difference between Pearson

• degree to which the findings of the sample truly represent the findings in the study population and Spearman correlation?
• dependent on the reliability, accuracy, and absence of other biases Different types of correlation are used
for different levels of measurement.
Pearson is for continuous and Normal
External Validity (i.e. Generalizability) data, Spearman is for ordinal or
• degree to which the results of the study can be generalized to other situations or populations non-Normal data. There are other
forms of correlation for other levels
of measurement (e.g. tetrachoric/
Common Statistical Tests polychoric)
Table 8. Statistical Tests

Two-sample Z-Test Analysis of Chi-Squared Test (χ2) Linear Regression Logistic Regression Pearson Product-Moment
Variance (ANOVA) Correlation (Pearson’s r)
What are you trying to show?
Compare the mean Compare the mean Test the correspondence between a Looks at associations Shows how a change in Assesses the strength of the linear
values of an outcome values of an outcome theoretical frequency distribution between two or more one explanatory variable relationship between two variables.
variable between two variable between two and an observed frequency variables (e.g. age affects the status (e.g. Ranges from -1 (perfect negative
groups (e.g. difference or more groups (e.g. distribution (e.g. if one sample of and BP) ill vs. non-ill) of the association, i.e. increases in
in average BP between difference in average 20 patients is 30% hypertensive outcome variable one variable are associated with
men and women) BP between persons in and another comparison group of decreases in another) to 1 (perfect
three towns) 25 patients is 60% hypertensive, a positive association, increases in
chi-squared test determines if this one variable are associated with
variation is more than expected due increases in the other). A correlation
to chance alone) of 0 indicates no relationship
What kind of variables do you measure?
Dependent Continuous Continuous Categorical (2 or more)/ordinal Continuous Categorical (outcomes Continuous
Variable usually dichotomous)
Independent Dichotomous Categorical/Ordinal (2 Categorical/Ordinal (2 or more) Continuous/Ordinal/ Continuous/Ordinal/ Continuous
Variable or more) Categorical Categorical
Assumptions Data follow a normal/t- “Normal” distribution Expected counts must be at least 5 Dependent variable’s Linearity (on logit scale) Underlying relationship is linear
distribution of dependent for all cells in n by n table error term has No influential values Data for both variables are normally
Equal variances variable’s error term Data are independent “normal” distribution Model has adequate distributed
Data are independent Data are independent Linear relationship goodness-of-fit Data are independent
between variables Data are independent
Homoscedasticity
No influential values
Data are independent
Causation
Criteria for Causation (Bradford Hill Criteria)
1. strength of association: the frequency with which the factor is found in the disease, and the
frequency with which it occurs in the absence of disease
2. consistency: is the same relationship seen with different populations or study design?
3. specificity: is the association particular to your intervention and measured outcome?
4. temporal relationship: did the exposure occur before the onset of the disease?
5. biological gradient: finding a dose-response relationship between the exposure-outcome
6. biological plausibility: does the association/causation make biological sense?
7. coherence: can the relationship be explained/accounted for based on what we know about science,
logic, etc.?
8. experimental evidence: does experimental evidence support the association (e.g. is there
improvement?)
9. analogy: do other established associations provide a model for this type of the relationship?
Note: Not all criteria must be fulfilled to establish scientific causation, and the modern practice of EBM
emphasizes ‘experimental evidence’ as superior to other criteria for experimental causation review.
However, many causation questions in health cannot be answered with experimental methods
Source: Bradford Hill A. The environment and disease: association or causation. Proc R Soc Med 1965;58(5):295-300.
Assessing Evidence
• critical appraisal is the process of systematically examining research evidence to assess validity,
results, and relevance before using it to inform a decision
Systematic
e
nc
Reviews
ide
Critically-Appraised
ev
FILTERED
Topics INFORMATION
of
(Evidence Syntheses)
ty
ali
Critically-Appraised Individual
Qu
Articles (Article Synopses)
Randomized Controlled Trials

(RCTs)
UNFILTERED
Cohort Studies INFORMATION
Case-Controlled Studies
Case Series / Reports
Background Information / Expert Opinion
Figure 13. Pyramid of pre-appraised evidence

© Copyright 2006. Trustees of Dartmouth College & Yale University. All rights reserved. Produced by Glover J., Izzo D., Odato K., and Wang L
A. Are the results of the study valid?

• see below for classifications of evidence that has already been assessed; see sidebar for assessing
primary studies
B. What are the results?

• what was the impact of the treatment effect?
• how precise was the estimate of treatment effect?
• what were the confidence intervals and power of the study?
C. Will the results help me in caring for my patients?

• are the results clinically significant?
• can I apply the results to my patient population?
• were all clinically important outcomes considered?
• are the likely treatment benefits worth the potential harm and costs?
Levels of Evidence: Classifications Cited in Guidelines/Consensus Statements

Level I evidence: based on RCTs (or meta-analysis of RCTs) big enough to have low risk of incorporating FP or FN results
Level II evidence: based on RCTs too small to provide Level I evidence; may show positive trends that are non-significant, or have a high
risk of FN results
Level III evidence: based on non-randomized, controlled or cohort studies; case series; case-controlled; or cross-sectional studies
Level IV evidence: based on opinion of respected authorities or expert committees, as published consensus conferences/guidelines
Level V evidence: opinions of the individuals who have written/reviewed the guidelines (i.e. Level IV evidence), based on experience/-
knowledge of literature/peer discussion
Notes: These 5 levels of evidence are not direct evaluations of evidence quality or credibility; they reflect the nature of the evidence. While
RCTs tend to be most credible (with <III), level III evidence gains credibility when multiple studies from different locations and/or time periods
report consistent findings. Level IV and V evidence reflects decision-making that is necessary but in the absence of published evidence.
Figure 14. Levels of evidence classifications

Note: This is only one method of classifying evidence. Various systems exist, but operate within the same premise that certain types of evidence
carry more weight than others
Health System Planning and Quality

Quality Improvement (QI)
• a means of evaluating and improving processes; focusing more on systems and systematic biases,
which are thought to cause variation in quality
• measures to increase efficiency of action with the purpose of achieving optimal quality
Quality Assurance
• process to guarantee the quality of health care through improvement and attainment of set standards
• “five-stage process of quality assurance”
Source: Public Health and Preventive Medicine in Canada, Shah
1. formulation of working goals
2. procedural changes to implement those goals
3. regular comparison of current performance with original goals
4. development of solutions to bring performance closer to goals
5. documentation of quality assurance activities
Quality Control
• a process of surveying the quality of all factors involved in the process to maintain standards

