Public health and environmental medicine

A.Y. 2021/2022
9
Max ECTS
108
Overall hours
SSD
MED/42 MED/44 SECS-P/06
Language
English
Learning objectives
The course integrates two modules. general and applied hygiene and occupational medicine.
The course integrates two modules: general and applied hygiene and occupational medicine.
In the first module, students will learn:
- the basic epidemiology principles, concepts, and procedures useful in the surveillance and investigation of health-related states or events.
- the objectives, strategies and actions put in place to control and prevent diseases and to promote health at the individual and community levels.
- the methodology of primary, secondary and tertiary prevention.
- the strategies and interventions able to avert, eliminate and eradicate infectious diseases on a global scale, the impact of vaccination in preventing infectious diseases at national and global level.
- the variety of factors which favor the risk of emerging and re-emerging infectious diseases to strengthen global surveillance and control.
- the educational strategies to support behaviors' change among patients and communities.
- the essential concepts of global health and trans-national determinants and solutions in health.
- the general principles and values of healthcare systems and their performance using different datasets. The Italian National health service is presented as a universalistic model of delivery of care.
- the risk management using the current taxonomy.
- the quality of all the elements of the process of care.
In the second module, students will learn:
- the history of Occupational Health, from its "clinical phase" to the current situation, characterized by a focus on primary prevention but without losing some specific medical aspects .
Basic principles regarding the main existing occupational diseases groups of risk factors and related occupational diseases together with criteria for diagnosis, prevention and compensation.
- the lists of occupational diseases (ILO, EU, National Lists) and Occupational Health in the forthcoming ICD11 as useful tools to drive the diagnosis, reporting and compensation of occupational diseases. The need of Occupational Health Surveillance addressed at monitoring new and emerging (or re-emerging) occupational risks and diseases will be also addressed with specific examples.
- The basic principles of human and occupational toxicology, including the concepts of: toxicokinetics of chemicals, dose-response relationship and quantitative evaluation of toxicity.
- selected aspects of regulatory toxicology useful for the medical doctors will be addressed: general concepts in risk assessment and management, health-based exposure limits setting and use, regulations for the management of chemical risk for human safety and health in a global and European perspective, including the "REACH System".
- the definition and the use of occupational and environmental exposure limits, and the classification and labelling of chemical products with a specific focus on the classification of carcinogens (research, international agencies, regulation).
- human exposure to chemicals in the working and living environment (risk assessment and management), pesticides, metals, organic solvents, persistent organic pollutants, benzene, the emissions of a steel smelter industry. Definition of a method to explore different databases for searching scientific documentation and papers on chemical toxicity.
- the main epidemiological methods to study the impact of the general and occupational environments on human health; the point of view of WHO.
- human exposure methods for epidemiological research are described.
- environmental epigenetics as the missing link between environment and chronic diseases.
-how medical decisions imply the use of scarce resources (time, drugs, technologies, etc.) and how doctors should use them effectively and efficiently.
Expected learning outcomes
At the endo of the course students are expected to have knowledge on:
- the basic epidemiology principles, concepts, and procedures useful in the surveillance and investigation of health-related states or events.
- the objectives, strategies and actions to control and prevent diseases and to promote health at the individual and community levels.
- the educational strategies to support behaviors' change among patients and communities.
- the essential concepts of global health and trans-national determinants and solutions in health.
- the general principles and values of healthcare systems and their performance.
- the risk management and the quality of the process of care.
- how to address suspected occupational diseases: diagnostic and exposure criteria, diagnosis and prevention.
- how to classify occupational diseases according to the existing national lists and the ICD codes.
- how to report an occupational disease.
- how to address chemical risks, to identify priorities, to decide prevention strategies.
- how the environment affects health through impact on genome and gene expression.
- how to manage big records of patients, from the general practice to specific specializations and to do basic statistical elaboration.
Course syllabus and organization

Single session

Responsible
More specific information on the delivery modes of training activities for academic year 2021/22 will be provided over the coming months, based on the evolution of the public health situation.
