CPH Exam Review Webinar Biological and Genetic …...CPH Exam Review Webinar Biological and Genetic Factors that Influence Health I’m sure most of you are familiar with the CPH credential
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CPH Exam Review Webinar Biological and Genetic Factors that Influence Health
CPH Exam Review Webinar Biological and Genetic Factors that
Influence Health
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I’m sure most of you are familiar with the CPH credential , or you wouldn’t be here. But we are always asked why. Why should I get certified. I don’t need it because I have my PhD, MD, CHES, etc… In brief, the Certified in Public Health is the only credential of its kind for public health that demonstrates not only your knowledge of key public health sciences, but also your commitment to the field through continuing education focused on emerging and established public health issues. As the field of public health grows and its mission becomes more defined, it is crucial for public health professions to stay current in this rapidly evolving field.
CPH Study Resources1. Content Outline2. Sample Exam
Questions3. Practice Exams4. Webinars5. ASPPH Study
Guide6. APHA Study
Guidewww.nbphe.org/cph-study-resources/
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We have resources to help you prepare to take the exam and earn your CPH credential. Each of these can be found by visiting nbphe.org/cph-study-resources/
Public Health Biology and Human Disease Risk (10%)
Collaboration and Partnership (10%)
Program Planning and Evaluation (10%)
Program Management (10%)
Policy in Public Health (10%)
Health Equity and Social Justice (10%)
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We always suggest candidates start by reviewing the content outline to determine which the topics of section seem familiar and which do not. Within each of these content areas is a list of identified job tasks outlining the skill set require for each area. This review is a good way to determine where to start studying.
Sample Exam Questions
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Sample questions in the format of the CPH exam
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The free sample questions are intended to give candidates a preview of the format of the questions.
Practice Exams
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Online mini-exam of 50 questions from the CPH item-bank
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Next we suggest candidates take the practice exam. The practice exam is a 50 question exam of items drawn directly from the item-bank. Candidates can take the practice exam as many times as they wish. Each time they receive a detailed report with the results. The practice exam is an excellent way for candidates to determine how prepared they feel to take the actual CPH exam.
Study Webinars
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Upcoming Webinars Lecture and Q&A
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Evidence Based Public Health: Biostatistics
October 22, 1-3 pm ET
Today’s webinar and all past webinars /presentations are posted on https://www.nbphe.org/cph-study-resources/
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Todays webinar is one of a series presented on each of the ten domains of public health. We have one more left in the series, Evidence Based Public Health, focus on Biostatistics on October 22. We hope you’ll join us. Each webinar is recorded and recorded and posted online following their original presentation date. Please take a look at our other sessions as you review.
The Association of Schools and Programs of Public Health provides a comprehensive practice exam experience. With a database of 400 questions developed by public health item writers, you take unique exams each time. You received immediate results with and each question has a detailed explanation of the correct answer, resources to review, and links to take you to further study materials.
APHA Press Study Guide
Editors: Karen Liller, Jaime Corvin and Hari VenkatachalamUniversity of South Florida College of Public HealthCertified in Public Health Exam Review Guide$41.95 APHA member /$51.95 non-member eBook and print available via the APHA Bookstore at https://www.apha.org/publications-and-periodicals
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Developed by our Faculty at the University of South Florida School of Public Health, this exam review guide provides a detailed chapter on each of the content areas, definitions, explanations and sample questions.
Before we begin the review, I want to cover a few administrative items. You will see an orange box with a white arrow. Click on the arrow and it will open your control panel. Here you will see a menu labeled questions. Please enter your questions at any time. At the end of the presentation, we will read them aloud and discuss as time permits. I will be monitoring the questions and will answer any general questions throughout the presentation. In addition, there will be an opportunity to respond to practice questions during the exam via text response. Please keep your cell hones handy! Again, this and all exam review webinars, are recorded and posted along with the ppt on NBPHE.org
Biological and Genetic Factors that Influence Health
Jaime Corvin, PhD, MSPH, CPHAssociate Professor and Director of the MPH
University of South Florida College of Public HealthASPPH CPH Exam Webinar Series
September 26, 2019
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Hello and welcome! My name is Jaime Corvin. I am an associate prof at the USF college of Public health and the director of our Masters programs. I am excited to be with you today to share some insight on taking – and successfully passing – the CPH exam. Today, we are going to specifically discuss biological and genetic factors that influence health.
Learning Objectives
1. Assess how biological agents affect human health2. Apply evidence-based biological concepts to inform public
health laws, policies, and regulations3. Identify risk factors and modes of transmission for infectious
diseases and how these diseases affect both personal and population health
4. Gain confidence in your ability to successfully complete the CPH exam
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As public health advances into the 21st century, an important focus on public health biology is reemerging. This focus includes not just our traditional focus on infectious disease, but also non-communicable and chronic diseases, nutrition, genetics and genomics and the cognitive sciences. So in this presentation, we are going to discuss the evolution of public health biology and disease risk, outlining how biological agents affect health and inform public health laws and regulations, and identifying factors that influence infectious and non-communicable diseases. I hope that we are also going to spend some time helping you to gain confidence in your ability to successfully complete the CPH exam. Trust me – you can do this!!
Topics
Biological Basis for Public Health Disease Transmission Immunity Global Burden of Disease Human Genetics and Genomics Injuries and Violence
Physical Environment• Air, water, soil
Social Environment Food Safety Hazardous Waste Chemical Agents Policies and Federal Law
When it is time – you will be promoted to text ASPPH to log into the poll.
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We will cover the following topics. I am going to try to hit on the most important points and I have embedded questions for you to answer.
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Poll Title: How are you feeling about the CPH exam?https://www.polleverywhere.com/free_text_polls/S3xuuOr7paHwSK4pbVgAe
Biological and Molecular Basis for Public Health
• Public Health– Based on premise health
events are not random • Occur as a result of risk
factors
– Risk factors are not randomly distributed in the population • Influenced by biological &
social determinants of health
Lyme disease: Caused by bacteria, Borrelia Burgdorferi. Transmitted to humans through bite from an infected deer tick.
Trypanosomiasis (African Sleeping Sickness) is transmitted by a blood sucking insect, the tsetse fly.
WHO estimates that more than 13 million deaths are due to preventable environmental causes
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Public health is based on the premise that health events (or disease) are not random events within the population. Rather, as you can see in these examples of the Trypanosomiasis or African Sleeping Sickness, which is transmitted by the tsetse fly, in Sub-Saharan Africa, or of Lyme Disease which is transmitted by the deer tick in New England, these conditions tend to have patterns to spread and exposure. And these conditions are more likely to occur as a result of risk factors. Further the risk factors are not randomly distributed within the population and are, in fact, influenced by social determinants of health. Understanding and addressing these conditions is vital, as the WHO estimates that more than 13 million deaths are due to preventable environmental causes each year.