• the process of ongoing service/product refinement via the vigilant review of expectant issues
detrimental to the system and regular incorporation of improvements
Quality Management
• combination of several processes (assurance, control, improvement) to maintain consistent quality
Total Quality Management

• management principle for advancing quality while minimizing additional expenditures
• focuses on the entire system rather than discrete elements
Audit
• methodical analysis of a quality system by quality auditors
• to determine whether quality processes and results comply with goals, and whether processes have
been implemented effectively
Systems Analysis Tools

1. 5 Whys: brainstorming to simplify the process of change; continue asking ‘why’ until the root of
the problem is discovered
2. Ishikawa Diagrams (i.e. Fishbone Diagrams): identify generic categories of problems that have an
overall contribution to the effect
3. Defect Check Sheets: consider all defects and tally up the number of times the defect occurs
4. Pareto Chart: x vs. y chart; x-axis = defect categories, y-axis = frequency; plot cumulative
frequency on the right y-axis; purpose is to highlight most important among large set of factors
contributing to defects/poor quality
Decreased Handwashing Improper Precautions
Lack of time Lack of training
Lack of hand sanitizer Improperly assigned
Nosocomial Infections
Not sterilizing stethoscope Common waiting

between patients rooms
Not changing uniforms More than 1
between shifts patient per room
Healthcare Team Patient Exposures
Figure 15. Ishikawa diagram
Precede-Proceed Model
• tool for designing, implementing, and evaluating health interventions/programs
Table 9. Precede-Proceed Model

PRECEDE Phase PROCEED Phase
Phase 1 – Identify the ultimate desired result Phase 5 – Implementation (design and conduct the intervention)
Phase 2 – Identify health issues and their behavioural and Phase 6 – Process evaluation (determine if the program is implemented
environmental determinants. Set priorities among them as planned)
Phase 3 – Identify the predisposing, enabling, and reinforcing factors Phase 7 – Impact evaluation (measure intermediate effects on the
that affect the behaviours and environmental determinants target population)
Phase 4 – Identify the administrative and policy factors that influence Phase 8 – Outcome evaluation (determine whether the original desired
what can be implemented result was achieved)
Planning Cycles/Models
1. APIE Planning Model: Assessment, Planning, Implementation, Evaluation
2. PDSA Planning Cycle: Plan, Do, Study, Act
Cost Analysis
Cost Benefit Analysis (CBA)
• an analysis which compares the total expected costs with the total expected benefits of actions in
order to choose the most profitable or beneficial option(s)
• costs are controlled for inflation and market changes so that the effect of the change is evaluated over
a consistent, preset financial value
Cost Effectiveness Analysis (CEA)

• ratio of change in cost (numerator) to change in effect (denominator) in response to a new strategy or
practice
■ the numerator highlights the cost of the health gain
■ some examples of changes in effect (denominator) could be years of life gained or sight-years
gained
■ the most commonly used outcome measure is quality-adjusted life years (QALY) (see Quality
Adjusted Life Year, PH14)
• can be used where an extensive cost benefit analysis is not applicable or appropriate
Managing Disease Outbreaks

COVID-19 precautions
Precautions include hand hygiene,
gown, eye protection, and well-
Definitions fitting masks (e.g. surgical mask).
N95 respirators are reserved for
aerosol-generating procedures,
Outbreak such as endotracheal intubation and
• incidence of new cases beyond the usual frequency of disease in a population or community in a given bronchoscopy
time For specific examples, see
“Communicable Diseases” section in:
Endemic Shah CP. Public health and preventive
medicine in Canada. 5th ed. Toronto:
• consistent existence of infectious agent or disease in a given population or area (i.e. usual rate of Elsevier; 2003
disease) Source: Public Health Ontario:
https://www.publichealthontario.ca/-/media/documents/
ncov/ipac/ipac-additional-precautions-acute-care.
Epidemic pdf?la=en
• an increase, often sudden, in cases of a disease above what is usually expected in a particular
population (e.g. SARS epidemic)
• can occur due to a recent increase in the virulence or amount of an agent, introduction of a new agent
to an area, enhanced mode of transmission of the agent, altered host response, and/or increased host Active Surveillance
susceptibility through more exposure or portals of entry Outreach such as visits or phone calls by
the public health/surveillance authority
Pandemic to detect unreported cases (e.g. an
infection control nurse goes to the ward
• epidemic that has spread across international or intercontinental boundaries, affecting a large and reviews temperature charts to see if
number of people (e.g. COVID-19 pandemic) any patient has a nosocomial infection)
Attack Rate Passive Surveillance

• proportion of an initially disease-free population that develops the disease over a specified time A surveillance system where the public
health/surveillance authority depends
period on others to submit standardized forms
• = [(# of new cases of disease) / (initial population size)] * 100% or other means of reporting cases (e.g.
ward staff notify infection control when
Secondary Attack Rate new cases of nosocomial infections are
• the proportion of individuals who develop disease as a result of exposure to primary contacts during discovered)
the incubation period
• = [(total # of cases - initial # of cases) / (# of susceptible individuals - initial # of cases)] * 100%
• measure of infectiousness, which reflects the ease of disease transmission
Canada’s Response to the COVID-19
Pandemic
Virulence • In late 2019, the novel coronavirus
• measure of an infectious agent to cause significant sickness (COVID-19) led to a global pandemic
• = (# of cases that are severely ill or died) / (total # of cases) • By May 2020, there were over 70000
cases in Canada and more than 4.3
Case-Fatality Rate (CFR) million cases worldwide
• Symptoms of the virus varied from
• proportion of individuals with the disease who died as a result of the illness during a specified time dry cough, fever, and fatigue, to more
period severe respiratory symptoms such as
• must be clearly differentiated from the mortality rate dyspnea and chest pain
• PHAC developed the following
Mortality Rate response:
• Development and implementation
• proportion of the population that died from any cause during a specified time period of new diagnostic tests based on
• crude mortality rate (unadjusted for age) the genetic sequence of COVID-19
• Prompt identification, risk
Basic Reproduction Number (R0) assessment, management, and
• the average number of secondary infections that arise from one infection placement of confirmed cases by
healthcare professionals
• can only be calculated in a susceptible population • Application of routine practices
and additional precautions for
Steps to Control an Outbreak healthcare workers: gloves, long-
sleeved gowns, facial protection,
and masks
Infection Control Precautions • Enforcement of national physical
distancing protocols and 14-day
self-isolation for those returning
Contact (e.g. impetigo, chicken pox, warts) from international travel
• wash hands • Free vaccines against COVID-19
• gloves were made available to everyone in
• gown Canada over the course of 2021
• wipe equipment after use • The temporary closure of many
institutions and reduction in income
for millions of Canadians resulted in
Droplet (e.g. influenza, mumps, pneumonia) novel social assistance programs,
• contact precautions PLUS such as the Canada Emergency
• goggles/face shield Response Benefit
Source: Government of Canada. Coronavirus (COVID-19):
• surgical mask Canada’s Response [Internet]. Ottawa (ON): Government
of Canada; 2020 [updated 2020 Jun 18; cited 2020
Jun 20]. Available from: https://www.canada.ca/en/
public-health/services/diseases/2019-novel-coronavirus-
infection/canadas-reponse.html?topic=tilelink
Airborne (e.g. TB) Figure 16. Epidemic curves

