Subsidy Programs for Seasonal Influenza Vaccination of Children and Pregnant Women in Japanese Municipalities.

In Japan, influenza vaccination is offered to children and pregnant women at clinics or hospitals as an elective, self-funded treatment, as the vaccination is not included in the national vaccination subsidy program. However, some Japanese municipalities offer a discretionary subsidy for seasonal influenza vaccination of children and pregnant women as a local policy. We identified these local subsidy programs during 2019/2020 seasonal influenza season by conducting a cross-sectional survey across Japan. Out of a total of 1741 municipalities, responses were received from 1732; therefore, the response rate was 99.5%. The local influenza vaccine subsidy programs for children were offered in 45.7%, and for pregnant women in 10.2%, of Japanese municipalities. This is the first survey of subsidy programs for pregnant women. While policy diffusion of subsidy programs for children was observed during the 9 years since a previous study, such programs for pregnant women remain limited. Despite many municipalities having subsidy programs, we found that their provision still remains limited when viewed as a whole.

Exploring the Threefold Viewpoint on Children's Oral Health in a Cross-Sectional Study.

Oral health is situated within the framework of the global health agenda, addressing facets pertaining to well-being and quality of life. The research is based on the need to address variables at the community level to improve schoolchildren's oral health and promote healthy behaviors and aims to carry out an in-depth analysis from the perspective of the factors that influence children's oral health. Step 1, designed by the World Health Organization, was utilized. An easy-to-use web interface was created for data collection. The statistical analysis consisted of using multinomial and binominal logistic regression models. The level of education of the adult has a high probability of influencing the consumption of unhealthy or healthy foods, it has a significant probability of exerting influence on social or medical problems and a correlation was found between the level of academic education and the pattern of dental visits. The development of health-promoting behaviors begins in childhood and involves parents, who have an essential role in the education of their children. Oral health promotion programs in schools need to target the child-adult-teacher-dentist relationships. Taking into consideration the aforementioned, a threefold viewpoint is necessary for the development of a national program aimed at promoting the oral health of schoolchildren in Romania.

Construction of an indicator framework for vaccine inclusion in public health programs: A Delphi-entropy method study.

Governments must decide which vaccine priority to include in their public health programs. Using the modified Delphi and entropy method, we developed an indicator framework for vaccine inclusion at the national, provincial, municipal, and district/county levels, each containing three dimensions. In total, 4 primary indicators, 17 secondary indicators, and 45 tertiary indicators were selected, covering vaccine-preventable diseases, candidate vaccines, and social drivers of the supply and demand sides. From a subjective perspective, there was no significant weighting difference in the primary and secondary indicators at all administrative levels. "Vaccine-preventable diseases" as a primary indicator had the greatest weight in the peer group, of which "Health burden" had the highest weight among the secondary indicators. From the objective perspective, the social drivers on the supply and demand sides of the primary indicators accounted for 65% and higher. Among the secondary indicators, "the characteristics of the candidate vaccine" and "vaccine-related policies on the supply side" held 8% of weights or more at both national and provincial levels. "Demographic characteristics" held the highest weight at the municipal (13.50) and district/county (15.45) level. This study indicates that China needs different considerations when using WHO-recommended vaccines at the national, provincial, municipal, and district/county levels. In addition, this study highlights that behavioral and social drivers are important indicators that need to be considered for decision-making. This framework provides a tool for policymakers to determine the inclusion priority of candidate vaccines.

Evaluation of School-Age Children's Intelligence Quotient and Their Chronic Exposure to Trace Elements in Ambient Air.