Disease Causation
• One role of Public Health – Determine causes of
disease• i.e. the etiology (cause,
origin)
– Determine environmental factors that play a role
– Understand the mechanisms
Discover the factors which affect health so that we can prevent disease and promote health!
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A primary objective of Public Health is to obtain the scientific basis to prevent disease and to promote health. To accomplish this, we need to complete several activities: 1. to discover the agent/cause, 2. to determine the environmental factors that put that agent in contact with the human host, 3. and finally which mechanisms are affected in the host that generate disease. Let’s mention again that a ‘cause’ is a factor that influences the occurrence of disease and recall that one of the functions of epidemiology is to search for causes of disease, to determine the etiology.
Models of Disease Causation
• The Epidemiologic Triangle– One of the most
commonly used models to explain infectious disease
– Illustrate relationship between:
• Agent• Host• Environment.
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To help us understand disease transmission and how these conditions influence the public’s health, epidemiologist have developed models of disease causation. The Epidemiologic Triad, or Epidemiologic Triangle, is one of the most commonly used models to explain infectious disease and to illustrate the relationship between an agent, a host, and the environment. Figure 1. illustrates the Epidemiologic Triad. I love this figure because it outlines all of the important elements of the triangle. The Epidemiologic Triangle explains that disease occurs when an outside agent capable of causing the disease interacts with a vulnerable host in an environment that is conducive to disease spread (While the environmental conditions are not part of the agent or the host, it influences their interaction). Public Health practitioners, thus, focus on trying to break a leg of the triangle, essentially stopping the spread of disease. Part of why I love this diagram is because it also helps us to think through the types of interventions that might be helpful in addressing agent, host or environment. For the condition to occur, the basic elements of causation and an adequate chain of transmission (i.e. environmental pathway) must be present.
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Poll Title: What is the chain of infection a model of?https://www.polleverywhere.com/multiple_choice_polls/DCNG97gPUHlSQv0nNsCvf With that, I want to jump into our first question. I just mentioned the chain of infection. What is the chain of infection a model of?
This was a tough question. The purpose of the model is to explain how pathogenic organisms are transmitted. While the understanding of how disease is transmitted allows us to think about prevention points, the goal of this particular model is to explain the transmission process. The Chain of Transmission of Infectious Disease helps to illustrate how an infectious agent develops and spreads. The six elements of this chain are elaborated in this diagram. We start with a Causative Agent: Any microorganism that can cause infection. Example: the common cold virus Reservoir or Source: The environment where the agent resides; water sources, feces, bodily secretions Example: an individual’s nasal cavity Portal of Exit: How the agent leaves the reservoir of the host Example: when the host sneezes Mode of transmission: How the agent travels to another host. This may be direct or may include an intermediate or indirect contact Example: droplets are picked up by another individual Portal of Entry: Where the infectious agent enters a susceptible host Example: An opening, including the nose or mouth Susceptible Host – Individual or animal that is susceptible to infection. Example: Individual with low immune system. As I mentioned before, to control disease conditions, public health professionals seek to break any of the legs of the Epidemiologic Triangle or the links in the chain of infection. We hope to apply prevention efforts that break any of these links, stop the spread of the condition and prevent disease transmission. Now this is a point, where I want to remind you – so much of what we do in public health is broken into lists and cycles and it feels overwhelming to memorize. DON’T! Instead, take a break, think about what you are being asked or the focus of that list and you can talk your way through it. I promise. For every cycle or list we have to start somewhere, In this example, we will start with the agent. Think about it as the germs – you Agent. Those guys need somewhere to live – the resevour. Let’s think of the flu virus in humans. People are the reservoir. If an infected person is sick but the germs don’t get out, no one gets sick. But what happens when your child has the flu? They sneeze – if they are small enough right in your face --- every time! drop tissues, and ohh the toilet. There is your portal of exit. Once they get out, you know they get around. Suddenly you have touched that counter or you caught a sneeze right to the face. The virus has been transmitted. And they have to get into the new host. Mouth, eyes, cuts, all portals of entry. Then you have your next suspectable host and the chain continues.
Theories of Infectious Diseases
• Past scholars sought ways to:– Explain how infectious
diseases work– Underlying biologic
mechanisms.
Understanding predicting spread of infectious diseases.
Pasteur: Father of germ theory and bacteriology• created the first vaccines for rabies and anthrax • Best known for:
Invention of the technique of treating milk to stop bacterial contamination --
pasteurization.
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We would be remiss in our discussions if we didn’t highlight history here. As expected, past scholars sought ways to explain how infectious diseases work, and their underlying biologic mechanisms. Following the assumption of epidemiology that disease is not random, those postulating about infectious disease sought explanations that would eventually assist in predicting the spread of infectious diseases. One popular theory was the Germ Theory, explaining specific etiology of disease. Louis Pasteur along with Robert Koch developed the Germ Theory of Disease, which states that "a specific disease is caused by a specific type of microorganism." Now you might not know this but Pasteur was not the first to propose germ theory (Girolamo Fracastoro, Agostino Bassi, Friedrich Henle (1840) and others had suggested it earlier), but he articulated it and did the experiments that clearly indicated germ theory is correct. Today he is often regarded as the father of germ theory and bacteriology. Now I always joke with my students – that I want them to represent well at trivia night – so its important to know – while we know Pastuer for germ theory and he was the one who created the first vaccines for rabies and anthrax. He is best known for his invention of the technique of treating milk to stop bacterial contamination, a process now called pasteurization. But did you know he was originally working for a winery to help prevent their wine from turning into vinegar using pasteurization. This, of course was later replaced by the use of sulfites in winemaking In all Pasteur was vital in informing our understanding of disease and predicting how infectious disease spread.