• contact precautions PLUS
• N95 mask (fit-tested)
• negative pressure room 14
12
Number of Cases
Table 10. Ten-Step Approach
10
8
Steps Details 6
1. Identify the investigation team and resources Local public health units (e.g. Toronto Public Health) 4
2
Federal level (e.g. PHAC) 0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
2. Establish existence of an outbreak Compare the number of cases during the suspected outbreak to the Day of Onset
number of cases expected during a non-outbreak time frame
(e.g. receiving a report of a vomiting baseball team after a team dinner
at a restaurant)
Figure 16a. Point source epidemic
3. Verify the diagnosis Obtain medical records and lab reports curve
Conduct further clinical testing as needed
4. Define a case 3 components: Person, Place, Time (e.g. “Diagnosis A: Person with XYZ
signs and symptoms… Occurred after visiting X… During months/year”) 10
5. Find cases systemically and create a line listing A line listing should include clinical information (signs/symptoms, onset 9
8
Number of Cases
times/dates), demographic information, exposure information 7
6
6. Perform descriptive epidemiology and develop hypotheses Create epidemic curves (see Figure 16) 5
4
7. Evaluate hypotheses and conduct additional studies as needed Case-control studies: useful when not everyone exposed can be found 3
and included in the study 2
1
Cohort studies: useful when all persons exposed can be included in 0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
the study Day of Onset
8. Implement control measures Can occur at any stage in an outbreak (e.g. isolation)
9. Communicate findings Involve the media to address public concerns and call for public action
Figure 16b. Extended continuous
10. Continue surveillance Determine when the outbreak is over source epidemic curve
Document the effectiveness of control measures
Source: Adapted from Moore Z. Outbreak Investigations: The 10-Step Approach [Internet]. North Carolina: Government of North Carolina; [updated
2019 Dec 16; cited 2020 Jun 20]. Available from: https://epi.dph.ncdhhs.gov
14
12
Number of Cases
10
Infection Control Targets 8
4
• interventions should target host, agent, environment, and their interactions 2
0
1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64 67 70 73 76 79
nutrition, Day of Onset
©Derek Ng 2016
host
age, immune sickle cell trait
response, antimalarials,
susceptibility proper nutrition Figure 16c. Propagated source
epidemic curve
educate,
DEET avoid exposed
skin at dusk
DISEASE MALARIA
agent environment plasmodium remove stagnant tropical,

virulence, toxicity, climate, physical falciparum water sources stagnant water
ability to survive structures, population eradicate, mosquito netting on homes
outside body density genetically modify
Figure 17. Epidemiology triad as framework for infection control interventions: practical example using
malaria
The International Health Regulations (IHR)