Background Children's exposure to different trace elements in their air, water, and food or even present in paints or toys can affect their intelligence quotient (IQ) score. However, this correlation needs to be analyzed and evaluated in different contexts. This study aimed to investigate the associations between airborne concentrations of lead (Pb), manganese (Mn), cadmium (Cd), chromium (Cr), and arsenic (As) and intellectual function in school-age children in Makkah, Kingdom of Saudi Arabia. Methodology Our cohort study aimed to explore the link between exposure to various trace elements in the surrounding air and the IQ scores of children residing in the vicinity of Makkah. We included 430 children in the study and collected information about demographic and lifestyle factors using a structured questionnaire. We employed a mini volume sampler (MiniVol, AirMetrics, Springfield, OR, USA) to collect 24-hour PM10 samples from five locations in Makkah, representing various residential areas with small-to-medium industrial activities and traffic load. We analyzed the samples for Pb, Mn, Cd, Cr, and As concentrations using inductively coupled plasma-mass spectrometry with Perkin Elmer 7300 (Perkin Elmer, Waltham, MA, USA). The combined impact of heavy metals on continuous outcomes was assessed using the Bayesian kernel machine regression model. Results The mean atmospheric concentrations of Pb, Mn, Cd, Cr, and As in summer were 0.093, 0.006, 0.36, 0.15, and 0.017 µg/m3, respectively, while in winter, they were 0.004, 0.003, 0.12, 0.006, and 0.01 µg/m3, respectively. The findings of our study revealed that children's IQ scores were independently associated with co-exposure to the five metals, namely, Pb, Mn, Cd, Cr, and As. Conclusions This study demonstrates a link between combined exposure to five heavy metals (Pb, Mn, Cd, Cr, and As) and children's IQ scores. Regularly evaluating trace elements in children's biological samples is crucial to comprehend their effects on cognitive growth. To explore the possible future health risks of multimetal exposures and their interaction effects, it is imperative to conduct additional studies that involve repeated biological measurements of metal concentrations.

Optimizing Primary Healthcare in Hong Kong: Strategies for the Successful Integration of Radiology Services.

The primary healthcare system in Hong Kong plays a crucial role in addressing the healthcare needs of its population. However, the integration of radiology services into primary care settings has not been fully realized, and there is significant potential for improvement. Incorporating radiology services into primary healthcare can enhance patient care, promote cost-effectiveness, and increase the overall efficiency of the healthcare system by enabling earlier diagnosis and intervention for various health conditions. To successfully integrate radiology services, key strategies include the establishment of public-private partnerships, the adoption of teleradiology and telemedicine services, the development of comprehensive regulatory and policy frameworks, and the exploration of innovative financial models and incentives. By embracing these strategies, Hong Kong can optimize its primary healthcare system and ensure more equitable, effective care for its population.

The Significant Impact of Narcan Reversals on Overdose Mortality in Peoria County, IL.

OBJECTIVES: Determine the impact of Narcan administrations in Peoria County, IL on the number of overdose deaths by testing the statistical significance of the association between monthly Narcan reversals and overdose mortality. As well as re-shedding the light on the opioid pandemic post-COVID. METHODS: We collected data on Narcan reversals from hospital emergency departments, Emergency Medical Services (EMS), the County Sheriff's Office, local police departments, and other agencies that distributed and/or administered Narcan in Peoria County from January through December 2018. Data for the 2018 overdose mortality was collected through vital records at the Peoria City/County Health Department. RESULTS: Results from simple linear regression suggest that a significant proportion of the total variation in overdose mortality over 2018 was predicted by the Narcan reversals, F(1, 11) = 5.872, p< 0.05. Multiple R2 indicates that approximately 30.7% of the variation in overdose mortality was predicted by the Narcan reversals. If there were 0 Narcan reversals, there would be 8.362 overdose deaths per month. CONCLUSIONS: Narcan is known to save lives in cases of opioid overdose, and the need for increased administration campaigns is warranted to further battle the opioid epidemic. As this study has proven, Narcan administration has the potential to significantly decrease overdose mortality.

The Effect of Structured Education Training Program on Oral Health Awareness Among School-Going Children of Central India: A Cross-Sectional Study.

Background In order to curb the ever-increasing load of diseases related to the oral cavity, there is a call for generating organized school-based oral health education and training programs. It is proposed that there will be an emphasis on the primary care of oral health of school-going children proven, which is often neglected. This will be beneficial for the early detection, intervention and thus prevention of further debilitating conditions of the pathologies pertaining to the oral cavity with the assistance of the structured program suggested in this article. Aim The aim of the study was the evaluation of oral health programs for oral health awareness and knowledge among school-going children in the Central India region. Settings and design This is a cross-sectional study with measurements before and after the implementation of the oral care program.  Materials and methods This cross-sectional study, approved by the Institutional Ethical Committee, Datta Meghe Institute of Medical Sciences, Wardha, has been done according to the STROBE (Strengthening the Reporting of Observational studies in Epidemiology) checklist. A study based on certain questions was carried out amongst the school-going children of Central India, especially the Vidarbha region. A total of 250 school-going children were enrolled in the study. A survey based on a questionnaire was carried out among the study participants in the age group of 12-16 years of age, which consisted of questions pertaining to knowledge of oral health and hygiene maintenance. The program consisted of presentation slides, role-plays, and demonstrations for inculcating the knowledge. Result A total of 200 study participants responded to the questionnaire. Overall, the baseline mean score of knowledge with scale was 2.80 ± 1.73 SD, which after the intervention was observed to be 10.70 ± 0.54 SD, which showed an increase. There was an aptly 60.4% increase in test scores related to oral health after the specific oral health inculcation program based on questionnaire execution which was statistically significant (p<0.001). Conclusion A properly constructed school children-based oral health education and training program induces better results in the oral health-related comprehension of students.

