Future Public Health Threats Research Articles

Interspecies Jumping of Bat Coronaviruses.

In the last two decades, several coronavirus (CoV) interspecies jumping events have occurred between bats and other animals/humans, leading to major epidemics/pandemics and high fatalities. The SARS epidemic in 2002/2003 had a ~10% fatality. The discovery of SARS-related CoVs in horseshoe bats and civets and genomic studies have confirmed bat-to-civet-to-human transmission. The MERS epidemic that emerged in 2012 had a ~35% mortality, with dromedaries as the reservoir. Although CoVs with the same genome organization (e.g., Tylonycteris BatCoV HKU4 and Pipistrellus BatCoV HKU5) were also detected in bats, there is still a phylogenetic gap between these bat CoVs and MERS-CoV. In 2016, 10 years after the discovery of Rhinolophus BatCoV HKU2 in Chinese horseshoe bats, fatal swine disease outbreaks caused by this virus were reported in southern China. In late 2019, an outbreak of pneumonia emerged in Wuhan, China, and rapidly spread globally, leading to >4,000,000 fatalities so far. Although the genome of SARS-CoV-2 is highly similar to that of SARS-CoV, patient zero and the original source of the pandemic are still unknown. To protect humans from future public health threats, measures should be taken to monitor and reduce the chance of interspecies jumping events, either occurring naturally or through recombineering experiments.

Digital Health and the Climate Change: Introductory key concepts and Research Topics

Starting with telemedicine movement 50 years ago, digital health has been changing slowly the healthcare paradigm since. Now with COVID-19 Epidemics has raise the bar and pushed for digital health across the healthcare services. Likewise, public Health should be more engaged on studying future impacts of climate change on health care and look for the opportunities that digital health can bring. At the same time, European Public Health should propose new models for healthy living in the line with sustainable circular economy. Digital health is about health service delivery but it is much more about patients' behaviour and participation in the healthcare process. Digitalization is enabling a change in the role of patients in the healthcare value chain, moreover considering the new European strategy of Health Data Space combined with the European Green Deal. We will present a set of European and American case studies already showing the positive impact of digital health in mitigating climate crises factors, by reducing transportation and materials costs and improving health professionals efficiency, among others. An overview of the recent trends will be discussed and links to public health will be addressed. A special attention will be drawn to a digital public health framework to tackle the climate change future's public health threats.

9.K. Workshop: “Coopera(c)tion” at points of entry – Joint COVID-19 efforts and lessons from the JA Healthy Gateways

Although numerous efforts in the past have been supporting and enhancing infectious disease preparedness and response at points of entry and in the transport sector, COVID-19 has provided unprecedented challenges. The sectors were forced to constantly adjust to new epidemiological situations and required measures. Cooperation ánd action has been required amidst a complex set of actors from within and outside public health. The EU Healthy Gateways Joint Action has been founded to improve and support technical experience and cooperation in the transport sector and at points of entry in Europe. COVID-19 did no longer allow gradual improvement through meetings, training and exercises, but only allowed improvising and learning on the job. This pandemic also coincides with the final year of this EU Healthy Gateways (2018 - 2021). The consortium and many partners has spent 2021 so far by combining its predefined and pre-pandemic tasks while supporting in the ‘emergency mode' the European workforce in the ongoing pandemic. Ending the JA halfway a pandemic demands critical reflection made public. In this workshop, we share the diversity of challenges, and reducing these to urgent recommendations for cooperation at and among European points of entry of the near future. In four presentations, we present cooperation alongside coordinated action during COVID-19 at point-of-entry and at European level, sharing several contributions from science and practice. The first presentation will be the experience from the Netherlands with their in-action review (IAR) focused on the response at ports and airports. IAR have flourished this year although organizing one can be challenging amidst response efforts. Is an IAR for points of entry worth the drill? Second, international communication has been secured and tested during the development of a guideline for international communication and a related European table-top exercise that took place in March last year. Have our international communication lines been up to date? European cooperation is essential during international contact tracing. In our third presentation, the development, testing and implementation of the digital passenger locator forms (PLF) for air- maritime- and land-travel will be shown. Is a digital PLF system ready to unite all European countries into one system? The last presentation will provide lessons of organizing and coordinating, and sustaining the products and results for points of entry following from this Joint Action. This presentation will end in a brainstorming session with the panelists and the audience on what a next joint action would look like. Have European cooperation and collaborative action been feasible in transport industries, at and among points of entry? What are the urgent lessons for the near future?Key messages The ongoing COVID-19 pandemic has demonstrated the importance in strengthening cooperation and coordinated action of MS to improve their preparedness and response capacities at points of entry.The COVID-19 pandemic emphasizes the need for the availability of a cross-European network to transfer lessons learned for an enhanced preparedness and response to future public health threats.