• an international agreement involving 196 nations to prevent, protect against, control, and provide a
public health response to pandemics
• a public health emergency of international concern (PHEIC) is “an extraordinary event which is
determined to constitute a public health risk to other States through the international spread of
disease and to potentially require a coordinated international response”
• the IHR Emergency Committee provides the WHO Director-General with temporary
recommendations on PHEIC events
Environmental Health
Environmental Health Jurisdiction
Definition - Taking an Environmental Health
• study of the association between environmental factors, both constructed and natural, and health History
CMAJ 2002; 166(8):1049-1055
• environmental exposures
■ four common hazards: chemical, biological, physical, and radiation CH2OPD2
■ four main reservoirs: air, food, water, and soil Community
■ three main routes: inhalation, ingestion, or absorption (skin) Home
• usually divided into two main settings Hobbies
Occupation
■ workplace (including schools): may see high level exposure in healthy individuals (see Personal habits
Occupational Health, PH30) Diet
■ non-workplace: lower levels of exposure over a longer period of time; affects vulnerable Drugs
populations more severely, such as at extremes of age, and the immunosuppressed; may be
teratogenic
• health impacts of the environment also include factors such as urban planning and how individuals
interact with the built environment (e.g. safe pedestrian and bicycle paths can facilitate more active BPA, The Toxin Concern of 2009
lifestyles) Bisphenol A (BPA) is a chemical
compound found in some hard,
clear, lightweight plastics and resins.
Table 11. Environmental Health Jurisdiction According to the NIH, animal studies
Public Health Unit Enforcement of water and food safety regulations (including restaurant food safety) suggest that ingested BPA may imitate
Assessment of local environmental risks estrogen and other hormones. In
Monitoring and follow-up of reportable diseases October 2008, Canada became the first
Investigation of environmental contamination, clusters of disease country in the world to ban the import
and sale of polycarbonate baby bottles
Municipal Government Waste disposal, recycling, water and sewage treatment/collection/distribution containing BPA, stating that although
Provincial and Territorial Government Water and air quality standards exposure levels are below levels that
Industrial emission regulation cause negative effects, current safety
Toxic waste disposal margins need to be higher. The US FDA
does not consider normal exposure to
Federal Government Designating and regulating toxic substances
BPA to be a hazard, however the NIH
Regulating food products (e.g. Health Canada (drugs), Canadian Food Inspection Agency (CFIA))
has some concern that fetuses, infants,
Setting policy for pollutants that can travel across provincial boundaries
and children exposed to BPA may be at
International Multilateral agreements (e.g. Kyoto Protocol, UN Convention on Climate Change, International increased risk for early-onset puberty,
Joint Commission) prostate, and breast cancer
Source-Path-Receiver Model
• to prevent workplace injuries, strategies can be implemented to improve the safety profile of the
source, modify the path, and/or protect the receiver Cannabis Legalization and Driving
Under the Influence of Cannabis (DUIC)
Environmental Risk Assessment Source: Public Health Ontario. Evidence Brief-Driving
Under the Influence of Cannabis, 2017
Since the Government of Canada stated
its commitment to legalize cannabis
Hazard Identification and Risk Assessment (HIRA) via the Cannabis Act (Bill C-45) on April
13, 2017, the Canadian Task Force on
Hazard Identification Cannabis Legalization and Regulation
• what is the hazard involved? specifically noted driving impairment
• assess potential hazards by taking environmental health history as an important consideration. Higher
cannabis use, cannabis-dependence,
lower perceived risk from DUIC and
Risk Characterization normative beliefs about DUIC were
• is the identified agent likely to elicit the patient’s current symptoms? identified as risk factors. As such, an act
• review known health impacts of the hazard and identify specific properties that contribute to or to amend the Criminal Code Bill C-46
diminish adverse effects (e.g. evaluate hazard threshold levels) was simultaneously introduced to enable
the police to request an oral fluid sample
for roadside drug screening and to
Exposure Assessment implement THC per se whole blood limits
• is the patient’s exposure to the environmental agent sufficient to have caused the current symptoms? (>2 ng/mL punishable). Public health
• quantify exposure through direct measurement or by reviewing frequency and nature of contact with was also advised to devise population-
hazard based interventions such as 6 hour
Adapted from p.250, Sixth Edition of A Dictionary of Epidemiology by Miquel Porta waiting period recommendations before
driving, as well as preventive strategies
through addiction services, mass-
Air media campaigns, and school-based
instructional programs
Biological Hazards
• moulds thrive in moist areas; 10-15% of the population is allergic
• bacteria survive as spores and aerosols, can be distributed through ventilation systems (e.g.
Legionella)
• dust mites (yr-round) and pollens (seasonal) can trigger upper- and lower-airway symptoms
Chemical Hazards
• ground-level ozone
■ main component of smog with levels increasing in major cities
■ worsens asthma, irritates upper airway
• carbon monoxide (fossil fuel-related, common byproduct of combustion)

■ aggravates cardiac disease at low levels
■ headache, nausea, dizziness at moderate levels Particulate Matter Air Pollution and
■ fatal at high levels Cardiovascular Disease: An Update to the
• sulphur dioxide (fossil fuel-related), nitrogen oxides Scientific Statement from the American Heart
■ contribute to acid rain and exacerbate breathing difficulties Association
Circulation 2010;121(21):2331-2378
• organic compounds at high levels (e.g. benzene, methylene chloride, tetrachloroethylene) A scientific statement by the American Heart
■ tend to be fat-soluble, easily absorbed through skin, and difficult to excrete Association in 2004 reported that exposure to
• heavy metal emissions (e.g. nickel, cadmium, chromium) particulate matter air pollution contributes to
■ variety of health effects: upper airway disease, asthma, decreased lung function cardiovascular morbidity and mortality. An updated
• second-hand tobacco smoke American Heart Association statement in 2010
confirmed a causal relationship between particulate
■ respiratory problems, increased risk of lung cancer matter exposure and cardiovascular morbidity
■ particulates associated with decreased lung function, asthma, upper airway irritation and mortality. The statement reported that such
an exposure over several hr to wk may trigger
Radiation Hazards cardiovascular disease-related mortality and non-
• sound waves fatal events, whereas longer exposures over several
yr may further increase cardiovascular mortality risk
• ionizing radiation and reduce life expectancy within highly-exposed
■ radon is naturally produced by soil containing uranium or radium; can contaminate indoor air, populations by several mo to yr.
and is associated with ~20% of lung cancers
• ultraviolet radiation is increasing due to ozone layer destruction and increases risk of skin cancer
• non-ionizing radiation
■ visible light, infrared, microwave The Walkerton Tragedy
In May 2000, the drinking water system
Water
in the town of Walkerton, ON, became
contaminated with Escherichia coli
O157:H7 and Campylobacter jejuni.
Over 2300 individuals became ill; 27
Biological Hazards people developed hemolytic uremic
• mostly due to human and animal waste syndrome and 7 individuals died in the
• Indigenous peoples, Black Nova Scotians, and rural Canadians at higher risk outbreak
• bacteria: Escherichia coli (e.g. Walkerton, ON), Salmonella, Pseudomonas, Shigella Source: Ministry of the Attorney General. Report of the
Walkerton inquiry. Ontario, 2002
• protozoa: Giardia, Cryptosporidium (e.g. North Battleford, SK)
Chemical/Industrial Hazards
• chlorination by-products (e.g. chlorinated water can cause cancer at high levels)
Water Fluoridation
• volatile organic compounds, heavy metals, pesticides, and other industrial waste products can be Water fluoridation, and the resulting
present in groundwater decrease in dental caries and reduction
• mercury from fish (exposure during pregnancy can be neurotoxic for the fetus) in health inequities, is one of the
• asbestos (e.g. from old buildings) greatest public health achievements of
• lead (can be found in paint, older buildings, and traditional medicines in dangerous quantities) the 20th century. At the recommended
concentration of 0.7 mg/L, fluoride
reduces cavities by 18-40%. Small but
Soil vocal groups opposed to fluoridation
have claimed that fluoride intake is
not easily controlled, and that children
Biological Hazards may be more susceptible to health
• biological contamination: tetanus, Pseudomonas problems. These claims have been
widely debunked but still persist, and
have led some communities to opt not
Chemical Hazards to fluoridate their water, resulting in
• contamination sources: rupture of underground storage tanks, use of pesticides and herbicides, increased dental caries (e.g. Calgary).
percolation of contaminated water runoffs, leaching of wastes from landfills, dust from smelting and Fluoride concentrations in municipal
coal burning power plants, residue of industrial waste/development (e.g. urban agriculture), lead water should be 0.7 ppm
deposition, leakage of transformers
• most common chemicals: petroleum hydrocarbons, solvents, lead, pesticides, motor oil, other
industrial waste products
• infants and toddlers at highest risk of exposure due to hand-mouth behaviours
• effects dependent on contaminant: leukemia, kidney damage, liver toxicity, neuromuscular blockade,
developmental damage to the brain and nervous system, skin rash, eye irritation, headache, nausea,
fatigue
Food
Biological Hazards
Organic Foods
Table 12. Comparison of Select Biological Contaminants of Food and Effects on Human Health • Foods designated as “organic” in
Canada must conform to the Organic
Source Effects
Products Regulations enforced by the
Salmonella Raw eggs, poultry, meat GI symptoms Canadian Food Inspection Agency
Campylobacter Raw poultry, raw milk Joint pain, GI symptoms • Organic foods are not free of synthetic
pesticide residues but typically
Escherichia coli Various including meat, sprouts Watery or bloody diarrhea contain smaller amounts compared to
Primarily undercooked hamburger meat Hemolytic uremic syndrome (especially conventionally grown foods
children) • Currently, there has not been
Listeria monocytogenes Unpasteurized cheeses, prepared salads, Listeriosis: nausea, vomiting, fever, headache, strong evidence to suggest that
cold cuts rarely meningitis or encephalitis eating organic foods is safer or
more nutritious compared to eating
Clostridium botulinum Unpasteurized honey, canned foods Dizziness, weakness, respiratory failure conventionally grown food
GI symptoms: thirst, nausea, constipation Sources: Organic foods. Ann Intern Med 2012;157:348-
366. Health Canada. Pesticides and food, 2011. UpToDate.
Prion (BSE*) Beef and beef products Variant Creutzfeldt-Jakob disease
Organic foods and children, 2009
*BSE = bovine spongiform encephalopathy
• other biological food contaminants include:

