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SESSION 50
Mass gatherings and public health risks: Local and provincial perspectives on hazard identification risk assessment (HIRA) approaches in Ontario
Panel presentation
March 28, 2019
The Ontario Public Health Convention
Emergency Preparedness, Response and Recovery pathway
3:00 p.m. to 4:30 p.m.
PublicHealthOntario.ca
Disclosure of commercial support
2
• None of the presenters at this session have received financial support or in-kind support from a commercial sponsor.
• None of the presenters have potential conflicts of interest to declare.
PublicHealthOntario.ca
Learning objectives
3
At the end of this session, participants will be able to:
1. Describe evidence-informed practices for hazard identification and risk assessment (HIRA) relevant to public health activities in mass gatherings.
2. Compare and contrast examples of HIRA approaches for mass gatherings, based on panelists’ presentations.
3. Reflect on strategies and challenges in applying HIRA approaches in public health practice.
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Panelists
4
• Dr. Yasmin Khan (Public Health Ontario)
• Clint Shingler (Ministry of Health and Long-Term Care)
• Ellen Chan (Public Health Ontario)
• Kelly Magnusson (Simcoe Muskoka Dist. Health Unit)
• Effie Gournis (Toronto Public Health)
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Session agenda
5
Topic Speaker Time
Welcome, introductions and opening activity Yasmin Khan & Ellen Chan
20 min
HIRA context Clint Shingler 8 min
Developing a HIRA framework for infectious diseases
Yasmin Khan & Ellen Chan
10 min
Presentation Q&As All 5 min
Role of HIRA in planning for mass gathering events Kelly Magnusson 10 min
Linking HIRA to surveillance tools in Toronto Effie Gournis 10 min
Presentation Q&As All 5 min
Small-group discussions All 7 min
Closing remarks and questions Panel 10 min
Wrap-up and evaluation Yasmin Khan 5 min
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Yasmin Khan
Mass gatherings and public health
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What is a mass gathering (MG)?
7
A planned or spontaneous event where the number of people attending could strain the planning and response resources of the community or country hosting the event.
http://www.who.int/ihr/publications/WHO_HSE_GCR_2015.5/en/
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Types of MG events
8
http://www.who.int/ihr/publications/WHO_HSE_GCR_2015.5/en/
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Public health planning for mass gatherings
9
• Largely driven by context and risk
• An assessment process is crucial to understanding risks
• Enables analysis of MG characteristics which introduce or enhance threats to public health
http://www.who.int/ihr/publications/WHO_HSE_GCR_2015.5/en/
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Three steps for reducing public health risks at MGs
10
1. Risk assessment: What might happen, and how likely is it to happen?
2. Surveillance: How will we know when it happens?
3. Response: What will we do when it happens?
http://www.who.int/ihr/publications/WHO_HSE_GCR_2015.5/en/
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Questions to consider during presentations
11
1. Which tools/templates could be useful in planning for a mass gathering in your jurisdiction? Which types of the presented tools could be useful to your context?