Prerequisites for admission
To take the Public Health and environmental Medicine exam, students must have already passed all the exams of the first and second year (Fundamentals of Basic Sciences, Cells, Molecules and Genes 1 and 2, Human Body, Functions and Mechanisms of Diseases).
Assessment methods and Criteria
Students' assessment is conducted with a proficiency test carried out through a written assessment based on 60 questions with multiple choice answers. Each correct answer gives a score of 0,54. No score for missed or incorrect answers. In some cases, the mark can be increased based on selected activities made by the students. Questions are based on the different topics indicated in the program, with a composition balanced on the time allotted in the different lectures.
General and applied hygiene
Course syllabus
MODULE: GENERAL AND APPLIED HYGIENE
Topic 1. Epidemiology and public health: role of epidemiology in public health
Define hygiene, epidemiology, prevention and public health
Identify the core epidemiology functions
Describe primary applications of epidemiology in public health practice
List the key features and uses of descriptive epidemiology
List the key features and uses of analytic epidemiology
Apply the appropriate measures of association and measures of public health impact
Topic 2. Health education and health promotion targeting patients and communities
Health promotion. Students will learn how to use educational strategies to support behaviors' change among patients and the communities. The importance of health education and health promotion will be discussed. Students will understand why it is so important to integrate the clinical work with these two strategies as a way to help patients to become persons in charge of their own health. The students will also learn why Health education is a strategic and preventative priority in developmental age with a specific focus on interventions to be promoted in pre - adolescence and adolescence to prevent at-risk behaviors and addictive behaviors.
Understand why and how to include educational interventions into primary, secondary and tertiary prevention strategies
The role of neurosciences in the development of new preventative approaches targeting children, pre-teens and teens
Apply the most important health education models and theories to implement prevention programs targeting patients and communities:
The Theory of Reasoned action (Fisbejn and Ajzen)
The ecological model (Brofenbrenner)
The stages of change model (Prochaska-Di Clemente)
The diffusion of innovation (Rogers)
The health belief Model
Topic 3. Introduction to the methodology of prevention of infectious diseases
Describe aims of prevention
Define the objectives, strategies and actions put in place to control and prevent diseases and to promote health at the individual and community levels
Describe goals and methodology of primary, secondary, and tertiary prevention
Learn about the natural history of infectious diseases and the way pathogens spread through the chain of infection
Describe the strategic objectives of infectious diseases prevention
Topic 4. Vaccines and vaccinations as safe and effective public health tools to reduce, eliminate and eradicate infectious diseases on a global scale
Explain the importance of vaccination in the control of IDs
List the main types of vaccine and illustrate them with examples
List types of vaccine components and explain their functions
Describe the routes of administration of the vaccines
Define associated vaccinations and combination vaccines
List the characteristics of the "ideal vaccine"
Define vaccines side-effects, contraindications and precaution to vaccine administration
Describe strategies of vaccination
Define "herd immunity" and "vaccination coverage"
Describe the main policies of vaccination and with the legal and ethical issues involved
Describe the current situation of vaccine-preventable IDs in Italy
Topic 5. Emerging and re-emerging infectious diseases in the era of globalization. A public health problem of major concern
Define emerging, re-emerging and deliberately emerging IDs and factors influencing their onset.
Define the interactions of host-agent-environment triad.