■ viruses, mould toxins (e.g. aflatoxin has been associated with liver cancer), parasites (e.g.
Toxoplasma gondii, tapeworm), paralytic shellfish poisoning (rare), genetically modified
organisms (controversial as to health risks/benefits)
Chemical Hazards
• many persistent organic pollutants are fat-soluble and undergo bioamplification
• drugs (e.g. antibiotics, hormones)
• inadequately prepared herbal medications
• food additives and preservatives
■ nitrites highest in cured meats; can be converted to carcinogenic nitrosamines
■ sulphites commonly used as preservatives; associated with sulphite allergy (hives, nausea, shock)
• pesticide residues
■ older pesticides (e.g. DDT) have considerable human health effects
• polychlorinated biphenyls (PCBs)
■ effects (severe acne, numbness, muscle spasm, bronchitis) much more likely to be seen in
occupationally-exposed individuals than in the general population
• dioxins and furans
■ levels highest in fish and marine mammals, also present in breast milk
■ can cause immunosuppression, liver disease, respiratory disease
Examples of Simple Interventions to Reduce Environmental Exposures and Risk of

Disease
• sunscreen to prevent sunburns and UV-related damage
• ear plugs to prevent damage from high intensity sound waves
Environmental Racism
• defined as the deliberate and disproportionate development of environmental hazards and toxic
facilities near to communities of colour and/or lower income communities
• furthermore, historic and present-day colonialist and racist practices contribute to the
marginalization of these communities, resulting in a diminished organizational capacity and political
power to advocate against the placement and impacts of these environmental hazards
• exposure to these environmental hazards therefore undergird to poorer health outcomes and
marginalization already faced by affected individuals and communities
• examples of environmental racism in Canada are ubiquitous against Indigenous communities and
communities of colour. Present-day examples include: the placement of oil and gas industries (e.g.
the Trans-Mountain pipeline across Indigenous lands); a lack of access to potable water, as seen in
communities such as Attawapiskat, Ontario; and other environmental hazards, with two specific
examples provided below
Grassy Narrows, Ontario

• a reserve in northwest Ontario, which came to public attention in the 1970s when many of its
residents began to develop symptoms of mercury poisoning, including severe neurotoxicity
• the source of contamination was attributed to an upstream paper mill dumping tonnes of untreated
mercury into the water over a period of several years
• a loss of natural resources and environmental stewardship had a devastating pervasive impact on the
community:
■ the decimation of two major sources of employment in the area (fishing and working as guides)
■ contaminating local food and water supplies
■ leaving the community with limited resources to manage the short- and long-term effects of
mercury poisoning
• despite ongoing protest, agreement from the federal government to build a mercury treatment facility
was not reached until 2020, approximately 50 years following the initial contamination of Grassy
Narrows. At time of writing, construction of such a facility had yet to begin
• despite the federal government’s promise to eliminate drinking water advisories on reserves, 61
remain in effect as of February 2020, many in communities that are not even isolated
• oil sands, hydroelectric, diamond mines, and many other projects have negatively impacted
Indigenous territories across Canada. Indigenous peoples have reaped very little of the economic
benefits from these activities
• the remote geographic location of many Indigenous communities, in conjunction with complex
jurisdictional issues, lead to debate over who is responsible for the health of these communities; this
often leaves communities with delayed and inadequate responses to community needs
• Canada’s adoption of the United Nations Declaration on the Rights of Indigenous Peoples (UNDRIP)
will help rectify some of these detrimental activities on our environment and Indigenous peoples
Africville, Nova Scotia

• Halifax was founded in 1749
• African people, many of whom were descendants of slaves in Jamaica, dug out roads and built much
of the city
• the early Black community lived a few kilometres north of the city in a community established on the
Bedford Basin in Halifax, an area that became Africville
• the proximity to the waterfront for fishing, prospects for wage labour in the city, and establishment of
structures including a post office, school, and church created a tight-knit Black community which, at
one point, housed over 400 individuals and families
• facilities deemed otherwise unfit for surrounding areas were established in Africville by city council
and businesses, including an oil plant, tar factory, prison, hospital for infectious diseases, and open
garbage dump, with raw sewage and waste products emptying directly into the water supply
• the community was denied resources available to predominantly White neighbouring areas, despite
being within the municipal jurisdiction, including garbage collection, law enforcement, paved roads,
and appropriate water treatment
• in 1957, the city expropriated the land for industrial use and forced the relocation of residents, many
of whom into public housing
• a settlement was reached between some former Africville residents and the City of Halifax in 2010,
although an application for a class-action lawsuit submitted to the Supreme Court of Halifax was
overturned in 2018
• on 24 February 2010, Halifax Regional Municipality Mayor Peter Kelly apologized for the destruction
of Africville
Occupational Health Taking an Occupational Health Hx