2. Are there specific considerations for your jurisdiction?
3. What other resources would be helpful for your local work?
HIRA Context
Clint Shingler
Health System Emergency Management Branch
Ministry of Health and Long-Term Care
March 28, 2019
Outline
1. Expectations
2. Current State
3. HIRA at HSEMB
4. From HIRA to Awareness
A Ready & Resilient Health System
13
Expectations
• World Health Organization
– 2005 International Health Regulations (IHR)
– 2018 Self-Assessment Reporting Tool (SPAR)
– 2018 Joint External Evaluation (JEE) of Canada
• Office of the Fire Marshall and Emergency Management
– 2009 Emergency Management and Civil Protection Act (EMCPA)
• Requirement for all municipalities, provincial ministries and designated ABCs
to conduct HIRA
– 2018 Provincial HIRA currently in approvals
• Ministry of Health and Long-Term Care
– 2018 Ontario Public Health Standards (OPHS)
14
IHR, SPAR and JEE Highlights
• IHR 2005 – Formal expectations for surveillance and notification
• “Each State Party shall develop, strengthen and maintain…the capacity to detect, assess, notify and report events…”
• SPAR 2018 – Indicators regarding risk assessment, 5-level scale
• “Qualitative or quantitative estimation of the likelihood of adverse effects that may result from exposure to specified health hazards or the absence of beneficial influences.”(adapted from Last JM, Spasoff RA, Harris SS, ed. A dictionary of epidemiology. Fourth edition. New York: Oxford University Press;2001)
• JEE of Canada 2018 – Indicators regarding surveillance, reporting and
preparedness
15
IHR, SPAR and JEE Highlights
16
SPAR
Example
indicators
and levels
IHR, SPAR and JEE Highlights
17
D2 REAL TIME SURVEILLANCE D2.1 Indicator and event based surveillance systems D2.2 Interoperable, interconnected, electronic real-time reporting system D2.3 Analysis of surveillance data D2.4 Syndromic surveillance systems D3 REPORTING D3.1 System for efficient reporting to WHO, FAO and OIE D3.2 Reporting network and protocols in country R1 PREPAREDNESS R1.1 Multi-hazard national public health emergency preparedness and response plan is developed and implemented R1.2 Priority public health risks and resources are mapped and utilized
JEE
Example
indicators
EMCPA
18
Hazard and risk assessment and infrastructure
identification
5.1 (2) In developing an emergency management program,
every minister of the Crown and every designated agency,
board, commission and other branch of government shall
identify and assess the various hazards and risks to public
safety that could give rise to emergencies and identify the
facilities and other elements of the infrastructure for which
the minister or agency, board, commission or branch is
responsible that are at risk of being affected by
emergencies. 2002, c. 14, s. 7.
OPHS 2008 1) Identify and assess the relevant hazards and risks to
public health
a) The board of health shall identify and assess relevant
hazards and risks to public health by:
i) Identifying the hazards relevant to public health within the
health unit that may give rise to a public health emergency
and/or emergency with public health impacts.
ii) Assessing the risk of the identified hazards using qualitative
and/or quantitative measures of probability and consequence
which, at a minimum, capture information through a risk-
assessment methodology.
iii) Ranking and recording the assessed risks to public health
based on qualitative and/or quantitative measures of probability
and consequence. Risks shall be prioritized from high to low
based on the ranking of probability and consequence.
iv) Including hazard-identification and risk-assessment materials
in a confidential appendix to the board of health emergency
response plan.* At a minimum the following shall be included:
• Process for hazard identification;
• Methodology for risk assessment; and
• Results of hazard identification and risk assessment.
b) The board of health shall include as a high priority risk
any hazard of provincial significance that is identified by the
Chief Medical Officer of Health.
2018
5) The board of health shall conduct processes that maintain awareness of:
a) Public health hazards and risks that may give rise to an emergency or disruption;
b) Incidents that may disrupt public health service delivery;
c) Continuity of operations vulnerabilities to disruption; and
d) Priority populations in the community and the potential for them to experience disproportionate health impacts from emergencies or disruptions.
19
HIRA at Different Levels
20
HIRA at Different Levels
• But for a mass gathering?
21
HIRA at HSEMB (The Past)
• Annual HIRA
• Lessons from mass gatherings:
– A good HIRA important to scale and focus health planning
– The development of tools and capacity will help streamline
process and build local resilience
– How far to take low-likelihood, high impact hazards?
– Link with non-health partners critical, i.e. security
22
HIRA at HSEMB (The Present)
• “Daily HIRA” …not a HIRA
– Ongoing, active gathering and sensemaking
– All staff participate
– Intelligent social media flagging
– Mass gathering decision flow
• Mass Gathering HIRA Tool
– For hazards outside of public health
– Comprehensive
23
HIRA at HSEMB (The Present)
Mass gathering decision flow
• Assess influencing factors
• Local check-in
• Determine posture
24
Passive Monitoring Info Sharing, Tracking &
Engagement
Dedicated Project Team, MEOC
Response
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Yasmin Khan, Consultant Physician Ellen Chan, Senior Program Specialist
Developing an internal framework for infectious disease mass gathering HIRAs
PublicHealthOntario.ca 26
• To develop an evidence-informed HIRA framework that supports preparedness and planning for the provincial public health system of infectious disease impacts on population health during mass gatherings.