What is next? Vision statement and reflections for sustaining project outcomes in a possibly post-pandemic era

IntroductionThe ongoing COVID-19 pandemic has demonstrated the importance in strengthening cooperation and coordinated action of Member States (MS) to improve preparedness and response capacities at points of entry (PoE). This emphasizes the need for perpetuating the work of EU HEALTHY GATEWAYS (EU HG) and the availability of this cross-European network to transfer lessons learned for future public health threats.MethodsAn interdisciplinary sustainability working group identified options for continuity of activities at EU level and provided a template national sustainability plan to be adapted by MS based on national needs and priorities.ResultsSince the beginning of the pandemic EU HG provided 37 consultations to MS, developed 15 advice documents, delivered training courses, produced a study on preparedness and response at PoE and developed the EU digital Passenger Locator Form (EUdPLF) system. A European web-based network for PoE was developed including discussion forums, e-learning platform, searchable network of professionals' at PoE registry, bibliographies, web-based training resources and best practice catalogues. Overall, the 533 inspectors in the EU SHIPSAN INFORMATION SYSTEM (EU SIS) recorded 29268 IHR (International Health Regulations) certificates, followed up 69 public health events via the communication network for EU ports, and recorded >4600 hygienic deficiencies.ConclusionsEU HG has a holistic approach, supporting operations on local, regional, national and European level and by taking into account all transport sectors. The web-based systems and capacity building activities support EU Decision 1082/2013/EU for serious cross-border health threats and the EUdPLF supports implementing Decision (EU) 2017/253 for the contact tracing of passengers identified through PLFs. Adoption of components of EU SIS will support implementation of Regulation (EU) 2019/1239 which includes the provision of a common ship sanitation database.

Local Public Health System Capacity and Its Relationship to COVID‐19 Mortality Patterns across the U.S

Research ObjectiveAs of January 5, 2020, the United States confirmed over 20 million cases of COVID‐19 resulting in at least 353,730 deaths. The public health response to COVID‐19 in the U.S. is trailing many countries and the bulk of the response burden is left to state and local public health systems. Studies comparing public health systems across the U.S. reveal gaps in the capacity and capabilities of public health systems at the state and local level. These gaps can lead to further disparities in public health access, policy enactment, emergency preparedness and preventable outcomes. Our study explores the potential associations between local public health system capacity and COVID‐19 death rates.Study DesignPublic health system capacity was assessed using a public health system composite measure developed from the National Longitudinal Survey of Public Health Systems (NALSYS). This measure combines information about the extent to which a set of 20 guideline‐recommended public health activities are implemented in the community (i.e., conducting needs assessments for the community's health status, investigating adverse health events, etc.) and information about the network of community organizations that contribute to implementing these activities. Combining this information into a composite measure resulted in three distinct classifications of local public health system capacity: Comprehensive, Conventional and Limited. Comprehensive systems deliver the most public health activities and have the largest network of community partners, while limited systems deliver the fewest public health activities and have the smallest network of community partners. Two‐part generalized linear models (GLM) were used to estimate the relationship between this system composite measure and COVID‐19 death rates while controlling for a range of population and community characteristics associated with COVID‐19 risks, distinguishing counties with and without at least one COVID‐19 death. Falsification tests and several model‐specification checks where performed to further verify the association between the system composite measure and COVID‐19 death rates.Population StudiedThe 2018 wave of the NALSYS includes a stratified national sample of 725 local governmental public health agencies.Principal FindingsUsing mortality data between April and July 2020, counties served by comprehensive public health systems had 11.9 fewer COVID‐19 deaths per 100,000 residents than counties with conventional systems (z‐statistic = 3.13; p‐value = 0.002), and 9.94 fewer COVID‐19 deaths per 100,000 residents than counties with limited systems (z‐statistic = 3.69; p‐value <0.001) after controlling for other model covariates. These results remained consistent and significant when mortality data were included from later in the pandemic through January 2021.ConclusionsCommunities with stronger local public health systems, as measured by scope of activity and network density, experienced significantly fewer deaths attributable to COVID‐19.Implications for Policy or PracticeEfforts to contain the adverse health consequences associated with COVID‐19 and future public health threats should include initiatives to strengthen local public health system capacity, such as through increased funding, training and network coordination.Primary Funding SourceThe Robert Wood Johnson Foundation.