WHACS
What do you do?
• a field involved in the prevention of illness or injury and the promotion of health in the work How do you do it?
Are you concerned about any particular
environment exposures on or off the job?
• services encompass recognizing and controlling exposure to hazards (primary prevention), Co-workers or others with similar
occupational health surveillance and screening (secondary prevention), and treatment and problems?
rehabilitation (tertiary prevention) Satisfied with your job?
Source: J Occup Environ Med 1998;40:680-684
• occupational disease often looks clinically the same as non-occupational disease and, without a
thorough occupational health history, may go unrecognized as distinct
Taking an Occupational Health History Occupational Health Statistics

• In 2018, 1027 workers died of work-
• current and previous duties at place of employment related causes in Canada
• The average time-loss injury rate
• exposures between 2014-2018 ranged across
■ identification: screen for chemical, metal, dust, biological, and physical hazards as well as Canadian provinces and territories
psychological stressors - workers may bring safety data sheets (formerly MSDSs) that provide from 1.02 to 2.89 per 100 workers
information about hazards of exposure • Provincial and territorial compensation
■ assessment: duration, concentration, route, exposure controls (e.g. ventilation and other boards do not cover all workplaces
(e.g. most agricultural workers)
environmental controls, personal protective equipment) • Compensation board insurance
• temporal relationship: changes in symptoms in relationship to work environment, latency between coverage ranges across provinces
first exposure and current symptoms and territories from 74-99% of the
• presence of similar symptoms in co-workers workforce
Source: 2020 Report on Work Fatality and Injury Rates
• non-work exposures to hazardous agents: home, neighbourhood, hobbies in Canada
• additional assessment may be required (e.g. chest radiography, ultrasound, PFT)
Information about worker’s

compensation at: https://awcbc.org/en/
Occupational Hazards
Occupational Safety And Health Enforcement
Tools For Preventing Occupational Diseases
Table 13. Occupational Hazards And Injuries
Cochrane DB Syst Rev 2013:CD010183
Physical Chemical Biological Psychosocial Ergonomic / Safety Purpose: To assess the effects of occupational
Noise (e.g. hearing loss) Organic solvents (e.g. Exposure to bacteria, Workload stressors Workload stressors safety and health regulation enforcement tools for
Temperature benzene, methyl alcohol; viruses, fungi, protozoa, Responsibility Responsibility preventing occupational diseases and injuries.
Heat cramps, heat most toxic is carbon Rickettsia Fear of job loss Fear of job loss Outcome: Inspections decrease injuries in the long
exhaustion, heat stroke tetrachloride) Exposure to biological Geographical isolation Geographical isolation term, but not short term, with an unclear magnitude
Hypothermia, Mineral dusts (e.g. proteins, endotoxins, Shift work Shift work of effect.
frostbite silica leads to silicosis enzymes, animal excreta Bullying Bullying
Air pressure (e.g. and predisposition to Blood should be Harassment (sexual/ Harassment (sexual/non-
barotrauma, TB, asbestos leads to considered a potentially non-sexual) sexual) Most Effective
decompression sickness) diffuse fibrosis and toxic substance due to Incurs high cost from Incurs high cost from
Radiation mesothelioma, coal leads blood-borne infectious absenteeism, poor absenteeism, poor
Non-ionizing: visible light, to pneumoconiosis) diseases (e.g. HIV, productivity, mental illness productivity, mental illness
infrared Heavy metals (e.g. nickel, hepatitis B) (e.g. post-traumatic stress (e.g. post-traumatic stress
Elimination
Ionizing: UV, x-rays, γ rays cadmium, mercury, lead) Consider exposure to disorder) disorder) Physically remove
Vibration-related disorders Gases (e.g. halogen gases, disease in endemic Workplace violence Workplace violence hazard
(e.g. secondary Raynaud’s, sulphur dioxide, carbon countries, travellers from (involving staff, clients, (involving staff, clients, e.g. driverless car
whole body vibration) monoxide, nitrogen oxides) endemic countries, or the general public) the general public)
Second-hand smoke recent travel history in the Substitution
(causal factor for lung setting of acute onset of Replace hazard
cancer, lung disease, symptoms (e.g. malaria,
heart disease, asthma SARS, TB) e.g. replace with train
exacerbations; may be
linked to miscarriage) Engineering
Skin diseases (major Controls
portion of compensations, Isolate from hazard
e.g. contact dermatitis, e.g. airbags
occupational acne, Administrative
pigmentation disorders)
Controls STOP SPEED
Change the way LIMIT
20
people work
Workplace Legislation e.g. traffic laws
PPE
• universal across Canada for corporate responsibility in the workplace: reasonable precautions Protect worker with PU
SH
to ensure a safe workplace, application of Workplace Hazardous Materials Information System protective equipment
(WHMIS), existence of joint health and safety committees in the workplace with representatives from e.g. seatbelts
workers and management Least Effective ©Kristen Browne 2016
• jurisdiction in Canada is provincial (90% of Canadian workers), except for 16 federally-regulated Figure 18. Hierarchy of controls for
industries (e.g. airports, banks, highway transport) under the Canada Labour Code reduction of occupational exposures
• Ontario’s Occupational Health and Safety Act Source: Modified from CDC. 2015. Hierarchy
of controls. http://www.cdc.gov/niosh/topics/
■ sets out rights of workers and duties of employers, procedures for workplace hazards, and law hierarchy/
enforcement
■ workers have the right to:
◆ know (e.g. be trained and have information about workplace hazards)
◆ participate (e.g. have representatives on joint health and safety committees) Ontario’s Workplace Safety and
◆ refuse work (e.g. workers can decline tasks they feel are overly dangerous) Insurance Act (each province will have
– note: for some occupations, this right is restricted if, for example, danger/risk is normal their own corresponding legislation)
• Establishes Workplace Safety
part of work or refusal would endanger others (e.g. police, firefighters, some health care and Insurance Board (WSIB), an
workers) autonomous government agency that
◆ stop work (e.g. ‘certified’ workers can halt work they feel is dangerous to other workers) oversees workplace safety training
and administers insurance for workers
■ enforced by Ministry of Labour via inspectors and employers
• Health Protection and Promotion Act (HPPA) (Ontario) • WSIB decides benefits for workers,
• Medical Officer of Health has right to investigate and manage health hazards where workplace which may include reimbursement for:
exposures may impact non-workers (e.g. community members living close to the work site) • Loss of earned income
• Non-economic loss (e.g.
physical, functional, or
Workplace Health Promotion psychological loss extending
beyond the workplace)
• Loss of retirement income
• a strategy for addressing the health and well-being of workers in the workplace, not legislated • Health care expenses (e.g. first-
aid, medical treatment)
• may include education, event planning, information campaigns, workplace supports to promote • Survivor benefits (e.g.
personal worker health and a healthy workforce dependents and spouses can
receive benefits)
• Employers pay for costs (e.g. no
Workplace Primary Prevention government funding)
• No-fault insurance (e.g. worker has
no right to sue the employer) in
• proactive efforts to reduce workplace illness or injury return for guaranteed compensation
• achieved through anticipating, recognizing, evaluating, and controlling workplace hazards for accepted claims
• hierarchy of controls (see Figure 18) is followed to minimize exposure – elimination/substitution • Negligence is not considered a factor
• Physicians are required to provide
of hazards is most superior, followed by isolation (engineering controls), training and behavioural the WSIB with information about a
efforts (administrative controls), and lastly personal protective equipment worker’s health without a medical
waiver once a claim is made
For more information: http://www.wsib.on.ca/en/
community/WSIB
Workplace Secondary Prevention

