Frameworks

Question 1

Framework for consideration of a new screening program

Answer 1

1. Outline public health importance of issue, importance of balancing benefits and harms of screening, need to demonstrate that screening is the most cost-effective intervention, consider equity issues, and framework to be used (WHO principles of screening and Australian population-based screening framework)
2. Consider context and resources:
   - consider sociopolitical context and sensitivities: why is this being considered now?
   - clarify role/expectations, budget and timeframe
   - form a team/working group - epidemiologist, health economist, policy officer.
3. Identify stakeholders and form an advisory group to be consulted with at each step of the process.
   - Government/clinical/academics/NGOs/community
4. Gather evidence to assess whether the condition, screening test and treatment meet acceptable parameters:
   - Condition must be an important public health problem with well defined epidemiology in terms of incidence, prevalence, mortality and burden of disease by age and sex; natural history must be known; must have a long latent or early asymptomatic phase; must be a clear and agreed population to screen.
   - There must be a validated test available that is safe/acceptable to population, ideally simple/cheap, have adequate sensitivity (low false negatives) and specificity (low false positives); have a clearly defined screening interval; have appropriate health system infrastructure to enable equity of access for delivery of test, follow-up of results and further referral for diagnostic testing; have evidence-based policies for assessment/diagnosis/intervention for positive results.
   - Treatment: an effective treatment must be available and benefits must outweigh harms; there must be an agreed policy on who to treat; there must be available resources to enable equitable access to treatment.
5. Gather data to assess feasibility and cost-effectiveness of screening program
   - Require high quality evidence from RCTs or meta-analyses that screening program reduces mortality and morbidity/burden of disease.
   - Must assess benefits and harms (false positives/overdiagnosis/over-treatment).
   - Economic evaluation must demonstrate that screening is the most cost-effective intervention to reduce the burden of disease.
   - Case finding must be continuous and not a ‘once off’.
   - Assess feasibility in terms of systems for recruitment/follow-up/QA, staff, space and support.
6. Consult with advisory group and make a recommendation.
7. Publish a report.

Question 2

Outbreak investigation framework

Answer 2

Key memory points:
- verify diagnosis, establish existence of outbreak, develop case definition, develop case investigation form, find cases, develop case-line listing, describe by person/place/time, perform analytic epi, implement control measures, communicate, ongoing surveillance, declare outbreak over.

1. Verify the diagnosis to rule out lab error
2. Establish the existence of an outbreak by comparing observed rates to expected rates:
   - state objectives of outbreak investigation (I.e. identify pathogen/source, identify cases and contacts and implement infection control measures to prevent further transmission).
3. Consider scientific and investigative resources required and form a team.
   - review literature and guidelines
   - consider need to include people from other teams and agencies (e.g. lab staff, EH officers)
   - plan for field investigation (if required) including PPE and specimen collection
4. Construct a case definition based on clinical and/or laboratory findings and person/place/time.
   - note that a looser case definition will be more sensitive, but it may need to be tightened to make it more specific as the investigation continues.
5. Undertake active case finding, develop a case investigation form and develop a line listing.
6. Perform descriptive epidemiology and identify hypotheses:
   - graph an epi curve to describe cases over time
   - may also want to develop a geographical map of cases
   - may also want to describe host characteristics and exposure characteristics (e.g. occupation/leisure activities/medication use/smoking/drugs)
7. Test hypothesis and undertake additional studies as necessary:
   - test hypotheses through environmental evidence, lab evidence and/or analytic epidemiology
   - conduct retrospective cohort study if outbreak occurs in a small, well-defined population (e.g. gastro outbreak at wedding). Calculate attack rate for exposed versus non-exposed for each potential causative exposure, and then use this to calculate relative risk between exposed and unexposed. Can test statistical significance through Chi-squared test (for >30 people) or Fisher Exact test.
   - conduct a case control study if the population is not well defined. Calculate odds ratios. Controls must not have the disease being studied but should be representative of the population in which cases occurred. Can source controls through survey methods (e.g. household survey), neighbours of cases, friends of cases, patients from same GP clinic or hospital without disease.
   - if analytic studies are not revealing, must rethink hypothesis.
8. Implement control and prevention measures:
   - interrupt transmission and prevent further cases through control measures targeting one or more stages of transmission (agent/host/environment/vector/mode of transmission).
9. Communicate findings
10. Continue surveillance and declare outbreak over once two incubation periods have passed.