Another prominent theory is Koch’s postulates, explaining transmission of the organism to the host. Koch’s postulates are four criteria designed to establish a causal relationship between a causative microbe and a disease. The postulates were formulated by Robert Koch and Friedrich Loeffler in 1884 but later refined by Koch who published them in 1890…so he gets all the credit. Koch applied the postulates to establish the etiology of anthrax and tuberculosis, but they have been generalized to other diseases. Koch’s postulates are four criteria designed to establish a causal relationship between a causative microbe and a disease. And again – an overwhelming diagram. But take a step back and think about what it is trying to prove – that a particular microorganism causes disease. How would we do this? We have to find the organism and it should be in : 1. all animals suffering from the disease, but not in healthy animals (Abandoned later when carriers where discovered). 2. The organism must be isolated from a diseased animal and grown in pure culture. 3. The cultured organism should cause disease when introduced into a healthy animal (this does not hold true with many agents, where people show resistant). 4. The organism must be reisolated from the experimentally infected animal. Thus proving organism caused disease Now I must note, there are a number of infectious agents are accepted as the cause of disease despite their not fulfilling all of Koch’s postulates. Since, Koch, we have discovered asymptomatic carriers for disease – individuals that can spread the disease but do not have the symptoms. We also have learned that some people may show resistance to disease. Therefore, while Koch’s postulates retain historical importance and continue to inform the approach to microbiologic diagnosis, fulfillment of all four postulates is not required to demonstrate causality.
Poll Title: A mosquito bites an individual who later develops a fever and abdominal rash. What type of transmission would this be?https://www.polleverywhere.com/multiple_choice_polls/i4jsS77RMdekPyHze3alq This would be biological vector transmission. Remember…
(a) A mechanical vector carries a pathogen on its body from one host to another, not as an infection.(b) A biological vector carries a pathogen from one host to another after becoming infected itself.
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The best answer there as biological vector transmission.
Poll Title: A blanket belonging to a child who has chickenpox is likely to be contaminated with Varicella-zoster virus, the virus that causes chickenpox. What is the blanket called?https://www.polleverywhere.com/multiple_choice_polls/CNcYcaHsfKEVF3d984Z8q The blanket is a fomite.
The classic example of a fomite is a park water fountain from which many people drink. Infectious agents deposited by one person can potentially be transmitted to a subsequent drinker.
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Fomites are inanimate objects that can become contaminated with infectious agents. These objects serve as a mechanism for transfer between hosts. The classic example of a fomite is a park water fountain from which many people drink. Infectious agents deposited by one person can potentially be transmitted to a subsequent drinker.
LEISHMANIASIS Leishmania donovani, L. infantum, L. chagasi
Lutzomyia spp. sandflies Biological
RIVER BLINDNESS Onchocerca volvulus Simulium spp. (major vector S. damnosum in Africa)
black flies Biological
GUINEA WORM Dracunculus medinensis Cyclops spp. water fleas (copepods)
Biological
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Biological insect vectors include mosquitoes, which transmit malaria and other diseases, and lice, which transmit typhus. Other arthropod vectors can include arachnids, primarily ticks, which transmit Lyme disease and other diseases, and mites, which transmit scrub typhus and rickettsial pox. Biological transmission, because it involves survival and reproduction within a parasitized vector, complicates the biology of the pathogen and its transmission. There are also important non-arthropod vectors of disease, including mammals and birds. Various species of mammals can transmit rabies to humans, usually by means of a bite that transmits the rabies virus. Chickens and other domestic poultry can transmit avian influenza to humans through direct or indirect contact with avian influenza virus A shed in the birds’ saliva, mucous, and feces.
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Poll Title: The infectious agent that causes malaria is known as which of the following?https://www.polleverywhere.com/multiple_choice_polls/tTXQwhiEJqMKzt9pFpE0z
Mosquitoes
• 3,000+ species worldwide!!
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Malaria is caused by members of the protozoan genus Plasmodium
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And just a little motivation and humor. As you are preparing for this exam, you might be questioning what you are doing. I want to assure you – what you are doing is SO valuable. Never before have public health practitioners like you been more needed. And don’t underestimate what you, armed with this degree, can do.
Infectious Disease Models
SEIR infection model• Susceptible, Exposed,
Infectious, Recovered• Simulate progress of epidemic
in a human population. o LPi: latency periodo IPi: infectious periodo ti: first time individual is
exposed to the viruso xLP: number of days for an
exposed individual to become infective
o xIP: number of days for an individual to recover from the disease. States of the SEIR infection model
An agent-based approach for modeling dynamics of contagious disease spread - Scientific Figure on ResearchGate. Available from: https://www.researchgate.net/figure/Different-states-of-the-SEIR-infection-model-to-simulate-theprogress-of-and-epidemic-in_fig1_26718591 [accessed 23 Sep, 2019]
Why Is Surveillance Important?• Surveillance is VITAL to Public Health:
– Monitoring disease trends– Describing natural history of diseases– Identifying epidemics or new
syndromes– Monitoring changes in infectious
agents– Identifying areas for research– Planning public health policy– Evaluating public health
policy/interventionsImage source: West Umatilla Mosquito Control;http://www.wumcd.org/surveillance/chicken.html
A NOTE ABOUT WEST NILE VIRUS: • As of September 24, 2019, 46 states and the District of Columbia have
reported West Nile virus infections in people, birds, or mosquitoes.• 543 cases of WNV in people have been reported to CDC.
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Surveillance information has many uses, including monitoring disease trends, describing the natural history of diseases, identifying epidemics or new syndromes, monitoring changes in infectious agents, identifying areas for research, evaluating hypotheses, planning public health policy, and evaluating public health policy and interventions. Seen in this diagram are the sentinel chickens in Florida.
Strategies Used to Prevent Epidemics and Spread of Disease
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The timeline you completed highlights the discovery of several important strategies to prevent disease. These include pasteurization, disinfection, antibiotics and vaccination. Our focus will be primarily on immunization.
Immune System
Network of organs, cells, tissues
– Skin– Lymphatic system– Thymus – Bone marrow– Spleen – White blood cells (leukocytes)
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To better understand how immunizations work it can be helpful to review information about the immune system. The immune system is a network of cells, tissues, and organs that work together to defend the body against infectious diseases. To perform this function, the immune system must distinguish one’s own cells from foreign substances. When the immune system fails to identify one’s own cells and attacks those cells, an autoimmune disease results. The body also needs to determine which foreign substances are pathogens and which are harmless substances. When the immune system attacks foreign substances that are otherwise harmless (such as pollen) it causes allergy symptoms. The immune system also helps to prevent cancer and this latter function has been harnessed as part of new cancer treatments referred to as immunotherapy.