Political attitudes and efficacy of health expert communication on the support for COVID-19 vaccination program: Findings from a survey in Hong Kong.

Despite evidence suggesting that vaccines offer protection against COVID-19, the uptake rates of COVID-19 vaccines have been low in some high-income regions. Support for vaccination program is important to fight the pandemic. This study aimed at exploring two research questions: first, to what extent political attitudes are associated with support for COVID-19 vaccination program; and second, whether health expert communication is effective in increasing the support. An online survey was undertaken by 1079 Hong Kong residents aged 18-77 years from May 26 to June 3, 2021. The survey found higher support in pro-government respondents, and lower support in political opposition. A strategy of positive communication by health experts could increase support in the opposition and politically attentive respondents. Other variables that were positively related to program support were quarantine experience, trust in government, preference for pandemic control over freedom, political attentiveness, and disagreement with China's influence on Hong Kong's COVID-19 policymaking. This study contributes to understanding the relationship between political attitudes and support for vaccination program and provides empirical evidence of the efficacy of health expert communication strategy in improving support for vaccination program for people with certain political attitudes.

IsiPAN (Isinusulong ang Psychiatry At Neurology): Kalusugan ng diwa, utak at kaisipan tungo sa malusog na pamayanan at kinabukasan. A community-based mental health program

@#<p style="text-align: justify;">Currently, mental health issues are of greatest importance to society as it is considered to be a growing invisible pandemic. It is strongly suggested to address concerns in the field of neurology and psychiatry, especially at the community level. One of the most popular interventions that the World Health Organization (WHO) recommends is to bring health promotion to the periphery. With this in mind, a public health campaign in one of the University of Santo Tomas Simbahayan partner communities, Kasiglahan Village Rodriguez, Rizal was born. This project aims to bring health awareness to the community, especially at the grassroots levels involving the municipal rural health unit, barangay health care workers and allied specialist stakeholders. They were taught symptom recognition, proper referral to specialists and prevention measures that the community may benefit from, which is much needed at this day and age. Further, this program can serve as a precursor to more public health initiatives regarding mental health in the community to spread awareness and aid in the prevention of mental health illnesses.</p>

Evaluation of a pilot program that integrated prenatal screening into routine antenatal care in western rural China: an interrupted time-series study.

BACKGROUND: We evaluated a large-scale pilot program in Shaanxi Province, western rural China, which integrated prenatal screening interventions for congenital abnormalities into routine antenatal programs. METHODS: We surveyed 1,597 mothers who gave birth between 2009 and 2016. Adopting the interrupted time-series design, we evaluated the program's impact on awareness, coverage, and cost, by comparing two counties with only supply-side policies, and two counties from the neighbouring province with no policies; and among the two counties with both supply- and demand-side policies and the two counties with only supply-side policies. We adjusted the sampling procedure and women's background characteristics. We conducted subgroup analyses by women's education. FINDINGS: After one year of implementation, the coverage of prenatal foetal aneuploidies and B-ultrasound screening rose by 25.0% and 23.5%. The program's supply-side policies attributed to 17.2 percentage points (90%CI 7.8-26.6%) and 27.3 percentage points (90%CI 16.2-38.5%) in coverage, and contributed to a higher median cost of 796.5RMB (90%CI 595.5-997.5). These significantly affected women with secondary education and above. However, the program's demand-side measures, that is, vouchers, seemed to be effective only in the mountainous regions, which raised awareness, and increased coverage of prenatal foetal aneuploidies screening by 28.6 percentage points (90%CI 13.4-43.8%), while not increasing costs. These significantly affected women with primary education and below. Education-related inequalities widened post-program in counties with only supply-side policies, but no inequalities existed in counties with demand-side policies. INTERPRETATION: Shaanxi's program made a pilot study to other provinces of China to integrate antenatal services. Government subsidies might be more effective in targeting specific geographic locations and people with primary education and lower.