Deployment of Infectious Disease Experts and Prevalence of Antimicrobial Resistance in Okayama: A Call for Training of Specialists.

ObjectiveDuring the ongoing global pandemic of novel coronavirus disease 2019 (COVID-19), an emerging infectious disease, the implementation and execution of infection prevention and control (IPC) is of paramount importance. In this study, we aimed to assess the current deployment of infection control medical personnel in Okayama prefecture, who are supposed to play an essential role to prevent the outbreak of infectious diseases, and the current prevalence of antimicrobial-resistant (AMR) bacteria isolated in Okayama.Materials and methodsThis was a descriptive study using publicly available data. The numbers of infectious disease (ID)-doctors and the certified nurses in infection control (CNIC) per 100,000 population in 47 prefectures in Japan were calculated. We then compared the detected proportions of AMR pathogens among the prefectures in 2019 to be employed as a comparative parameter, which was obtained from Japan Nosocomial Infections Surveillance (JANIS) data.ResultsThe number of ID-doctors was the 11th highest in Japan; however, they were unevenly distributed in southern Okayama, particularly at three tertiary hospitals. While the deployment of CNIC was geographically less uneven in the prefecture, their number was lower than the domestic average. According to the JANIS data, isolation rates of AMR pathogens were high in Okayama compared to other prefectures in Japan: vancomycin-resistant Enterococcus faecium (the third-worst); cefotaxime-resistant Escherichia coli and Klebsiella pneumoniae (the third-worst and the second-worst, respectively); and meropenem-resistant Pseudomonas aeruginosa (the worst).ConclusionsOur assessment provides underlying data and reinforces the need for educating multi-professional experts in the field of infectious diseases to prevent future public health threats in Okayama.

Reopening Oral Health Services during the COVID-19 Pandemic through a Knowledge Exchange Coalition.

Background:The COVID-19 novel coronavirus closed oral health care in Nova Scotia (NS) Canada in March 2020. Preparing for a phased reopening, a knowledge exchange coalition (representing government, academia, hospitals, oral health professions, and regulators) developed return-to-work (RTW) guidelines detailing the augmentation of standard practices to ensure safety for patients, oral health care providers (OHPs), and the community. Using online surveys, this study explored the influence of the RTW guidelines and related education on registered NS OHPs during a phased return to work.Methods:Dissemination of R2W guidelines included website or email communiques and interdisciplinary education webinars that coincided with 2 RTW phases approved by the government. Aligned with each phase, all registered dentists, dental hygienists, and dental assistants were invited to complete an online survey to gauge the influence of the coalition-sponsored education and RTW guidelines, confidence, preparedness, and personal protective equipment use before and after the pandemic.Results:Three coalition-sponsored multidisciplinary webinars hosted 3541 attendees prior to RTW. The response to survey 1 was 41% (881/2156) and to survey 2 was 26% (571/2177) of registrants. Survey 1 (82%) and survey 2 (89%) respondents “agreed/strongly agreed” that R2W guidelines were a primary source for guiding return to practice, and most were confident with education received and had the skills needed to effectively treat patients during the COVID-19 pandemic. Confidence and preparedness improved in survey 2. Gowns/lab coat use for aerosol-generating procedures increased from 26% to 93%, and the use of full face shields rose from 6% to 93% during the pandemic.Conclusions:A multistakeholder coalition was effective in establishing and communicating comprehensive guidelines and web-based education to ensure unified reintegration of oral health services in NS during a pandemic. This multiorganizational cooperation lay the foundation for responses to subsequent waves of COVID-19 and may serve as an example for collaboratively responding to future public health threats in other settings.Knowledge Transfer Statement:The return-to-work strategy that was developed, disseminated, and assessed through this COVID-19 knowledge exchange coalition will benefit oral health practitioners, professional regulators, government policy makers, and researchers in future pandemic planning.