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Poll Title: Which of the following best describes how vaccines work?https://www.polleverywhere.com/multiple_choice_polls/xR6BxJHaljHIORmrQDaZX Most vaccines work by triggering the body's adaptive immune system including antibody production that can target a specific pathogen
Poll Title: Which of the following is the best description of herd immunity?https://www.polleverywhere.com/multiple_choice_polls/j96KqHWz13WhBOCo1IGfj Resistence within a population
Herd Immunity
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Herd immunity is vital to public health and, unfortunately, at present, we have pockets in the US that no longer have the parameters for herd immunity due to anti-vax campaigns. At a population level vaccination will only prevent widespread outbreaks if a large enough proportion of the population is immunized. In this top example, the population experiences a widespread outbreak because nobody is immunized. In the second example, where a large proportion of the population is vaccinated, an outbreak is prevented and even most of the individuals who were not immunized remained unaffected. This second example demonstrates the concept of herd immunity, which can be defined as the extent to which a population is resistant to a certain infection. Herd immunity can help protect those in the population who cannot be immunized because they are too young or are immunocompromised.
Data from Epidemiologic Reviews 1993
Why do we need such high vaccination rates for pertussis and measles?
Herd Immunity Threshold
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This table shows the approximate proportion of the population that must be immunized in order to prevent widespread outbreaks. Answer: Pertussis and measles are highly contagious because they are caused by airborne pathogens that can linger in the air for quite a while. Thus a person can get these diseases simply by being in a room even up to a couple hours after an infected person has sneezed or coughed. Given how infectious these conditions are it means that in order to prevent an outbreak a higher proportion of the population must be immunized.
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Poll Title: New vaccines for influenza must be developed every year because:https://www.polleverywhere.com/multiple_choice_polls/1aQJBjVlLwxvn1AfbmCfO
Influenza & Antigenic Drift and Antigenic Shift
• Antigenic Drift - Minor– Minor change within
subtype• Point mutations
– Occurs in A and B Subtypes
– May cause epidemics
• Antigenic Shift - Major– Major change
• New subtype• Exchange of gene
segments
– Occurs ONLY in A subtypes
– May cause Pandemic
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Both antigenic drift and antigenic shift are terms used to describe ways in which the flu virus changes over time. A drift is a minor change while a shift is a major one.
Usually disease is caused by:
Complex interactions between genes and environment
Genes(biology)
Disease
Environment(including lifestyle)
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As you discovered, most of the leading causes of death result from diseases that develop through complex interactions between genes and environmental risk factors. Examples of environmental factors include the air we breathe, pathogens to which we are exposed, as well as lifestyle factors such as diet and exercise.
Congenital Disorders
Cause 1 in 5 deaths during first year of life
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Poll Title: Which of these groups of conditions include one or more single gene disorders that are part of the recommended uniform newborn screening panel?https://www.polleverywhere.com/multiple_choice_polls/ZBir07sgIjZuPe0zTkRa9 CPH never has all of the above but we wanted to use this as a starting point for discussion. Newborn screening is a public health service done in each U.S. state. Every newborn is tested for a group of health disorders that aren't otherwise found at birth. With a simple blood test, doctors can check for rare genetic, hormone-related, and metabolic conditions that can cause serious health problems.
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Poll Title: Which of the following is true about newborn screening programs?https://www.polleverywhere.com/multiple_choice_polls/jiHvc1h1g8ZMMGPYlsXAM Even if the specificity is above 99% which it is, there are more false positives than actual cases identified Newborn screening is a state public health service that reaches each of the nearly 4 million babies born in the United States each year. It ensures that all babies are screened for certain serious conditions at birth, and for those babies with the conditions, it allows doctors to start treatment before some of the harmful effects happen. Newborn screening began in the 60s when scientist Robert Guthrie, MD, PhD, developed a blood test that could detect whether newborns had the metabolic disorder, phenylketonuria (PKU). Since then, scientists have developed more tests to screen newborns for a variety of severe conditions. Screening tests are currently available for more than 60 disorders. However, there is variability in the number and types of conditions found on each state’s newborn screening panel, which is determined by each state public health department. Screening, in general, is a public health service designed to identify individuals in a population who may be at an increased risk of a certain disease. Because the test is performed before an individual has any observable symptoms, it allows a condition to be identified and treated before a problem occurs. A screening test cannot confirm or rule out a particular condition. Stated differently, newborn screening is not a diagnostic test. It identifies individuals who may have the condition so that definitive follow-up testing can be offered to determine if the condition is truly present.
Environmental Teratogens
Teratogens are agents that induce structural abnormality, growth deficiency or functional alteration during prenatal development
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A teratogen is an environmental agent that can cause abnormalities in an exposed fetus. ... Teratogenic agents can be environmental chemicals, maternal metabolic factors, drugs, or infections.
Many physical defects arise during embryonic development. These diseases are called teratogenic and the external factors that cause them are called teratogens. Teratogens fall under the following categories: Ionizing radiation Gamma or x-rays – this may cause problems with eyes, microcephaly or intellectual disabilities Chemicals Accutane: Commonly used in the treatment of acne. When used during pregnancy can result in birth defects Alcohol: May cause fetal alcohol syndrome when consumed during pregnancy Cigarette smoke: Associated with low birth weight, stillbirth or miscarriage Dioxin: Group of chemically related compounds called persistent organic pollutants (POP) which break down slowly, are highlight toxic and linked to cancer, reproductive issues and developments problems. Thalidomide: A sedative used widely in the 1960s that resulted in phocomelia (the absence of long bones in the legs and arms) Pathogens Rubella: Virus that crosses the placental barrier, causing congenital defects Syphilis: A sexually transmitted disease that produces microcephaly and intellectual disabilities Toxoplasmosis: A disease that results from infection with toxoplasma gondii parasite; infection linked to undercooked contaminated meat, exposure to infected cat feces and mother to child transmission. Most teratogens effect the embryo during organogenesis, a critical stage of early development when tissues and organs are formed. From Living with the Earth
Demographic Transition
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We would be remiss in this section is we didn’t mention non-communicable diseases. While this will be covered greatly in other webinars
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Poll Title: Compared with the situation in 1900, the prevalence of deaths due to infectious diseases in the USA is:https://www.polleverywhere.com/multiple_choice_polls/qubbN1EnKP9nn8OHauHTJ A century ago, infectious diseases were the main cause of death in the USA. These have been largely eliminated, and the current main causes of death are conditions such as heart disease and cancer.
Leading Causes of Deathmid1800 1900 2017Tuberculosis Pneumonia Heart Disease
Dysentery/diarrhea Tuberculosis Cancer
Cholera Diarrhea Chronic lower respiratory Dz
Malaria Heart Disease Unintentional Injuries
Typhoid fever Cerebrovascular Disease
Stroke
Pneumonia Liver Disease Alzheimer's Disease
Diphtheria Injuries Diabetes
Meningitis Cancer Influenza and Pneumonia
Whooping Cough Senility Liver Disease
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Here you can see the shift in disease from the 1800s to present day. Red being infectious, purple being non-communicable in nature.