List the main characteristics of the microbial pathogens and environmental factors that can favor the occurrence of EIDs
Describe the epidemiology of vector-borne diseases
Topic 6. Public health surveillance and surveillance of infectious diseases
Define public health surveillance and its critical components
List the main purposes and uses of surveillance
Describe the steps to establish and maintain a surveillance system
List the attributes used to evaluate a surveillance system
Describe the role of laboratory in public health surveillance
Describe the global influenza surveillance as an example of surveillance system
Topic 7. Key concepts and definition of global health
Understand the essential concepts of global health: its definition(s) and its evolution from tropical medicine and public health through international health. A brief history of WHO and some key global stakeholders will allow the student to become familiar with key global actors
Awareness of the conceptual differences and commonalities among global health, public health and international health
Understand of the reasons why global health is a crucial topic in the XXI century for all students in health sciences and beyond
Topic 8. Global burden of diseases
Understand the current burden imposed by various diseases and conditions to humanity in a quantitative manner with realization of what the biggest causes of suffering and deaths are today based on global estimates and assessment of progress
Understand the main indicators of health used in the context of the global burden estimates
Awareness of the epidemiological transition in health and the future challenges to be faced when addressing health issues globally
Understand the epidemiological, policy and political implications of epidemics and pandemics such as COVID-19
Topic 9. Recent phenomena and future of global health
Understand the events and factors that determined the status of health in the world over the past few decades
Understand demographic changes, urbanization and aging of human populations
Trying to foresee the future of global health based on current economic, policy and political trends
Topic 10. Social and economic determinants of health and sustainable development goals (SDGs)
Become familiar with determinants of health
Be acquainted with the United Nations Sustainable Development Goals (SDGs) set for 2030 and the health targets established as part of the SDG framework
Understand the concepts of universal health coverage, social protection and access to health as fundamental within global health and sustainable development
Topic 11. Tuberculosis as a model in global health burden and response
Understand how global health issues work: tuberculosis (TB) as a model
Familiarize with the concept of the global burden of a disease applied to a global health threat like TB, how it is estimated and how it is influencing action
Understand how global health policies for a response to challenges are developed, promoted and implemented by agencies such as WHO and other key actors
The global strategy to control and eliminate TB, the policy environment and the political factors
Topic 12. Global governance of health
Understand how global health is influenced by different actors and how many such actors are today
Have a deep dive into WHO history, structure, and functions and understand how this Organization works, providing the example derived from the management of a global programme
Understand in detail other key global health actors such as cooperation agencies, non-governmental organizations, partnerships, and the corporate sector
Understand the principles of international cooperation
Topic 13. The big challenges: climate change and migration
Be acquainted with the essentials of climate changes and their consequences on health
Familiarize with migrant health issues
Understand some of the major burden diseases in migrants and the necessary response
Topic 14. Organization and management of Health Services
Understand the ways health care can be delivered to a given population
Appreciate how the performance of a health care organization can be measured
Understand the organization of the Italian National Health Service as a model of universalistic approach.
Understand the main challenges health systems have to face both in hospital and primary care organization
Topic 15. Risk Management in the Health Care Systems
Understand the concept of risk in health care organizations
Quantify the dimension of the phenomenon in health care settings
Distinguish between active and latent errors
Analyze a case study in order to find out the latent errors
ICA and patient safety
Topic 16. Patient safety 1
Define the concept of quality
Define the dimensions of quality
Describe the process of monitoring cycle of quality improvement
Describe the accreditation process
Topic 17. Patient safety 2
Discussion about risk management in clinical setting
Quality evaluation in health structures
Patient safety
Teaching methods
Synchronous learning: in presence and video conferences, interactive webinars, chat-based online discussions and lectures
Asynchronous learning: audio-video based (pre-recoreded, multimedia platforms); text-based (e-mail, electronic documents, discussion boards, blogs); mixed (virtual libraries, social networks)
Teaching Resources
PUBLIC HEALTH
Oxford Textbook of Public Health, Oxford University Press
Skolknik R. Global Health 101, Fourth Edition. Jones & Bartlett Learning, Burlington, MA, USA, 2021
OCCUPATIONAL HEALTH
Hunter's Diseases of Occupations. Editors Baxter PJ, Aw T-C, Cockcroft A, Durrington P, Harrington JM. Tenth Edition, London: Hodder Arnold, 2010 (advanced textbook)
Pocket Textbook: TC Aw, K. Gardenerm, JM Harrington. Pocket Consultant. Occupational Health. Black Publishing. ISBN-13: 978-1- 4051-2221-4; ISBN-10: 1-4051-2218.
European Commission, Directorate-General for Employment, Social Affairs and Equal Opportunities, F4 unit. Information notices on occupational diseases: a guide to diagnosis. Luxembourg: Office for Official Publications of the European Communities, 2009 ISBN 978-92- 79-11483-0; doi 10.2767/38249 (provided without costs by the course coordinator)
APPLIED ECONOMICS
Lega F., Prenestini A., Spurgeon P., Is management essential to improving the performance and sustainability of healthcare systems and organizations? Value in Health, 2013.