Association of Human Mobility Restrictions and Race/Ethnicity–Based, Sex-Based, and Income-Based Factors With Inequities in Well-being During the COVID-19 Pandemic in the United States

An accurate understanding of the distributional implications of public health policies is critical for ensuring equitable responses to the COVID-19 pandemic and future public health threats. To identify and quantify the association of race/ethnicity-based, sex-based, and income-based inequities of state-specific lockdowns with 6 well-being dimensions in the United States. This pooled, repeated cross-sectional study used data from 14 187 762 households who participated in phase 1 of the population-representative US 2020 Household Pulse Survey (HPS). Households were invited to participate by email, text message, and/or telephone as many as 3 times. Data were collected via an online questionnaire from April 23 to July 21, 2020, and participants lived in all 50 US states and the District of Columbia. Indicators of race/ethnicity, sex, and income and their intersections. Unemployment; food insufficiency; mental health problems; no medical care received for health problems; default on last month's rent or mortgage; and class cancellations with no distance learning. Race/ethnicity, sex, income, and their intersections were used to measure distributional implications across historically marginalized populations; state-specific, time-varying population mobility was used to measure lockdown intensity. Logistic regression models with pooled repeated cross-sections were used to estimate risk of dichotomous outcomes by social group, adjusted for confounding variables. The 1 088 314 respondents (561 570 [51.6%; 95% CI, 51.4%-51.9%] women) were aged 18 to 88 years (mean [SD], 51.55 [15.74] years), and 826 039 (62.8%; 95% CI, 62.5%-63.1%) were non-Hispanic White individuals; 86 958 (12.5%; 95% CI, 12.4%-12.7%), African American individuals; 86 062 (15.2%; 95% CI, 15.0%-15.4%), Hispanic individuals; and 50 227 (5.6%; 95% CI, 5.5%-5.7%), Asian individuals. On average, every 10% reduction in mobility was associated with higher odds of unemployment (odds ratio [OR], 1.3; 95% CI, 1.2-1.4), food insufficiency (OR, 1.1; 95% CI, 1.1-1.2), mental health problems (OR, 1.04; 95% CI, 1.0-1.1), and class cancellations (OR, 1.1; 95% CI, 1.1-1.2). Across most dimensions compared with White men with high income, African American individuals with low income experienced the highest risks (eg, food insufficiency, men: OR, 3.3; 95% CI, 2.8-3.7; mental health problems, women: OR, 1.9; 95% CI, 1.8-2.1; medical care inaccessibility, women: OR, 1.7; 95% CI, 1.6-1.9; unemployment, men: OR, 2.8; 95% CI, 2.5-3.2; rent/mortgage defaults, men: OR, 5.7; 95% CI, 4.7-7.1). Other high-risk groups were Hispanic individuals (eg, unemployment, Hispanic men with low income: OR, 2.9; 95% CI, 2.5-3.4) and women with low income across all races/ethnicities (eg, medical care inaccessibility, non-Hispanic White women: OR, 1.8; 95% CI, 1.7-2.0). In this cross-sectional study, African American and Hispanic individuals, women, and households with low income had higher odds of experiencing adverse outcomes associated with the COVID-19 pandemic and stay-at-home orders. Blanket public health policies ignoring existing distributions of risk to well-being may be associated with increased race/ethnicity-based, sex-based, and income-based inequities.