Question 3

Control measures in an institutional outbreak

Answer 3

Key memory points:

1. Patient/resident management
2. Staff management
3. Facility management

Patient/resident management:

• cohorting and isolation
• restriction of admissions and ward closures
• no transfer of residents between wards or facilities
• prophylactic meds if available

Staff management:

• exclusion of ill staff
• communication and training of staff in infection control procedures/outbreak management.
• cohorting of staff so that no movement between affected an unaffected areas
• handwashing
• PPE and training in donning and doughing

Facility management:

• Cleaning
• handling of soiled linen/materials
• Closure of common areas
• Cancelling of group activities
• Management of relatives/visitors

Question 4

Continuous quality improvement

Answer 4

Plan - define the question, plan the methodology/analysis/data collection
Do - collect and analyse data
Check - interpret the results, reflect on the findings, consider what changes could be made to address findings.
Act - implement measures to address the findings

Question 5

Policy/Program development

Answer 5

1. Opening statement - set the scene and outline why this is important, highlight importance of involving stakeholders throughout the process and striking the best balance between public health impact, feasibility and acceptability.
2. Consider the context (political, social and economic) and sensitivities.
3. Clarify role/resources (time, budget, staff) and form a team (may include SMEs, policy officers/analysts, epidemiologists, health economists)
4. Identify stakeholders and form an advisory group/reference group/steering committee.
5. Identify/characterize the problem, target population and health needs:
   - Consult with stakeholders to characterize the problem in terms of the epidemiology, current services/programs and health needs (e.g. map and gap) and synthesize this into a problem statement that frames the problem and sets the agenda for policy/programmatic action.
6. Policy analysis and options development:
   - Review literature, relevant guidelines/strategies and analyse policies implemented elsewhere to identify evidence-based best practices.
   - Describe and analyse the possible policy options, in terms of effects (public health impact, unintended consequences, equity/differential effects on different population segments) and implementation (cost, feasibility, acceptability/cultural appropriateness, quality, sustainability).
   - For health promotion, list the possible options under each area (healthy public policy, supportive environments, strengthen community actions, develop personal skills, reorient health services).
7. Consult with stakeholders:
   - to test the validity and strength of the analysis, ensure coherence of policy between different agencies/organizations, identify barriers and enablers to policy implementation.
   - document results of consultation
   - refine the program/policy based on consultation feedback
8. Draft final policy, enact policy and communicate new policy.
   - draft final policy
   - enact policy via relevant approval process
9. Develop implementation and evaluation plan, and supporting communications.
   - develop an implementation plan, ensuring this is framed around SMART goals and objectives (simple, measurable, achievable, realistic and timely) and clearly articulates roles and responsibilities, actions, timelines, budget and resources required to implement policy.
   - develop a communications/education plan to support implementation.
   - develop an evaluation plan and consider indicators of success in terms of process, impact and outcome and ensure baseline data is collected to support evaluation.

Question 6

Program evaluation

Answer 6

1. Opening statement emphasizing importance of stakeholder engagement and ‘no surprises’
2. Clarify role/expectations, timeframe and resources.
3. Form team
4. Identify and engage stakeholders (those involved in program operations/those served or affected by program/those who will use the evaluation results).
5. Describe program in terms of:
   - objectives
   - current stage of program (planning, implementation or effects)
   - sensitivities/context/concerns
   - whether any targets or indicators were set
   - whether there is a pre-existing evaluation plan
   - map out program logic in terms of inputs/activities/outputs/impacts
6. Focus the evaluation design:
   - determine purpose and scope of evaluation (process, impact, outcome)
   - draft evaluation questions
   - tabulate potential indicators and data sources for effectiveness of each activity/output
   - work out what data has already been collected and what additional data would be feasible to collect within the timeframe/resources available.
   - develop methodology and plan for data collection and analysis
   - determine whether ethics approval is required.
   - synthesize all of this into an evaluation plan and consult with stakeholders to refine plan, clarify roles and responsibilities and agree on how evaluation findings will be disseminated.
7. Gather and analyze the evidence, prepare evaluation report, justify conclusions and recommendations.
8. Disseminate findings.