Lega F., DePietro C, Converging patterns in hospital organization: beyond the professional bureaucracy, Health Policy, n. 74 2005.
Lega F., Calciolari S., Coevolution of hospitals and patients: how changing epidemiology and technology advances drive organizational innovations and lay new challenges, Journal of healthcare management, February 2012.
Additional material, in particular to online content, will be made available during the course.
Occupational medicine
Course syllabus
MODULE: OCCUPATIONAL MEDICINE
Introduction into Occupational Health
The story of Occupational Health since the beginning
From disease diagnosis and treatment to primary prevention
Meaning of "occupational medicine" and "occupational health"
The burden of occupational diseases and accidents
Additional information provided: the structure of the module, the teachers and the programme
Topic 1. Introduction into occupational and environmental toxicology
An historical perspective
The WHO evaluation of burden of diseases due to environmental causes (2 Hrs)
The European regulation for chemical risk (REACh and CLP)
Topic 2. Introduction to Risk Assessment
What is Risk Assessment: definitions, components, roles of different stakeholders
Risk perception and risk communication
Topic 3. Toxicodynamic
Paracelso and the definition of toxicity
The classification of toxicity
The process for classifying a chemical as carcinogen: from research to legal classification
The dose-response relationship
The quantitative parameters of toxicity (NOEAL, LOAEL, LD)
Labelling hazardous chemicals according to CLP
Topic 4. Industrial and environmental hygiene 1
The presence of hazardous chemicals in working and living environment
Asbestos: the magic stone
The living environment and the exposure to emissions from a steel smelter industry
Topic 5. Industrial and environmental hygiene 2
Limit values: tools to manage chemical risks in occupational and living environments
Different limit values: definition and meaning
Limit values in a historical perspective: the case of benzene Examples of application of limit values
Use of experimental data and data from studies in humans
Thresholded- and non-thresholded effects
Use and significance of health-based exposure limits
Tools to enforce the limits
Topic 6. Toxicokinetics
Adsorption, Distribution, Biotransformation, elimination of chemicals
Biological monitoring
Biological limit vales
Biological monitoring applied to assess exposure in the work and living environments
Topic 7. Searching scientific information on toxicology
Electronic resources for retrieving information on the toxicity of chemicals
IARC
Toxnet
GESTIS
ECHA
Topic 8. Chemical risk factors: metals
What is a metal and why and how a metal can represent an health risk
The toxicology of the most common and hazardous metals (Lead, Cadmium, Mercury, Arsenic, Nickel, manganese)
The criteria for prevention, including biological monitoring
What any medical doctor must know regarding metal toxicity
Topic 9. Chemical risk factors: solvents
What is an organic solvent and why and how an organic solvent can represent an health risk
Chemical groups of organic solvents
Principles of toxicokynetics of organic solvents
Principles of toxicodynamics of organic solvents
The criteria for prevention, including biological monitoring
What any medical doctor must know regarding metal toxicity
Topic 10. Chemical risk factors: pesticides
The specificity of pesticides compared to other chemicals
Chemical groups of pesticides
The global burden of acute pesticide poisoning in the world
Epidemiological data
Toxicity of individual (groups of) compounds
The general population and the problem of pesticide residues in food and environment
The criteria for prevention, including biological monitoring
What any medical doctor must know regarding pesticides
Topic 11. Disease caused by mineral dusts
Concept of sclerogenic and non sclerogenic dusts
Particles vs fibers
When and how a particle/fiber can reach the human lung
The main pulmonary fibroses (silicosis and asbestos)
The cancers due to mineral dusts/fibers: pulmonary neoplasm, pleural mesothelioma, other cancers
The criteria for prevention
What any medical doctor must know regarding mineral dusts
Topic 12. Occupational cancers: an overview
Most relevant occupational cancers and related agents and exposures
Asbestos: lung cancer and mesothelioma
Silica: lung cancer
Other cancers: bladder, nasal sinus, liver angiosarcoma and carcinoma.