From denial to hope: Brazil deals with a prolonged COVID-19 epidemic course.

Brazil must strengthen science-based education to improve human development and responses to future public health threats.

#Ebola: Emergency Risk Messages on Social Media.

Public health threats require effective communication. Evaluating effectiveness during a situation that requires emergency risk communication is difficult, however, because these events require an immediate response and collecting data may be secondary to more immediate needs. In this article, we draw on research analyzing the effectiveness of social media messages during times of imminent threat and research analyzing the emergency risk communication conceptual model in order to propose a method for evaluating emergency risk communication on social media. We demonstrate this method by evaluating 2,915 messages sent by local, state, and federal public health officials during the 2014 Ebola outbreak in the United States. The results provide empirical support for emergency risk communication and identify message strategies that have the potential to increase exposure to official communication on social media during future public health threats.

Learning health systems, embedded research, and data standards-recommendations for healthcare system leaders.

Learning health systems that conduct embedded research require infrastructure for the seamless adoption of clinical interventions; this infrastructure should integrate with electronic health record (EHR) systems and enable the use of existing data. As purchasers of EHR systems, and as critical partners, sponsors, and consumers of embedded research, healthcare organizations should advocate for EHR system functionality and data standards that will increase the capacity for embedded research in clinical settings. As stakeholders and proponents for EHR data standards, healthcare leaders should support standards development and promote local adoption to support quality healthcare, continuous improvement, innovative data-driven interventions, and the generation of new knowledge. “Standards-enabled” health systems will be positioned to address emergent and critical research questions, including those related to coronavirus disease 2019 (COVID-19) and future public health threats. The role of a data standards officer or champion could enable health systems to realize this goal.

Transport policymaking that accounts for COVID-19 and future public health threats: A PASS approach

The novel coronavirus 2019 (COVID-19) outbreak has had wide-reaching and unprecedented impacts on the transport sector worldwide. At present, there is no globally agreed timeframe for when this pandemic will end. The current and near-future potential impacts must be addressed in a relatively comprehensive and seamless way. The present study proposed a PASS (P: Prepare–Protect–Provide; A: Avoid–Adjust; S: Shift–Share; S: Substitute–Stop) approach for policymaking that accounts for COVID-19 and future public health threats. The PASS approach was illustrated conceptually, and then policy measures were recommended by referring to the past and ongoing best practices. Policymaking challenges and research issues were discussed.

Envisioning the Post-COVID-19, Pre-Vaccine Emergency Department.

Envisioning the Post-COVID-19, Pre-Vaccine Emergency Department.

Concern and Attitudes Toward Zika Virus in Jarabacoa, Dominican Republic: A Cross-Sectional Study

BACKGROUND &amp;amp; OBJECTIVES: The Zika virus, a member of the flavivirus genus, is an emerging threat to many tropical regions of the world. This study was designed to assess the level of knowledge, attitudes and concern in regards to the Zika virus in the community of Jarabacoa, Dominican Republic, with the hopes of guiding future efforts toward public education and prevention of future public health threats. &#x0D; &#x0D; METHODS: A cross-sectional survey was conducted in the rural communities of Jarabacoa during October 2016 and October 2017. Individuals completed a 14-point survey evaluating: level of concern towards Zika (1=no concern, 3=neutral, 5=extremely concerned), knowledge level of the disease, use of personal protection against the virus, how people initially heard about the disease and contraception use. &#x0D; &#x0D; RESULTS: Overall, women were more concerned than men about contracting the virus (p&amp;lt;.001, CI -2.510, -0.826). Of the respondents (N=138), 66% learned about Zika from the TV/news and 24.6% from their medical provider. 5% knew Zika was contracted from blood and 2% from pregnancy, and only 17% of respondents knew that it was contracted through sex. For protection from Zika, only 8% used condoms. Of the women trying to get pregnant, none knew Zika could be transmitted through sex. &#x0D; &#x0D; CONCLUSION: This study revealed that women were more concerned about the Zika virus than men and that knowledge about the virus was limited. In general, people are protecting themselves against vector borne transmission but not non-vector borne modes of transmission such as sexual intercourse. Also, public health education is lacking. Further studies are needed with more male participants, focus on contraception and social media&amp;rsquo;s effect on public health education.