Comparative Assessment of the Pharmacovigilance Systems within the Neglected Tropical Diseases Programs in East Africa-Ethiopia, Kenya, Rwanda, and Tanzania.

Monitoring the safety of medicines used in public health programs (PHPs), including the neglected tropical diseases (NTD) program, is a WHO recommendation, and requires a well-established and robust pharmacovigilance system. The objective of this study was to assess the pharmacovigilance systems within the NTD programs in Ethiopia, Kenya, Rwanda, and Tanzania. The East African Community Harmonized Pharmacovigilance Indicators tool for PHPs was used to interview the staff of the national NTD programs. Data on four components, (i) systems, structures, and stakeholder coordination; (ii) data management and signal generation; (iii) risk assessment and evaluation; and (iv) risk management and communication, were collected and analyzed. The NTD programs in the four countries had a strategic master plan, with pharmacovigilance components and mechanisms to disseminate pharmacovigilance information. However, zero individual case safety reports were received in the last 12 months (2017/2018). There was either limited or no collaboration between the NTD programs and their respective national pharmacovigilance centers. None of the NTD programs had a specific budget for pharmacovigilance. The NTD program in all four countries had some safety monitoring elements. However, key elements, such as the reporting of adverse events, collaboration with national pharmacovigilance centers, and budget for pharmacovigilance activity, were limited/missing.

Janssen Pharmaceutica, Long-Acting Risperidone and Public Health Program of India.

Within the ambit of the National Mental Health Program, the Government of India has mandated long-acting risperidone, a patented molecule of Janssen Pharmaceutica. We contest that the healthcare system of India is ill-equipped (due to its weak infrastructure) to monitor side effects, regulate the use, and ensure informed consent. The process of including patented Risperdal Consta into the Indian formulary has lacked transparency and suggests undo favor towards Janssen. Janssen Pharmaceutica is known for its aggressive marketing strategy resulting in off-label use of oral risperidone in the US. Moreover, the lax regulatory structure for pharmaceutical dispensing in India coupled with Janssen's aggressive marketing is a potential cause of concern. We are critical of the decision to include a costly and patented molecule in a publicly financed health program otherwise sourced by generic drugs.

Academic publications of full-time master of public health program students / 上海预防医学

Objective:To investigate academic publications of students of the full-time master of public health （professional degree， MPH） program and explore their research capacity. Methods:A total of 160 students of the full-time MPH program admitted from 2010 through 2014 were included in the study. Their academic publications were retrieved for analysis. Results:The average number of academic publications was 1.35. Moreover， 10.2% of the students had academic publications in Chinese journals， and 12.5% had publications in SCI-indexed English journals. Type of disciplines， province they were from， and economic status of their family were determined to be significantly associated with academic publications in SCI-indexed journals. Conclusion:Students of the full-time MPH program have research capacity； however， they have achieved relatively few academic publications of high quality. Establishment of a teaching and training program is warranted in both practice and research for students in full-time MPH programs in universities.

Newborn Screening for Inherited Metabolic Disorders: Early Identification and Long-Term Care for Patients in the Plain Community, Wisconsin, 2011-2017.

The Plain community is the fastest-growing religious minority in Wisconsin. This community has a high incidence of genetic disorders, many of which are identifiable through newborn screening. We describe efforts by the Wisconsin Newborn Screening Program (WNSP) to improve health care in the Plain community by targeting early identification of, and intervention for, patients with inherited metabolic disorders. WNSP formed partnerships with families and health care providers to increase awareness of screening procedures and the intended benefits of screening, modify testing algorithms to enhance detection, and establish medical homes for patients with confirmed disorders. The estimated number of Plain newborns screened increased by 25.5% during the study period, from 547 in 2011 to 736 in 2017; 122 persons underwent carrier testing, and 143 newborns received second-tier testing. From 2014 to 2017, affected patients received 71 metabolic evaluations in their community medical home without travel to major health centers. This article demonstrates how a comprehensive public health program can help increase screening rates, enhance detection, and establish follow-up care in a hard-to-reach religious community. A key lesson learned was the importance of communication among all stakeholders to develop an effective public health program.