Project objective
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Project activities
27
Scoping review Review recent
PHO HIRAs Initial stakeholder
consultation
Iterative development:
HIRA framework
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How are risk assessments for mass gatherings conducted by other public health organizations?
A scoping review on MGs and risk assessment
Arksey, H. and O’Malley, L. Scoping studies: towards a methodological framework. International Journal of Social Research Methodology. 8:1 19-32
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Scoping review: Year of publication
29
0
2
4
6
2004 2006 2008 2009 2010 2012 2013 2014 2015 2016 2017
Nu
mb
er
of
Incl
ud
ed
Art
icle
s
Year
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Scoping review: Mass gathering type
30
4
8
5 2
1
8
Planned
Unspecified
Both
Sporting events
Political
n= 20
Music festival
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WHO Collaborating Centres for MGs
31
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WHO process
32
Dapeng J, Ljungqvist A, Troedsson H, editors. The health legacy of the 2008 Beijing Olympic Games: successes and recommendations. Geneva (CH): World Health Organization; 2010.
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Highlighted areas from the scoping review
33
1. Process: Many public health agencies have adapted WHO’s flowchart and process for conducting HIRAs
2. Event context: Factors such as event/participant characteristics, environmental factors provide staff with background information to guide assessments
3. Risk assessment: Probability and impact scales are commonly provided, with their combinations assigned a level of risk
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Stakeholder consultations
34
• Three groups of stakeholders consulted through facilitated in-person meetings
MOHLTC
• Request, use, disseminate HIRAs for health system planning
PHO managers & leaders
• Review, consult on, develop HIRAs
PHO staff
• Develop and/or consult on HIRAs
Scoping review Review recent
PHO HIRAs Initial stakeholder
consultation
Iterative development:
HIRA framework
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Needs identified from consultations
35
• Importance of initial scoping
• To understand context + intended use in planning/response
• Ongoing collaboration and leadership involvement throughout
• Support, structure and guidance for PHO staff to prepare HIRAs in a collaborative, consistent manner
• The “so what”: Preliminary recommendations for planning priorities based on HIRA results
• Simple and understandable results in a timely manner
• Build in evaluation after HIRA and event completion
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Development process
Scoping forms
Reference materials
Staff worksheet
HIRA template
Debrief questions
36
The HIRA framework
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Steps for developing a provincial HIRA
37
7) Complete evaluation activities and update framework
6) PHO submits final HIRA deliverable to MOHLTC
5) Review/ revise/approvals (PHO)
4) Analyze/ assess and prioritize risks (PHO)
3) Identify issues and risks (PHO)
2) Scoping, set context, define approach (MOHLTC + PHO)
1) MOHLTC requests HIRA from PHO
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Selected framework components
38
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Future sharing and discussion opportunities
39
• Knowledge sharing
• Looking for input from the group
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Acknowledgements
40
• PHO project advisory committee and project team
• Consulted stakeholders at MOHLTC and PHO
ROLE OF HIRA IN PLANNING FOR MASS
GATHERING EVENTS
KELLY MAGNUSSON
MANAGER, EMERGENCY MANAGEMENT PROGRAM
SIMCOE MUSKOKA DISTRICT HEALTH UNIT
SIMCOE MUSKOKA:
HOME TO MASS GATHERING EVENTS
42
MASS GATHERINGS
Mass Gathering versus Special Occasion
Events
SMDHU Definition
• Provincial/Municipal Planning Priority
• Coordinated Health System
• Multi-jurisdictional
• High Profile/Politically Sensitive
• Temporary Infrastructure
• Volume of People/Duration
43
SMDHU HIRA
Identify Hazards Risks
• Literature Reviews
• Community/Provincial Based HIRA
• Event Specific Hazards
• Previous Events
Determine Risk:
Probability/Consequences