• for workers who are exposed to workplace hazards, goal is to identify earliest signs of overexposure
or disease through medical surveillance (periodic examinations to identify early changes in a single
worker or multiple workers). Some examples include:
■ whole blood lead testing to identify effectiveness of controls, need to remove workers from
exposure
■ PFT for asthma (e.g. occupational dust exposure)
■ audiograms for hearing loss (e.g. occupational noise exposure)
Workplace Tertiary Prevention

• treatment of the disease or injury to facilitate safe and timely return to the workforce
• may require rehabilitation, retraining, change in job duties, and/or workers’ compensation (WSIB)
• often also involves accommodating the workplace for a worker who has a non-occupational injury
or illness, with routine reassessments of the fit between the worker and their duties - work that is
considered safety-sensitive may be restricted for workers with ailments that could impede their ability
to work safely, or a worker may be medically determined to have limitations with what they can
reasonably do at work
• advise relevant authorities if necessary (e.g. report notifiable diseases to public health, conditions
impeding driving to Ministry of Transportation)
Appendix – Mandatory Reporting
Reportable Diseases
As an essential part of the public health system, physicians in Canada are required by provincial law
to report certain diseases to public health. Physician reporting is also outlined by provincial physician
licensing Colleges (e.g. College of Physicians and Surgeons of Ontario (CPSO)). Failure to report can
result in suspension of a license to practice.
The reasons that reporting is mandatory include:

1. to identify and control an outbreak
2. to prevent spread if the disease presents a significant threat to individuals or a subset of the
population (e.g. Lassa Fever)
3. if the disease is preventable with immunization (e.g. polio, diphtheria, congenital rubella)
4. if infected individuals require education, treatment, and/or partner notification (e.g. gonorrhea,
TB)
5. surveillance (to monitor disease trends over time)
Diseases of Public Health Significance

Diseases marked with * (and Influenza in institutions) should be reported immediately to the Medical
Officer of Health by either telephone or fax. Other diseases can be reported the next working day by fax,
phone, or mail. Each province/territory has a similar legislation.
Acquired Immunodeficiency Syndrome (AIDS) Encephalitis, including: Lassa Fever* Rabies*

Acute flaccid paralysis <15 yr 1. Primary, viral Legionellosis Respiratory infection outbreaks in institutions
Amoebiasis 2. Post-infectious Leprosy and public hospitals*
Anthrax* 3. Vaccine-related Listeriosis Rubella*
4. Subacute sclerosing panencephalitis Lyme Disease Rubella, congenital syndrome
Botulism* 5. Unspecified
Brucellosis* Measles* Salmonellosis
Blastomycosis Food poisoning, all causes Meningitis, acute*: Shigellosis*
1. Bacterial* Smallpox*
Campylobacter enteritis Gastroenteritis, institutional outbreaks and in 2. Viral Syphilis
Carbapenemase-Producing public hospitals* 3. Other
Enterobacteriaceae (CPE) Giardiasis, except asymptomatic cases* Meningococcal disease, invasive* Tetanus
Chancroid Gonorrhea Mumps Trichinosis
Chickenpox (Varicella) Tuberculosis, active and latent Tularemia
Chlamydia trachomatis infections Haemophilus influenzae b disease, all types* Ophthalmia neonatorum Typhoid Fever
Cholera* Hantavirus pulmonary syndrome*
Clostridium difficile* associated disease Hemorrhagic fevers*, including: Verotoxin-producing E. coli infection* indicator
(CDAD) outbreaks in public hospitals 1. Ebola virus disease* Paralytic shellfish poisoning conditions, including Hemolytic Uremic
Coronavirus novel including SARS, MERS, and 2. Marburg virus disease* Paratyphoid fever Syndrome (HUS)*
COVID-19* 3. Other viral causes* Pertussis (whooping cough)
Creutzfeldt-Jakob Disease, all types* Hepatitis, viral*: Plague* West Nile Virus illness, including:
Cryptosporidiosis* 1. Hepatitis A* Pneumococcal disease, invasive 1. West Nile fever
Cyclosporiasis* 2. Hepatitis B Poliomyelitis, acute* 2. West Nile neurological manifestations
Diphtheria* 3. Hepatitis C Psittacosis/Ornithosis
Yersiniosis
Echinococcus multilocularis infection Influenza (Note: Influenza in institutions*) Q Fever*
Other Reportable Conditions

• in addition to reporting diseases, physicians have a legal responsibility to report certain conditions.
The list below highlights some reportable conditions for Ontario, but is not exhaustive. See your
jurisdiction’s regulatory body for the full list
Live Births, Stillbirths, and Deaths – to the Registrar General or Coroner*