Assessing and monitoring the impact of the national newborn hearing screening program in Israel.

BACKGROUND: The Israeli Newborn Hearing Screening Program (NHSP) began operating nationally in January 2010. The program includes the Otoacoustic Emissions (OAE) test for all newborns and Automated Auditory Brainstem Response (A-ABR) test for failed OAE and infants at risk for auditory neuropathy spectrum disorders. NHSP targets are diagnosis of hearing impairment by age three months and initiation of habilitation by six months. OBJECTIVES: (1) Review NHSP coverage; (2) Assess NHSP impact on age at diagnosis for hearing impairment and age at initiation of habilitation; (3) Identify contributing factors and barriers to NHSP success. METHODS: (1) Analysis of screening coverage and referral rates for the NHSP; (2) Analysis of demographic data, results of coverage, age at diagnosis and initiation of habilitation for hearing impaired infants pre-implementation and post-implementation of NHSP from 10 habilitation centers; (3) Telephone interviews with parents whose infants failed the screening and were referred for further testing. RESULTS: The NHSP coverage was 98.7% (95.1 to 100%) for approximately 179,000 live births per year for 2014-2016 and average referral rates were under 3%. After three years of program implementation, median age at diagnosis was 3.7 months compared to 9.5 months prior to NHSP. The median age at initiation of habilitation after three years of NHSP was 9.4 months compared to 19.0 prior to NHSP. Parents (84% of 483 sampled) with infants aged 4-6 months participated in the telephone survey. While 84% of parents reported receiving a verbal explanation of the screening results, more than half of the parents reported not receiving written material. Parental report of understanding the test results and a heightened level of concern over the failed screen were associated with timely follow-up. CONCLUSIONS: The findings indicate high screening coverage. The program reduced ages at diagnosis and initiation of habilitation for hearing impaired infants. Further steps needed to streamline the NHSP are improving communication among caregivers to parents to reduce anxiety; increasing efficiency in transferring information between service providers using advanced technology while ensuring continuum of care; reducing wait time for follow-up testing in order to meet program objectives. Establishment of a routine monitoring system is underway.

Determinants of an integrated public health approach: the implementation process of Greenland's second public health program.

BACKGROUND: Greenland struggles with a high prevalence of smoking, alcohol and drug abuse. In response to the increasing need for preventive initiatives, the first public health program Inuuneritta was introduced in 2007. Internationally, frameworks focus primarily on the implementation of a single, well-described intervention or program. However, with the increasing need and emergence of more holistic, integrated approaches, a need for research investigating the process of policy implementation from launch to action arises. This paper aims to augment the empirical evidence on the implementation of integrated health promotion programs within a governmental setting using the case of Inuuneritta II. In this study, the constraining and enabling determinants of the implementation processes within and across levels and sectors were examined. METHODS: Qualitative methods with a transdisciplinary approach were applied. Data collection consisted of six phases with different qualitative methods applied to gain a comprehensive overview and understanding of Inuuneritta II's implementation process. These methods included: observations and focus group discussions at the community health worker (CHW) conference, telephone interviews, document analysis, and a workshop on results dissemination. RESULTS: Enabling determinants influencing the implementation process of Inuuneritta II positively were high motivation among adopters, local prevention committees supporting community health workers, and the initiation of the central prevention committee. In contrast, constraining determinants were ambiguous program aims, high turnovers, siloed budgets and work environments, and an inconsistent and neglected central prevention committee. CONCLUSION: Inuuneritta II provided a substantial framework for an integrated health policy approach. However, having a holistic and comprehensive program enabling an integrated approach is not sufficient. Inuuneritta II's integrated approach does not harmonise with the government's inflexible organisational structure resulting in insufficient implementation.

Diagnostic Utility of Cord Blood Thyroid Stimulating Hormone in Congenital Hypothyroidism in the Era of Expanded Newborn Screening.