Vulnerabilities
• Vulnerable Populations
• Limitations (Capacity/Capability)
• Health System Readiness and
Resiliency
Identify Planning Priorities
• Mitigations/Contingency and IAP’s
HAZARD IDENTIFICATION RISK
ASSESSMENT
EXAMPLE OF SMDHU HIRA OUTCOME
ROLE HIRA PLAYS IN MASS GATHERING
PLANNING
• On-going hazard assessments
throughout event
• Determines potential public
health issues/hazards
• Establishes public health
planning priorities
• Identify public health roles &
accountabilities
• Informs planning and
development of IAP’s, Mitigation
and Contingency Plans
• Helps to assess health system
implications, gaps or needs
• Informs communication
planning & messaging
Planning Priorities
Operational Areas Related Activities
Environmental Health Investigations and Enforcement
Food Related Hazards
Water Related Hazards
Tobacco Enforcement
Health Hazard Investigations and Weather Related Assessments
Health Hazard Identification and Assessment
Hazardous Materials
Solid Waste Management
CBRNE
Indoor Air Quality
Flooding
Extreme Weather
Infection Control, Disease Investigation and Surveillance
Outbreak and Infection Control
Surveillance
Weather Related/Environmental Surveillance
Communicable and Non-Communicable Diseases – Acute Care Enhanced Surveillance (ACES)
SMDHU Public Inquiry Information Lines (Health Connection)
Mass Opioid Overdoses - ACES and through Community Partners
Safety, Health Promotion and Communication
Alcohol and Substance Misuse, Injury Related Events and Harm Reduction Strategies
Sexual Health
Drug and Alcohol Related Harms
Tobacco Education
Infection Control and Illness Prevention
Food and Water Safety
Extreme Temperature
Road and Pedestrian Safety
Incident Management Systems & Infrastructure
Modified IMS/EOC Activations (Command and Control Centers)
On-Site Unified Command (Headquarters Operations)
Communication Systems & Planning Cycles
Logistics Technological/Critical Infrastructure Failures
Health and Safety
PARTNERSHIPS & COLLABORATION
LOGISTICS
• Informs response and continuity
planning
• Determines capacity and
resourcing needs
• Assists with scheduling
• Identifies Health & Safety
considerations
• Impacts and needs (Costs:
Financial, Human Resource and
Physical Resourcing Needs)
HEALTH SYSTEM COLLABORATION
REPORTING & SURVEILLANCE
Linking HIRA to surveillance
tools in Toronto
Effie Gournis – Associate Director - CDC
Anne Arthur – Manager – CD Surveillance
TOPHC – March 28, 2019
Overview
o Mass gatherings and Toronto context
o When is Toronto HIRA needed?
o What does Toronto HIRA look like?
o Planning and tools developed
Toronto and mass events
• Canada’s largest city
• International hub
• Infrastructure and venues for large
events
• History of large scale events
• Actively wants to host events
https://www.toronto.ca/legdocs/mmis/2016/ex/bgrd/backgro
undfile-90908.pdf
Why Toronto?
Source: Tourism Toronto promotional material
Routine large events – part of annual plan
Mass gatherings – routinely happen
Large event vs mass gatherings –
when does it matter?
TPH considered mass gatherings as a function of
capacity of hosting community (as per WHO) rather than
number of participants.
o Informs planning and preparedness decisions
o Decision to enhance surveillance activities
Planning when Provincial/Federal HIRA exists
Questions:
o Does it apply to Toronto context?
o Is it current or too much time lapsed?
o Are there hazards that may present differential or
specific risk to Toronto’s population?
o Has anything changed in the larger disease
landscape?
Toronto HIRA process
Adapted from the Simcoe-Muskoka District Health Unit's Mass Gathering Plan and the Ontario Ministry of
Community Safety and Correctional Services' HIRA Workbook
o Review threats already identified by other HIRAs
o Review literature, media reports and health reports
for additional hazards
o Draft version of likelihood matrix (Table 5)
o Review with internal leads – mix of roles across
organization
Common threats and risk levels - example
Health Threat Risk Level
(Likelihood/Impact) Rationale
Food and waterborne illness Medium
(Frequent/Moderate) These tend to be among the most common infectious health events
experienced at MGs.28 The risk could be worsened by the time of year, as several of these illnesses increase during the summer in Toronto.