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Poll Title: The most important reason for reduced mortality during the initial stage of a demographic/epidemiologic transition in a population is:https://www.polleverywhere.com/multiple_choice_polls/XQzm0zhpPx5DcysU7jShd Reduced mortality due to improved sanitation outweighs the impact of immunization and antibiotic use. Immunization and antibiotics are vital and important but the greatest gains were seen with improved sanitation.
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Poll Title: Which of the following is currently the most common cause of unintentional death in the U.S.?https://www.polleverywhere.com/multiple_choice_polls/6l8bHKhc3tZdyq8R1RI5t Poisoning – then motor vehicle then falls then gunshot
Physical Environment
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As we are talking about these conditions, the role of the environment should be everpresent in your mind. Aside from hosting the vectors that cause disease, the environment itself can be critical to the individual and the community. And when I talk about environment, I am referring to both the physical and social environments. The physical environment is comprised of air, water, and soil through which exposure to biologic (e.g disease organisms present in food and water; insect and animal allergens), chemical (e.g. air pollutants, toxic wastes, pesticides, volatile organic compounds (VOCs) s) or physical (e.g. noise, ionizing and non-ionizing radiation) agents may occur, while the social environment includes the built space (e.g. housing, transportation, land use and development) and the industry or agriculture that also results in exposures to harmful agents, work-stress, injury or violence. As the population continues to expand, protecting the environment requires an understanding of the factors that ensure our air is safe to breath, the water is safe to drink, the land is free from toxins, and waste is managed well. This requires effective oversight through the development and enforcement of laws, policies and regulations.
6 Criteria Air Pollutants
• The Clean Air Act requires the Environmental Protection Agency’s (EPA) to set National Ambient Air Quality Standards for 6 primary criteria air pollutants:
1. Sulfur dioxide (acid rain): Causes respiratory effects• People with asthma and other susceptible populations
2. Nitrogen oxides (smog, acid rain): Linked to respiratory effects• People with asthma
3. Carbon monoxide: Reduces oxygen to body tissues.• Those with cardiovascular conditions.
4. Ozone: Causes airway irritation, coughing, and difficulty breathing. • Those with chronic obstructive pulmonary disease (COPD) or asthma
5. Lead: Can cause neurological effects • Children; Can also affect kidney, immune, development, and reproductive systems
6. Particulate matter: Smaller than 10 micrometers. Can cause respiratory effects• People with asthma
Air pollutants are chemicals in the atmosphere whose concentrations are high enough to cause harm
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The National Ambient Air Quality Standards (NAAQS) sets the limits for six primary criteria air pollutants: Sulfur dioxide (acid rain) – causes respiratory effects particularly in asthmatics and other susceptible populations Nitrogen oxides (smog, acid rain) – linked to respiratory effects; can affect asthmatics Carbon monoxide – reduces oxygen to body tissues; can affect those with cardiovascular conditions Ozone – airway irritation, coughing, difficulty breathing; can affect chronic obstructive pulmonary disease (COPD); asthmatics Lead – Metal that occurs naturally; can cause neurological effects in children can also affect kidney, immune, development, and reproductive systems Particulate Matter – particulates measuring below 10 micrometers includes both PM10 and PM2.5; can cause respiratory effects These limits are revised every five years. It is the responsibility of the States to ensure new NAAQS are met. https://globalclimatechange3b.weebly.com/air-pollutants.html Air pollutants are chemicals in the atmosphere whose concentrations are high enough to harm organisms, ecosystems, human-made materials, and alter the climate. Almost any chemical can become a pollutant if there is a high enough concentration of it in the atmosphere.
Let’s Practice
• In a small community in the highlands (elevation of 1,000 meters above sea level) of Ecuador, locals earned their living by manufacturing rugs. Rugs were made in indoor, closed rooms. The crowded rooms were heated by an open charcoal fire, provided approximately 5 cubic meters of air volume per person.
• Workers began to complain of stiffness in the shoulders, backache, fatigue, and dizziness. As the disease progressed, workers became short of breath on exertion and experienced tightness and pain below the breast bone, numbness in the arms and hands, and swelling of the face. The attacks of shortness of breath occurred mostly at night, whereas the episodes of pain and tightness around the heart, a condition known as angina pectoris, followed light work during the day.
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Poll Title: The most likely contaminants causing the described symptoms washttps://www.polleverywhere.com/multiple_choice_polls/KHIi3wQfxFkyD1erPzASI
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Poll Title: What was the portal of entry?https://www.polleverywhere.com/multiple_choice_polls/dHKsBYz2R0EE2T1Ke4IDV Respiratory
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Poll Title: What is a solution to the problem posed in the scenario?https://www.polleverywhere.com/multiple_choice_polls/8sjzTF2DSagvRB1mlnKbd Talk about distractors What is a solution to the problem posed in the scenario? *Larger, well-ventilated rooms Providing a medical staff to monitor workers Moving the industry to sea level Changing the material used to make the rugs
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Poll Title: Which term is used to characterize the social conditions of unequal distribution of environmental hazards?https://www.polleverywhere.com/multiple_choice_polls/szS9r2nq2Mgo5iwbiac2R
Ozone in the Work Place• Ozone is found in the Earth’s stratosphere
– absorbs most of the sun’s ultraviolet (UVB) radiation. – Stratosphere contains high concentrations of ozone (O3)
compared to other parts of the atmosphere• Still small in relation to other gases found in the stratosphere.
– Atmospheric ozone, therefore, can have a positive effect. • Ground-level ozone is a principal component of smog.