Question 7

Environmental health risk assessment

Answer 7

1. Opening statement - why issue is important, use of EnHealth EHRA guidelines, objectives of response.
2. Clarify role/resources, form team and brief up.
3. Identify key stakeholders to consult with regularly throughout assessment and management phases.
4. Implement initial control measures and risk communications.
5. Issue identification:
   - is EHRA required
   - who owns site/has accountability for the environmental health risk
   - elicit concerns from affected community and don’t make assumptions about their concerns
   - consider local population demographics and identify priority population groups.
   - based on these concerns, define questions to be answered by risk assessment and scope complexity and feasibility of EHRA required
   - define roles and responsibilities of evaluation team, set priorities and timelines.
6. Hazard identification
   - review evidence from in vitro, animal and human epidemiological studies to determine the potential for acute, chronic, reproductive, developmental and genetic toxic effects.
   - consider latency and duration of toxic effects.
   - useful data sources include the Australian Industrial Chemicals Introduction Scheme, PubChem (replaced toxnet), USEPA and the Agency for Toxic Substances and Disease Registry (ATSDR).
7. Assess dose-response relationship
   - determine what level of of exposure will cause adverse health effects based on guideline reference values.
   - consult with toxicologist to determine what type of model best describes data e.g. threshold versus non-threshold model.
8. Assess exposure
   - determine who might be affected and how
   - consider all possible exposure routes (dermal/inhalation/ingestion).
   - determine magnitude, duration and frequency of exposure according to worst-case scenario
   - identify differential impacts on priority populations (infants, children, pregnant women, breast-feeding women, elderly, homeless)
   - develop a conceptual site model to map sources of contamination, exposure pathways and potentially exposed populations
   - consider need for environmental sampling and conduct sampling where required.
   - develop predictive models to determine levels of exposure at different points in the exposure pathways.
9. Characterize risk
   - integrate hazard and exposure assessment to estimate the risk to populations of interest (may be quantitative or qualitative)
   - acknowledge strength of evidence and any uncertainties in the risk characterization
   - ensure issues identified at outset have been addressed
10. Risk management
    - options for risk management are to accept, control or eliminate.
    - control of risk can be done at the source level (contain at site and consider site remediation), individual level (education or alert to avoid individual exposure), community level (control access to site, issue warnings, undertake environmental monitoring).
    - important to consult with stakeholders and community on risk management actions.
11. Risk communication
    - communications need to be timely, transparent, consistent, appropriate, empathetic and accessible to priority populations.
    - engage credible experts to both warn and inform.
    - what we know, what we don’t know, what we are doing about it, what you can do.
12. Publish report

Question 8

Health impact assessment

Answer 8

1. Opening statement emphasizing need for ongoing community and stakeholder engagement and overall objective to minimize negative impacts and enhance positive impacts, identify equity issues and ways to minimize negative differential impacts on priority populations in the community.
2. Clarify role/expectations and context:
   - sociopolitical context/media interest
   - timeframe for development
   - relevant legislation and who is the decision maker (in the ACT the decision maker will be the Environment, Planning and Sustainable Development Directorate)
   - role of PHP will usually be advisory/supportive rather than leading the team undertaking the HIA.
3. Identity stakeholders:
   - proponent
   - decision-maker
   - community groups
   - experts
4. Undertake screening
   - gather initial data about the development, possible impacts, equity issues and population affected
   - consider using screening tool (e.g. NSW Health).
   - conduct a screening meeting with stakeholders
   - make a recommendation about whether an HIA should proceed.
5. Undertake scoping (set the parameters of the HIA)
   - form the HIA project team
   - form HIA steering committee with chair, ToR, regular meetings, agreed roles and responsibilities
   - choose appropriate level of depth for the HIA proportionate to the resources available, size of development and potential impacts (ie. desk based, rapid, intermediate or comprehensive).
   - set the parameters for the HIA in terms of positive and negative impacts to be considered, potentially affected populations, geographical boundaries).
   - develop project plan with methods, timelines and deliverables.
6. Profile the community in terms of:
   - demographic structure and projected population changes
   - socio economic profile
   - health status (morbidity and mortality, prevalence of risk factors for ill health).
   - data sources include ABS, AIHW, state health departments, local hospital data.
   - vulnerable or disadvantaged groups in proximity to development (e.g. ACFs, schools, childcare centers, hospitals).
   - vulnerability determined by magnitude of exposure, sensitivity to adverse effects and adaptive capacity
7. Risk assessment
   - determine direction of impact, magnitude of impact (proportion of population affected and severity), likelihood, groups most likely to be affected
   - acknowledge quality of evidence and uncertainties
   - useful to use a risk matrix or scale to present risk assessment
8. Outline options for managing risk
   - map out options for minimizing health risks and maximizing benefits
   - characterize residual health impact with management measures in place.
9. Issue a recommendation about whether the development should go ahead and the risk management measures that should be implemented.
10. Publish report.