Select respiratory diseases
(MERS-CoV, Legionnaire's
disease, other novel respiratory agent)
Medium
(Unlikely/Significant) Diseases in this category do not frequently occur at MGs that are similar to
those likely to be held in Toronto. Although MERS-CoV is a concern at the
Hajj,61 that MG is very different from the average Toronto MG. However, this
health threat would have a high impact and attract a lot of media attention if it did occur.
Other Communicable
Diseases (Measles, Mumps, Ebola)
Medium
(Probable/Moderate) While not every disease is likely to emerge at a MG in Toronto (e.g., Ebola,
Zika), outbreaks/cases of measles and mumps have been reported at MGs in the past.54,60
Bioterror Agents (e.g., Anthrax)
Medium (Rare/Major) Concern about these attacks has been heightened since the 2001 anthrax
attacks, but bioterror attacks are rare.56 It would attract an extreme level of
attention and cause a great deal of fear should it occur. It would most likely be reported to first responders than discovered through surveillance.
Injuries (related to
toxicity/substance use/abuse)
Low (Frequent/Minor) Injuries related to substance use have been observed at other MGs, including sporting events62 and music festivals.5
Injuries (physical harm, not
related to substance use/abuse)
Low (Frequent/Minor) Frequently observed at other MGs,5,63 these injuries can place a strain on the health care system.
Sexually transmitted infections
Low (Unlikely/Minor)
The impact will be seen after the event has passed.
Tool - Surveillance plan for large events
Developed a plan with following objectives:
o Decision-making process for identifying which events
require enhanced surveillance activities
o Tools to collect needed information
o Inventory of surveillance strategies and potential
enhancements
o List of scalable processes, communications pathways,
and a report template
Reasons for potential enhancements
o Event-specific surveillance requirements
o Provincial surveillance requirements
o TPH planning/response process initiated, with CD
surveillance considerations
o TPH is implementing and validating a new
data/info source
Assessment worksheet
Objective:
o Collect information about the event as it becomes available
o Assist surveillance team and other stakeholders in identifying event characteristics that would suggest enhanced surveillance
o Help efficiently develop initial surveillance recommendations
o Document identified risks and surveillance recommendations
Event characteristics collected and
assessed
oEvent Size (# of participants and attendees)
oDuration
oCurrent health risks (local, national, and international) in Toronto
oProfile of international visitors and their health risks (e.g. vaccination status)
oLocation (including whether there are multiple sites and/or jurisdictions)
oMedia profile
oSecurity concerns (including the presence of political and religious
dignitaries)
oTime of year (seasonality for weather-related issues)
oPresence of temporary food premise locations
oParticipant demographics
oOther information on specific health status (if known) concerns of the
attendees
Process flow chart
• Uses information collected on
worksheet to make decisions
• Consistent application of
decision points
• Applied to all new or updated
large events in Toronto
Hazard Identification and Risk Assessment •Review provincial HIRA (if applicable) •Assess need for TPH-specific HIRA
Check event against list of routine events types,
assess if any characteristics have changed Continue with routine surveillance
Consider sending information package
CDSU and IIS AD review, consultation, and
determination of whether enhanced
surveillance is indicated
Determine if a Hazard Identification and
Risk Assessment is needed
Event type is on list and characteristics are
unchanged
Event type is not on list or characteristics have
changed
Yes
No
Document recommended CD surveillance approach •Surveillance objectives by event phase
•Operational plan (e.g., system enhancements, scheduling, communication)
Review/discuss surveillance recommendations with stakeholders
Implement event-specific communicable disease surveillance
strategy
CDSU Assessment •Review surveillance requirements •Event •Province
•TPH
Evaluate/Assess (as needed)
Disseminate Findings
Indicated
Do any of the following considerations apply? •Event-specific surveillance requirements •Provincial surveillance requirements
•TPH planning/response process initiated, with CD surveillance considerations
•TPH is implementing and validating a new data/info source
Request/inquiry related to surveillance for a large
event received
Not indicated
Initiate MG Worksheet
Determine Recommended Surveillance Approach Conduct gap analysis with existing systems. Develop a tracking system for event escalation and investigation. Consider enhancements to: •Data access, collection, and management •Data analysis and interpretation •Reporting and dissemination
Not needed
Needed
No
Routine large events
• Toronto’s large recurring
events were assessed
and documented
• Assessments of events
updated if event
characteristics change
(e.g. World Pride,
change in time of year
for event)
Type Specific Events
Regularly Scheduled Sporting Events Maple Leafs games Honda Indy Raptors games Blue Jays games Argonauts games, etc.