Topic 13. Muscle-skeletal occupational disorders
Muscle skeletal disorders as the main component of the burden of disease in Europe
The main muscle skeletal disorders at the workplace
Principle for prevention; the role of ergonomy
Topic 14. Physical Risk Factors
The main physical risk factors present at the workplace: noise, vibrations, ultrasounds, optical radiations and the related health effects
Principles of workers' protection from noise, vibrations, ultrasounds, optical radiations
The burden of disease for physical risk factors
The criteria for prevention
What any medical doctor must know regarding physical risk factors
Topic 15. Physical risk factors: ionizing radiations
Basic knowledge on ionizing radiations.
Natural and artificial radiations, General characteristics and sources of production
Stochastic and non-stochastic ionizing radiations
The specific problem of radom
Exposure limits and criteria for prevention of effects
Topic 16. Allergic and immuno-mediated diseases
General aspects of occupational allergies
The main types of allergic reactions
Allergic dermatoses
Allergic respiratory diseases
The non-allergic but immune mediated diseases: the byssinosis
Criteria for diagnosis and prevention
What any medical doctor must know regarding occupational allergies
Topic 17. The lists of occupational diseases and occupational health in the new ICD 11
The key problem: a disease is a clinical entity, an occupational disease is an administrative decision
How to harmonize the approach of medical doctors at the diagnosis, reporting and prevention of occupational diseases: diagnostic and exposure criteria
Diagnostic and exposure criteria in the new ILO list of Occupational Diseases, in the EU list and in the forthcoming ICD11
The Occupational Health Surveillance
How to improve the reporting of occupational diseases: the approaches
How a medical doctor may use the existing tools.
Topic 18. Psychosocial risk factors at the workplace
Psychosocial risk factor as an emerging occupational risk in .modern society
Mobbing
Burnout
Post-traumatic stress disorder
Other psychosocial occupational diseases and syndromes
Criteria for risk assessment and prevention
Topic 19. Health effects of Air Pollution
Air pollutants: types and concentration
Current concentrations in Europe and Northern Italy
Short- and long-term health effects
Effect vs. Impact
Topic 20. Causality in diseases related to occupational and environmental factors
Characteristics of descriptive and analytical epidemiology
Bradford Hill's Viewpoints
Role of risk factors (confounding, effect modification, causal factor)
Rothman's causal pie model
Topic 21. Environmental epigenetics
Definition of epigenetics
Introduction of the most important molecular and epigenetics markers involved in occupational and environmental studies
Example of best research in occupational and environmental epigenetics
Teaching methods
Synchronous learning: in presence and video conferences, interactive webinars, chat-based online discussions and lectures
Asynchronous learning: audio-video based (pre-recoreded, multimedia platforms); text-based (e-mail, electronic documents, discussion boards, blogs); mixed (virtual libraries, social networks)
Teaching Resources
PUBLIC HEALTH
Oxford Textbook of Public Health, Oxford University Press
Skolknik R. Global Health 101, Fourth Edition. Jones & Bartlett Learning, Burlington, MA, USA, 2021
OCCUPATIONAL HEALTH
Hunter's Diseases of Occupations. Editors Baxter PJ, Aw T-C, Cockcroft A, Durrington P, Harrington JM. Tenth Edition, London: Hodder Arnold, 2010 (advanced textbook)
Pocket Textbook: TC Aw, K. Gardenerm, JM Harrington. Pocket Consultant. Occupational Health. Black Publishing. ISBN-13: 978-1- 4051-2221-4; ISBN-10: 1-4051-2218.
European Commission, Directorate-General for Employment, Social Affairs and Equal Opportunities, F4 unit. Information notices on occupational diseases: a guide to diagnosis. Luxembourg: Office for Official Publications of the European Communities, 2009 ISBN 978-92- 79-11483-0; doi 10.2767/38249 (provided without costs by the course coordinator)
APPLIED ECONOMICS
Lega F., Prenestini A., Spurgeon P., Is management essential to improving the performance and sustainability of healthcare systems and organizations? Value in Health, 2013.
Lega F., DePietro C, Converging patterns in hospital organization: beyond the professional bureaucracy, Health Policy, n. 74 2005.