Even in the era of expanded newborn screening, utility of cord blood thyroid stimulating hormone (cTSH) for diagnosis of congenital hypothyroidism (CH) cannot be marginalised. This study was to assess the diagnostic utility of cTSH > 20 µIU/L for screening CH. Generation of new cTSH value was the main outcome measure, to increase specificity. Designed as a cross-sectional analytic study in the neonatal unit of teaching hospital, 1200 term neonates with birth weight ≥2500 g, with no perinatal complications were included. Newborn cTSH assay was done by chemi-luminescence. All screen positive were followed up on day five, 14 and 28 of life, to rule in or out CH (true or false positive). Positive predictive value and specificity were calculated. Receiver operating characteristic (ROC) was done to assess diagnostic accuracy of cTSH > 20 µIU/L and to ascertain new cut-off to reduce false positivity. Of 1200 newborns screened, 69 (5.8%) were screen positive and followed up. In five, CH was confirmed (true positive); one in 240 newborns required thyroxine therapy. False positivity was noted in 59. Recall and dropouts were 6.25 and 7.2% respectively. Median cTSH of screen, true and false positives were 28.8, 43.5 and 27.2 µIU/L respectively. Comparison of median values of cord blood (U = 59; p = 0.017) and day five serum TSH (U = 0.0; p < 0.001) among true and false positive subjects were statistically significant. Specificity calculated was 94.6% and positive predictive value 7.25%. ROC generated new permissible cTSH cut-off value of 30 µIU/L. In conclusion, an extended cTSH cut-off value of 30 µIU/L improves specificity.

Indicadores de desempenho e redes sociais: existe algo em comum? / Performance indicators and social networks: is there something in common?

Resumo Introdução Este artigo objetiva identificar a relação entre o desempenho de um Programa de Controle da Hanseníase (PCH) e a sua relação com a rede social, em um município brasileiro. Método Foram realizadas coleta de dados secundários, visitas para observação e entrevistas com o coordenador local do programa (PCH), o secretário de saúde, outros dois coordenadores e com profissionais por estes citados, seguindo a técnica de gerador de nomes. Dezesseis entrevistas originaram a elaboração de seis redes individuais e três coletivas, configurando três momentos: (I) identificação do problema, (II) demonstração do problema e (III) tentativa de reestruturação. Resultados Observou-se uma centralidade de cliques, em que o coordenador do PCH e o da Vigilância Epidemiológica compartilhavam funções no PCH, com fortes laços pessoais. As demais ligações identificadas foram caracterizadas como fortes ou frágeis, e profissionais. Conclusão Foi identificada relação entre o desempenho do PCH (indicadores) e os diferentes tempos das redes sociais, o que acabou por influenciar no funcionamento deste.

Abstract: Introduction The aim of this study is to identify the relation between the performance of a Leprosy Control Program (LCP) and the social network, in a municipality of the brazilian north/northeast region. Method The social network analysis methodology was used. The criteria for choosing the municipality were defined based on low performance of its LCP. The researchers visited the municipality to conduct observations, interviews and secondary data collection. The interviews began with the local coordinator of the program (LCP), the health secretary and two other coordinators. Further interviews were performed with the professionals cited by the "key-informants", resulted by the use of the name generator technique. Sixteen interviews were conducted with professionals that work directly with the LCP, and it allowed the elaboration of six personal networks and three collective networks. From these, the scenario of the program in three stages were drew up, based on the social network structures: (I) problem identification, (II) statement of problem, and (III) restructuring. Results It was found a "double-centrality", what means that the general coordinator of the LCP and general coordinator of Epidemiologic Surveillance shared functions in the program, with very strong personal ties. Other relations were characterized as strong or weak and professional. Conclusion It was identified a relation between the LCP performance and the different times of the social networks, which influenced the functionality of this.

Frameworks for Preventing, Detecting, and Controlling Zoonotic Diseases.

Preventing zoonotic diseases requires coordinated actions by government authorities responsible for human and animal health. Constructing the frameworks needed to foster intersectoral collaboration can be approached in many ways. We highlight 3 examples of approaches to implement zoonotic disease prevention and control programs. The first, rabies control in Ethiopia, was implemented using an umbrella approach: a comprehensive program designed for accelerated impact. The second, a monkeypox program in Democratic Republic of the Congo, was implemented in a stepwise manner, whereby incremental improvements and activities were incorporated into the program. The third approach, a pathogen discovery program, applied in the country of Georgia, was designed to characterize and understand the ecology, epidemiology, and pathogenesis of a new zoonotic pathogen. No one approach is superior, but various factors should be taken into account during design, planning, and implementation.