• all live and stillbirths must be reported within 2 business days
• a physician with sufficient familiarity of a patient’s illness or who was in attendance of a deceased
patient’s last illness must complete and sign the medical certificate of death
• physicians must contact a coroner or the police if patient is suspected to have deceased from violence,
misadventure, negligence, misconduct or malpractice, or any cause other than disease; by unfair
means; during pregnancy or postpartum from circumstances reasonably attributed to the pregnancy;
suddenly and unexpectedly; from an illness not treated by a legally qualified medical practitioner; or
under circumstances that may require investigation*
• physicians must report all medically assisted deaths to the coroner*
Child Abuse – to Local Children’s Aid Society (CAS)

• all child abuse and neglect where reasonable grounds to suspect exist (including physical harm,
emotional harm, sexual harm, and neglect)
• ongoing duty to report: if additional reasonable grounds are suspected, a further report to CAS is
necessary
Gunshots Wounds – to Local Police Service

• all patients with gunshot or stab wounds should be reported as soon as is practical
• self-inflicted knife wounds are not reportable
Abuse of Long-Term Care or Retirement Home Residents – to the Registrar of the

Retirement Homes Regulatory Authority or Long-Term Care Home Director
• any resident suspected of being subject to or at risk of improper or incompetent treatment or care,
abuse or neglect, or unlawful conduct including financial abuse must be reported immediately
Unfit to Drive – to Provincial Ministry of Transportation

• all patients with a medical condition (e.g. dementia, untreated epilepsy, ophthalmological) that may
impede their driving ability
• if a physician does not report and the driver gets into an accident, the physician may be held liable
Unfit to Fly – to Federal Ministry of Transportation

• all patients believed to be flight crew members or air traffic controller with a medical or optometric
condition that is likely to constitute a hazard to aviation safety
Source: CPSO. Mandatory and Permissive Reporting. 2017. Available from: https://www.cpso.on.ca/Physicians/Policies-Guidance/Policies/
Mandatory-and-Permissive-Reporting
Landmark Public Health and Preventive Medicine Trials

Trial Name Reference Clinical Trial Details
Mammography
Swedish Two-County Trial Radiology 2011;260(3):658-63 Title: Swedish Two-County Trial: Impact of Mammographic Screening On Breast Cancer Mortality
During 3 Decades
Purpose: Evaluate the long-term effect of mammographic screening on breast cancer mortality.
Methods: 133065 women aged 40-74 yr were randomly assigned to either a group invited for
mammographic screening or a control group. A negative binomial regression analyzed mortality.
Results: At 29 yr of follow-up, a large significant reduction in breast cancer mortality was found in
the group invited for mammographic screening compared to the control group (relative risk = 0.69;
95% CI: 0.56 to 0.84).
Conclusions: Invitation to mammographic screening leads to a large significant decrease in breast
cancer-related mortality.
Vaccination
VAXICOL J Am Geriatr Soc 2009;57(9):1580-6 Title: Effect of Influenza Vaccination of Nursing Home Staff on Mortality of Residents: A Cluster-
Randomized Trial
Purpose: Evaluate the impact of influenza vaccination among staff on all-cause mortality in nursing
home residents.
Methods: 40 nursing homes matched in pairs were randomly assigned to the vaccination arm
or no-vaccination control arm. The vaccination arm involved a vaccine promotion campaign and
administration program for staff.
Results: Vaccination rates among staff in the vaccination arm were 69.9% compared to 31.8% in the
no-vaccination arm. A strong correlation between staff vaccination coverage and all-cause mortality
of the residents was found (correlation coefficient = -0.42, P=0.007).
Conclusions: The results support staff of nursing homes being vaccinated against influenza to reduce
all-cause mortality of residents.
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PH Public Health and Preventive Medicine

Glen Katsnelson and Caleb Tackey, chapter editors

PH1 Public Health and Preventive Medicine Toronto Notes 2022

Public Health Context

Figure 1. Population health model

Table 2. Equity-Seeking Groups Facing Systemic Barriers

Table 2. Equity-Seeking Groups Facing Systemic Barriers

Screening for Poverty

Impact of Sustained Caloric Restriction on Residential School Survivors and Other

Tuberculosis, Tuberculosis Sanatoriums, and “Indian Hospitals”

Sixties Scoop and Indigenous Child Welfare

Indigenous Approaches to Health and Wellness

Screening (Secondary Prevention)

Healthy Public Policy

Health Belief Model (1975)

4. Action: the individual is actively involved in making

5. Maintenance: the individual must learn to

Measurements of Health and Disease in a

Rates, Ratios, and Proportions

Crude Death Rate

Infant Mortality Rate (IMR)

Maternal Mortality Rate (MMR)

Quality Adjusted Life Year (QALY)

For additional rate calculations see Steps to Control an Outbreak, PH25

Sample SPIN: use a SPecific test to rule IN a

Interpreting Test Results Figure 5. Understanding sensitivity

Positive Predictive Value (PPV)

Negative Predictive Value (NPV)

Sensitivity = 68/284 = 23.9% NPV = 2234

Effectiveness of Interventions PRE - TEST POST - TEST

Types of Study Design

Quantitative Research Methods

Were exposures assigned by the investigator?

Experimental Study Observational Study

Random allocation to groups? Testing a hypothesis?

Randomized Non- Analytical Study Descriptive

Exposure Outcome Neither

Cohort Case-Control Cross-Sectional

Figure 8. Quantitative study designs

Observational Study Designs

Table 7. Observational Study Designs

Experimental Study Designs

RANDOMIZED CONTROLLED TRIAL (RCT)

© Emilie Wiens 2016 after Laura Greenlee 2014

Advantages Classify Exposure

© Emilie Wiens 2016 after Laura Greenlee 2014

Summary Study Designs

Confidence Interval (CI)

Validity/Accuracy (of a measurement tool)

Internal Validity What’s the difference between Pearson

Table 8. Statistical Tests

Articles (Article Synopses)

Randomized Controlled Trials

Background Information / Expert Opinion

Figure 13. Pyramid of pre-appraised evidence

A. Are the results of the study valid?

B. What are the results?

C. Will the results help me in caring for my patients?

Levels of Evidence: Classifications Cited in Guidelines/Consensus Statements

Figure 14. Levels of evidence classifications

Health System Planning and Quality

Continuous Quality Improvement

Continuous Quality Improvement

Total Quality Management

Public Health & Preventive Medicine - Toronto Notes 2022

Public Health & Preventive Medicine - Toronto Notes 2022