Lega F., Calciolari S., Coevolution of hospitals and patients: how changing epidemiology and technology advances drive organizational innovations and lay new challenges, Journal of healthcare management, February 2012.
Additional material, in particular to online content, will be made available during the course.
Applied economics
Course syllabus
Topic 1. Introduction to Health Economics and the complexity of Health Systems
Aim of this session is to prepare students:
to understand the specificities of health systems, such as "supply-induced demand" logics, market failures, moral hazards, the implications of having a third party payer;
to be aware of the economic implications of medical decisions;
to understand the problem of scarcity in sharing resources and setting priorities in health care
to acquainting with the logics of professionalism
to recognizes the challenges of modern medicine and the sustainability issues of health systems
Topic 2. Organization and Management of Health Services and Organizations
Aim of this session is to prepare students:
to understand what makes so distinctive and unique the management of health organizations
to familiarize with the leadership and performance cycles through which health organization are run;
to appreciate how health professional, and specifically clinicians, develop their careers and can become clinical leaders
to familiarize with the most important issues in "people management": group work and evaluation
Topic 3. Recent development in designing and reconfiguring Health Services
Aim of this session is to prepare students:
to understand how hospital are evolving beyond the traditional model of professional bureaucracies, adopting new schemes based on clinical services lines, focused-hospital models, divisionalizations;
to familiarize with new paradigms for the designing of health services within community settings: population health management, medicine of initiative, co- production, concordance etc.
To appreciate the implications for health professionals and emergence of new roles: operations managers, clinical leaders, medical directors, patient experience managers etc.
Teaching methods
Synchronous learning: in presence and video conferences, interactive webinars, chat-based online discussions and lectures
Asynchronous learning: audio-video based (pre-recoreded, multimedia platforms); text-based (e-mail, electronic documents, discussion boards, blogs); mixed (virtual libraries, social networks)
Teaching Resources
PUBLIC HEALTH
Oxford Textbook of Public Health, Oxford University Press
Skolknik R. Global Health 101, Fourth Edition. Jones & Bartlett Learning, Burlington, MA, USA, 2021
OCCUPATIONAL HEALTH
Hunter's Diseases of Occupations. Editors Baxter PJ, Aw T-C, Cockcroft A, Durrington P, Harrington JM. Tenth Edition, London: Hodder Arnold, 2010 (advanced textbook)
Pocket Textbook: TC Aw, K. Gardenerm, JM Harrington. Pocket Consultant. Occupational Health. Black Publishing. ISBN-13: 978-1- 4051-2221-4; ISBN-10: 1-4051-2218.
European Commission, Directorate-General for Employment, Social Affairs and Equal Opportunities, F4 unit. Information notices on occupational diseases: a guide to diagnosis. Luxembourg: Office for Official Publications of the European Communities, 2009 ISBN 978-92- 79-11483-0; doi 10.2767/38249 (provided without costs by the course coordinator)
APPLIED ECONOMICS
Lega F., Prenestini A., Spurgeon P., Is management essential to improving the performance and sustainability of healthcare systems and organizations? Value in Health, 2013.
Lega F., DePietro C, Converging patterns in hospital organization: beyond the professional bureaucracy, Health Policy, n. 74 2005.
Lega F., Calciolari S., Coevolution of hospitals and patients: how changing epidemiology and technology advances drive organizational innovations and lay new challenges, Journal of healthcare management, February 2012.
Additional material, in particular to online content, will be made available during the course.
Applied economics
SECS-P/06 - APPLIED ECONOMICS - University credits: 1
Lessons: 12 hours
Professor: Lega Federico
General and applied hygiene
MED/42 - HYGIENE AND PUBLIC HEALTH - University credits: 4
Lessons: 48 hours
Occupational medicine
MED/44 - OCCUPATIONAL MEDICINE - University credits: 4
Lessons: 48 hours
Professor(s)
Reception:
Weekly - plese write to federico.lega@unimi.it
Department of Scienze Biomediche per la Salute - Via Pascal 36
Reception:
via C. Pascal, 36 Milan