– Result of the chemical reactions between VOCs and nitrogen
– Harmful to human health – Responsible for aging lung tissue, reducing resistance to
colds, and breathing problems
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https://www.google.com/search?q=ozone&source=lnms&tbm=isch&sa=X&ved=0ahUKEwjAsPzB7bPeAhWIyVMKHZTsAOsQ_AUIDygC&biw=1680&bih=948#imgrc=mB60cFZ1LPlX4M: Ozone is found in the Earth’s stratosphere absorbs most of the sun’s ultraviolet (UVB) radiation. This region contains high concentrations of ozone (O3) compared to other parts of the atmosphere, yet this concentration is still small in relation to other gases found in the stratosphere. Atmospheric ozone, therefore, can have a positive effect. Ground-level ozone is a principal component of smog. As a result of the chemical reactions between VOCs and nitrogen Harmful to human health and responsible for aging lung tissue, reducing resistance to colds, and breathing problems
Ozone and the EPA• EPA strengthened the guidelines
– Reduced the NAAQS acceptable level of ground-level ozone to 70 parts per billion (ppb) or 0.07 parts per million (ppm)
• 0.2 ppm for no more than 2 hours exposure
• 0.1 ppm for 8 hours per day exposure doing light work
• 0.08 ppm for 8 hours per day exposure doing moderate work
• 0.05 ppm for 8 hours per day exposure doing heavy work
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https://www.google.com/search?q=ozone&source=lnms&tbm=isch&sa=X&ved=0ahUKEwjAsPzB7bPeAhWIyVMKHZTsAOsQ_AUIDygC&biw=1680&bih=948#imgrc=mB60cFZ1LPlX4M: It is important to note that the EPA strengthened the guidelines and reduced the NAAQS acceptable level of ground-level ozone to 70 parts per billion (ppb) or 0.07 parts per million (ppm).5,27 0.2 ppm for no more than 2 hours exposure • 0.1 ppm for 8 hours per day exposure doing light work • 0.08 ppm for 8 hours per day exposure doing moderate work • 0.05 ppm for 8 hours per day exposure doing heavy work
Climate Change
• Affects weather patterns that change disease patterns – Warm winters and hot, wet
summers• increase vector-borne
diseases – Ex. increases in tick
populations and Lyme disease
– Increased rainfall and flooding
• increase mosquito populations
– Higher CO2 levels• increase pollen
– Ex. increases to asthma rates
• Earths temperature increased by 1.5°F in the past 100 years
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The Earth’s average temperature has increased by 1.5°F in the past 100 years
Greatest Driver of Climate Change
• Greenhouse gases – Created by humans – Largest driver of climate change
The primary greenhouse gases found in Earth’s atmosphere include:carbon dioxide, methane, nitrous oxide, ozone, and water vapor.
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Greenhouse gases have been created by humans and are the largest driver of climate change. The primary greenhouse gases found in Earth’s atmosphere include carbon dioxide, methane, nitrous oxide, ozone, and water vapor.
Water
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https://olc.worldbank.org/sites/default/files/sco/E7B1C4DE-C187-5EDB-3EF2-897802DEA3BF/Nasa/chapter1.html Of all the water that exists on our planet, roughly 97% is saltwater and less than 3% is freshwater. Most of Earth’s freshwater is frozen in glaciers, ice caps, or is deep underground in aquifers. Less than 1% of Earth’s water is freshwater that is easily accessible to us to meet our needs, and most of that water is replenished by precipitation—a vital component of the water cycle, affecting every living thing on Earth. � �
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Poll Title: When the accumulation of rain flows over roadways and grasses, it washes pollutants, into local bodies of water. How is the pollution classified?https://www.polleverywhere.com/multiple_choice_polls/ANYTHHhw45fjN6U7rpRKw Ok – lets do some more practice. Here is my reminder to take a breath and don’t overthink. I see chloro floro something and I am certain that must be the answer. But remember: Chlorofluorocarbons (CFCs) are nontoxic, nonflammable chemicals containing atoms of carbon, chlorine, and fluorine. They are used in the manufacture of aerosol sprays, blowing agents for foams and packing materials, as solvents, and as refrigerants. Maybe organophosphate pollution goy you because they are in insecticides. But think about what the question is asking. We can guess where those pollutants are coming from – but always choose the best answer. The best answer here is non-point polluation. The answer here is non-point
Water Quality• Organophosphates
– widely used in insecticides• Chlorofluorocarbon
– volatile organic compounds• Point source pollution
– Direct source• Non-point source pollution
– runoff
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https://www.google.com/search?q=water+quality&source=lnms&tbm=isch&sa=X&ved=0ahUKEwiAzM-Z97PeAhXNq1MKHZx6AecQ_AUIDygC&biw=1680&bih=948#imgrc=ti6shZ-eQGHEVM: Organophosphates are the most widely used insecticides today. They are used in agriculture, the home, gardens, and veterinary
Drinking Water Standards
• Drinking water standards are regulated by the:
• Several pathogens are regulated by the EPA– Cryptosporidium– Giardia lamblia– Legionella– Enteric viruses
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Poll Title: An outbreak of pneumonia has occurred at a resort and it is determined that Legionella is the organism that is responsible. To find the source of the bacteria, one of the highest priorities would be to check:https://www.polleverywhere.com/multiple_choice_polls/BYV2t05ufZRRmLu2nAQLI To answer this question we have to know about Legionella, although we could likely rule out some responses if we feel comfortable with our understanding of food handling or influenza.
Legionella
• Legionellosis first discovered in 1976– 34 people attending the American
Legion bicentennial conference in Philadelphia, USA died of a severe respiratory flu-like disease.
– The bacterium responsible: Legionella pneumophila
– Source: contaminated water that contained the bacteria
– Approximately 8,000 to 18,000 individuals are hospitalized with Legionnaires’ disease each year in the U.S.
• To prevent major outbreaks– Proper maintenance of water systems
• drinking water systems, hot tubs, air conditioning lines, plumbing lines
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Legionella bacteria can cause a serious type of pneumonia (lung infection) called Legionnaires’ disease. The bacteria can also cause a less serious illness called Pontiac fever. Legionella is a type of bacterium found naturally in freshwater environments, like lakes and streams. It can become a health concern when it grows and spreads in human-made building water systems like Showerheads and sink faucets Legionella was discovered after an outbreak in 1976 among people who went to a Philadelphia convention of the American Legion. Those who were affected suffered from a type of pneumonia (lung infection) that eventually became known as Legionnaires’ disease.
Steps in Water Treatment• The most common steps in water treatment used by
community water systems (mainly surface water treatment) include:– Coagulation and Flocculation: First steps in water
treatment. Chemicals with a positive charge are added to the water
– Neutralizes the negative charge of dirt and other dissolved particles in the water
– Causes the particles bind with the chemicals and form larger particles, called floc.
– Sedimentation: Floc settles to the bottom of the water supply, due to its weight.
– Filtration: Once floc has settled, the clear water on top will pass through filters
– Varying compositions (sand, gravel, and charcoal) and pore sizes– Remove dissolved particles, parasites, bacteria, viruses, and
chemicals– Disinfection: After filtration, a disinfectant is added
– Chlorine or chloramine– Kills any remaining parasites, bacteria, and viruses– Protect the water from germs when it is piped to homes and
businesses.