Toronto Pride Month Pride Parade Dyke March Trans March, etc.
Community Fairs and Festivals Toronto Caribbean Carnival Taste of Little Italy Taste of the Danforth Canada Day fireworks, etc.
Canadian National Exhibition
Music, Film, and Art Festivals Toronto International Film Festival Canadian Music Week Field Trip NXNE Just for Laughs Word on the Street, etc.
Political Protests G20 protests Demonstrations at Queen's Park 2017 Women's March Toronto, etc.
Other Routine Events Conferences Marathons, etc.
Type Specific Events
Regularly Scheduled Sporting Events
Maple Leafs games Honda Indy Raptors games Blue Jays games Argonauts games, etc.
Toronto Pride Month Pride Parade Dyke March Trans March, etc.
Community Fairs and Festivals Toronto Caribbean Carnival Taste of Little Italy Taste of the Danforth Canada Day fireworks, etc. Canadian National Exhibition
Music, Film, and Art Festivals Toronto International Film Festival Canadian Music Week Field Trip NXNE Just for Laughs Word on the Street, etc.
Political Protests G20 protests Demonstrations at Queen's Park 2017 Women's March Toronto, etc.
Other Routine Events Conferences Marathons, etc.
• Assessing internal and external signals
• Daily aberration detection • Any regular seasonal monitoring • Changing frequency of analysis • Analyzing specifically for MG-related
exposures • Analyze local media for CD info • Add MG venues as GIS layer
• Routine reporting • Regular suite of reports,
including: • Monthly surveillance report • Weekly ARI report • VPD annual report
• Ad hoc media availability • Frequent MG-specific reporting • Syndromic surveillance reporting • Frequent conference calls
• Routine data sources, including: • iPHIS • ACES • Refer to matrix for more
• Use EMCT for situational awareness • Use FirstWatch • Use iPHIS for syndromic surveillance • Receive PHOL data
• Outbreak response support • Emerging disease support • Develop and iteratively review an
enhanced surveillance plan • Develop a structured communications
plan • Find new data/info sources • Enhanced surveillance evaluation and
assessment
Action
Data Access, Collection & Management
Data Analysis & Interpretation
Report & Dissemination
Changes to the Surveillance Cycle
Summary
o Planning is essential and tools help
o PH preparedness gaps identified through HIRA
o Assessments for routine large events can be done in
advance
o Assessments for common PH threats in mass events
can be available in advance
o Coordination and collaboration among federal,
provincial, and other municipal partners is key
Acknowledgements
o Martha Hunter
o Leslie Shulman
o CD Surveillance Team
Questions CDSU@Toronto.ca
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Small-group table discussions
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Questions to consider during presentations
71
1. Which tools/templates could be useful in planning for a mass gathering in your jurisdiction? Which types of the presented tools could be useful to your context?
2. Are there specific considerations for your jurisdiction?
3. What other resources would be helpful for your local work?
PublicHealthOntario.ca 72
Risk assessment, collaboration & resilience
Closing remarks and questions
From HIRA to Awareness: A Ready and Resilient Health System
73
From HIRA to Awareness: A Ready and Resilient Health System
From HIRA to Awareness: A Ready and Resilient Health System
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From HIRA to Awareness: A Ready and Resilient Health System
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From HIRA to Awareness: A Ready and Resilient Health System
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From HIRA to Awareness: A Ready and Resilient Health System
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From HIRA to Awareness: A Ready and Resilient Health System
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