Public drinking water systems use various methods of water treatment to provide safe drinking
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Drinking water sources are subject to contamination and require appropriate treatment to remove disease-causing agents. I included a lot of detail on this slide because I want you to be gable to go back and review. If you are scratching your head trying to remember the steps and thinking, what the floc – the details are here! Public drinking water systems use various methods of water treatment to provide safe drinking water for their communities. Today, the most common steps in water treatment used by community water systems (mainly surface water treatment) include: surface water treatment) include: oCagulation and Flocculation: First steps in water treatment. Chemicals with a positive charge are added to the water. The positive charge of these chemicals neutralizes the negative charge of dirt and other dissolved particles in the water. When this occurs, the particles bind with the chemicals and form larger particles, called floc. SedimentationDuring sedimentation, floc settles to the bottom of the water supply, due to its weight. This settling process is called sedimentation. FiltrationOnce the floc has settled to the bottom of the water supply, the clear water on top will pass through filters of varying compositions (sand, gravel, and charcoal) and pore sizes, in order to remove dissolved particles, such as dust, parasites, bacteria, viruses, and chemicals. DisinfectionAfter the water has been filtered, a disinfectant (for example, chlorine, chloramine) may be added in order to kill any remaining parasites, bacteria, and viruses, and to protect the water from germs when it is piped to homes and businesses.
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Poll Title: Safe drinking water is vital to public health. Which of the following should not be in potable water?https://www.polleverywhere.com/multiple_choice_polls/GQOGkDZ8rMl37aNPVE2Pq Radionuclides Any man-made or natural element that emits radiation and that may cause cancer after many years of exposure through drinking water. NOTE FOR IF ASKED: Since the mid-1940s, compounds containing the mineral fluoride have been added to community water supplies throughout the U.S. to prevent tooth decay. Health concerns expressed by opponents have largely been dismissed until recently. Now, evidence is mounting that in an era of fluoridated toothpastes and other consumer products that boost dental health, the potential risks from consuming fluoridated water may outweigh the benefits for some individuals. Last summer, for the first time in 53 years, the U.S. Public Health Service lowered its recommended levels of fluoride in drinking water.
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Poll Title: In low resource countries during an outbreak, what simple, low-tech sanitation measure can dramatically reduce the spread of enteric bacteria and viruses?https://www.polleverywhere.com/multiple_choice_polls/qJcALUcfjJUMxFitMwNkt Add chlorine to water storage containers In addressing an outbreak of bacteria and viruses in a low resource country, disinfection is considered a primary mechanism for inactivating/destroying pathogenic organisms and preventing the spread of waterborne diseases to downstream users and the environment. Some of the most commonly used disinfectants for decentralized applications include chlorine, iodine, and ultraviolet (UV) radiation. Chlorine is one of the most practical and widely used disinfectants.
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Poll Title: Cryptosporidium can become a problem in municipal water supplies because it:https://www.polleverywhere.com/multiple_choice_polls/c4rjHlag03PfStjKXt5pG Cryptosporidium is a microscopic parasite that causes the diarrheal disease cryptosporidiosis. Cryptosporidium oocysts are resistant to chlorine treatment of municipal water supplies.
Food Safety
• Foodborne Illness outbreaks– Tend to be detected on local or state
level• Health agencies are required to report
all cases of foodborne illness to CDC• Food and Drug Administration
investigates outbreaks that involve FDA regulated products
Danger Zone:39° F - 140° F
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Foodborne illness occurs from consumption of food or beverages containing harmful microorganisms or chemical contaminants
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Poll Title: If a food contaminated with a virus, such as hepatitis A, is left out for 4 hours in a kitchen at a temperature of 85 degrees Fahrenheit, the virus count in the food:https://www.polleverywhere.com/multiple_choice_polls/U6v7ufkp5vW8KA4VN3LfY This was another tricky one. Viruses can only grow in living cells and will not multiply under these circumstances. Therefore, it would not change.
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Poll Title: In some cases of food bourne illness, Hemolytic Uremic Syndrome is caused by which organism?https://www.polleverywhere.com/multiple_choice_polls/5BSJ20ZJkPUpgH9IWafRZ Hemolytic Uremic Syndrome is the fatal condition that arises in a minority of cases of food-poisoning caused by E. coli O157:H7, often caused by eating contaminated foodstuffs.
Dewey-Mattia D, et al. MMWR Surveill Summ. 2018;67(No. SS-10):1–11, http://dx.doi.org/10.15585/mmwr.ss6710a1.
Pregnant women are 10 times more likely to become infected with Listeria.
Poses a risk to both the woman and the fetus, potentially causing miscarriage, stillbirth or preterm labor,
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Unfortunately for those of us who love to cook or love to eat, nearly any food category can cause a foodborne disease outbreak And, the the most common organism implicated in deaths related to foodborne disease outbreaks for those listed is Listeria monocytogenes
https://marketbusinessnews.com/financial-glossary/haccp/ HACCP is a management system in which food safety is addressed through the analysis and control of biological, chemical, and physical hazards from raw material production, procurement and handling, to manufacturing, distribution and consumption of the finished product. But you are thinking, ahhh more steps. Simply, HAACP is a food safety system. This is another one of those take a breath and walk through it cycles. We start with conducting the hazard analysis. Why do we do this, to identify critical control points. Once those points are identified, we want to establish limits. To ensure that those limits are being met, we must then procedures for monitoring. If you have procedures for monitoring, what happens if rules are being broken? You need to establish corrective actions. Of course, we need the data to reflect upon so you want to establish procedures for recordkeeping. And we need to be sure that those records are accuate so we need verification procedures.
Hazard Analysis and Critical Control Points
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https://marketbusinessnews.com/financial-glossary/haccp/ HAACP is a food safety system employed to: (B) Before they happen, identify and control problems that may cause foodborne illness Reference: Frumkin, p. 608 Poll Title: Which of the following is the HAACP employed to:https://www.polleverywhere.com/multiple_choice_polls/a5njdas7pwmjxa6Y0RIqW
Solid Waste
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Waste management is a concept developed in the 20th century. Prior to that time, waste was often discarded in lakes, rivers, oceans or lands with little regard to the effects on the environment. However, in the early 20th century, processes for waste handling and disposal became widespread in the US and other developed countries. Today, municipalities are responsible for solid waste disposal, which includes recycling, landfilling, compositing, and combustion. The EPA has developed a hierarchy to describe the management of solid waste from the most environmentally friendly to least environmentally preferred, with a goal to reduce, reuse and recycle. Materials which are unable to be recycled or composted should be deposited in a local landfill to help reduce environmental effects. Landfills are composed of: 1) a bottom liner, 2) a system for collecting leachate, the water that has passed through the waste and collected contaminates of that waste, 3) a cover, and 4) an appropriate location to minimized groundwater contamination. Dangers of landfills that are note well constructed include air pollution and groundwater contamination. Federal laws require that the groundwater around landfills are routinely tested and corrective action is taken as necessary.
Hazardous Waste
• Potentially hazardous to human or environmental health when not disposed of properly– From home: pesticides,
cleaning products, paint and auto products
– Medical waste– Industrial hazardous waste
(Chemicals, solvents and heavy metals)
– Radioactive waste– Mining waste
Toxic Waste Site: The Love Canal
• Near Niagara Falls– Disposal of toxic
chemicals in 1952• Halogenated organic
compounds, chlorobenzenes, and dioxin
– High rates of miscarriage, birth defects and cancer
Illustrated link between hazardous chemicals and human health
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The Love Canal, located near Niagara Falls, was a toxic waste site that is significant to the field of Public Health as the incident helped to illustrate the link between hazardous chemical exposure and the possible influence on human health. When disposal of toxic chemicals ended in 1952, the presence of toxic chemicals was observed near the former site and residents in the area reported high rates of miscarriage, birth defects and caner. The love canal clearly and inextricably Illustrated link between hazardous chemicals and human health As a result the Superfund was created and administered by the EPA.
Superfund regulations
• Created and administered by the EPA
• Requires that responsible parties must assume liability for the cleanup of environmental hazards they cause.
• Superfund Sites– Any land contaminated by hazardous waste and
identified by the EPA as a candidate for cleanup because it poses a risk to human health and/or the environment.
– Sites are placed on the National Priorities List (NPL).
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Superfund regulations requires that responsible parties must assume liability of the cleanup of environmental hazards that they cause. Created and administered by EPA Superfund Sites Any land contaminated by hazardous waste and identified by the EPA as a candidate for cleanup because it poses a risk to human health and/or the environment. Sites are placed on the National Priorities List (NPL).
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Poll Title: In the US, which is the largest source of radiation does to the general public?https://www.polleverywhere.com/multiple_choice_polls/Dbwv9HrccTJtOBcksTdUo By far, the most significant source of man-made radiation exposure to the public is from medical procedures, such as diagnostic X-rays, nuclear medicine, and radiation therapy. Some of the major isotopes would be I-131, Tc-99m, Co-60, Ir-192, Cs-137, and others.
Toxicology
• Toxicology:– The study of how chemicals cause injury to living
cells• Dose:
– The amount of the chemical in the body• Risk:
– The probability that harm will occur
Risk = Toxicity x Exposure
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Toxicology is the study of how chemicals cause injury to living cells and whole organism. Dose is the amount of the chemical in body. Risk is the probability that harm will be produced under a specific set of conditions. Risk includes the combination of two considerations: the probability or likelihood that an adverse event will occur and the consequences or level of harm that will result if it does. Risk = Toxicity X Exposure
Dose Time Relationship
• Acute toxicity– The ability of a substance to do systemic damage
as a result of a one time exposure.• Example: Hydrogen Sulfide exposure
• Chronic toxicity– The harmful systemic effects produced by long-
term, low level exposure to chemicals. • Example: Asbestos exposure
• Assumed higher dose = greater effects• Deleterious effects are expected after reaching a
threshold amount– Exception: Carcinogen Rule
• For Carcinogens, there is no safe thresholds
• Lethal Dose 50 (LD50)– The most common measure of acute toxicity– The dose level at which 50% of the test population
will die• LD0: There are no resultant deaths
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The Dose-Response Curve illustrates the change in effect on an organism that is caused by differing levels of exposure. See Figure 3. It is assumed that the higher the dose, the greater the effects observed. An exception is the Carcinogen Rule. For carcinogens, there is no safe threshold level.
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Poll Title: The exposure standard for lead in children has been lowered over the years because even small amounts can result in:https://www.polleverywhere.com/multiple_choice_polls/EXTTuU4ELkEilSfI45xoB Current evidence suggests that any exposure to lead carries some risk of impaired cognitive development in children.
Let’s try a few questions….Blood lead levels are a public health concern, specifically for children. Until 2012, children were identified as having a blood lead “level of concern” if test results were 10 or more micrograms of lead per deciliter of blood. CDC is no longer using the term “level of concern” and is instead using the reference value to identify children who have been exposed to lead and require case management.
Experts now use a reference level of 5 micrograms per deciliter to identify children with elevated blood lead levels. This new level is based on the US population of children aged 1 to 5 years who are in the highest 2.5% of children tested for lead in their blood. This reference value is based on the 97th percentile of the National Health and Nutrition Examination Survey’s (NHANES’s) blood lead distribution in children. The new lower value means more children will likely be identified as having lead exposure, allowing parents, doctors, public health officials, and communities to take action earlier to reduce the child’s future exposure to lead.
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The issue of lead is a clear example of how public health researchers are using evidence-based biological claims to influence legislation that has been enacted to protect the health of the public. The other answers are not supported by the information. NHANES is a population-based survey to assess the health and nutritional status of adults and children in the United States and determine the prevalence of major diseases and risk factors for disease.
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Poll Title: Which of the following is this an example of?https://www.polleverywhere.com/multiple_choice_polls/HEYl8kyy7bF7JLOlLC9t6 The issue of lead is a clear example of how public health researchers are using evidence-based biological claims to influence legislation that has been enacted to protect the health of the public. The other answers are not supported by the information. NHANES is a population-based survey to assess the health and nutritional status of adults and children in the United States and determine the prevalence of major diseases and risk factors for disease.
Laws and Policies
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Poll Title: In 1980, the United States Congress enacted the Comprehensive Environmental Response, Compensation, and Liability Act (CERCLA), which is commonly called:https://www.polleverywhere.com/multiple_choice_polls/HokNUdy10JiWhk50mn0u0
Laws and Policies
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Poll Title: The Clean Air Act directs the Environmental Protection Agency (EPA) to establish national ____________ air quality standards?https://www.polleverywhere.com/multiple_choice_polls/DpzbQGzAX61MXogEiCr85 The Clean Air Act (CAA or Act) directs the EPA to establish national ambient air quality standards (NAAQS) for pollutants at levels that will protect public health.
• Don’t forget...– Take a breathe– Eliminate the distractors– Trust your gut– Don’t over think!