EUPHA member survey on future public health threats

EUPHA member survey on future public health threats

EUPHA member survey on future public health threats

EUPHA member survey on future public health threats

Lessons from Ebola: Sources of Outbreak Information and the Associated Impact on UC Irvine and Ohio University College Students

Objectives. We examined the role of outbreak information sources through four domains: knowledge, attitudes, beliefs, and stigma related to the 2014 Ebola virus disease (EVD) outbreak. Methods. We conducted an online survey of 797 undergraduates at the University of California, Irvine (UCI) and Ohio University (OU) during the peak of the outbreak. We calculated individual scores for domains and analyzed associations to demographic variables and news sources. Results. Knowledge of EVD was low and misinformation was prevalent. News media (34%) and social media (19%) were the most used sources of EVD information while official government websites (OGW) were among the least used (11%). Students who acquired information through OGW had higher knowledge, more positive attitudes towards those infected, a higher belief in the government, and were less likely to stigmatize Ebola victims. Conclusions. Information sources are likely to influence students’ knowledge, attitudes, beliefs, and stigma relating to EVD. This study contains crucial insight for those tasked with risk communication to college students. Emphasis should be given to developing effective strategies to achieve a comprehensive knowledge of EVD and future public health threats.

The making of public health emergencies: West Nile virus in New York City

In this article we use the case of the West Nile virus (WNV) to investigate the social construction of public health emergencies (PHEs) and the subsequent changes in public health governance that they instigate. Informed by medical sociological literature on the social construction of illness, science and technology studies, and risk and disaster literature, we create a conceptual framework for connecting health and crisis. Our investigation of the WNV analyses PHEs as brief, but vitally important, moments in which a 'crisis' is co-constructed between states, affected populations and disease vectors. In these moments of crisis new interventions are enacted, which have long-term effects for institutional structures and disease management. Using extensive qualitative data collection, we conceptualise two mechanisms that underlie the declaration of PHEs and the expansion of related 'emergencies' across space and time: (i) crisis interventions that have the potential to marginalise the interaction of citizens with state institutions and (ii) institutional rearrangement of state agencies stemming from the original crisis issue, resulting in altered networks and institutional practices and drawing heavily upon the crisis as a symbol of similar, future public health threats.

Chronicle of a Pandemic Foretold: Lessons from the 2009 Influenza Epidemic

The A(H1N1) influenza epidemic provided the first indication of the effectiveness of the pandemic preparations that countries and international organizations initiated in the wake of the 2003 SARS epidemic. In the case of SARS, China was criticized for not reporting the outbreak quickly enough. This led to new reporting requirements under WHO regulations. In the case of the 2009 influenza epidemic, Mexico and the United States complied with their obligations to report outbreaks to the WHO as soon as they detected a problem. Nevertheless, this reporting was delayed due to the timing of the outbreak, which coincided with regular influenza season. The WHO declared a public health emergency of international concern within 48 hours of laboratory confirmation that the Mexican and US viruses were a new strain. While the WHO issued recommendations against trade and travel restrictions, a significant number of countries chose to ignore those recommendations. What was most worrying was the decision of many countries to apply more severe restrictions against Mexico than against the United States. The initial lack of access to accurate testing equipment severely hampered Mexico’s ability to confirm quickly the cause of deaths and illness. Moreover, Mexico kept the world informed of every development in the epidemic with honesty and transparency, in accordance with WHO guidelines and regulations. This led to the perception that Mexico’s epidemic was far worse than the US epidemic. While Mexico initially reported suspected cases on a daily basis, the United States limited its release of information to confirmed cases. This reinforced the perception that Mexico was much more seriously affected and the likely point of origin. Once Mexico had the capacity to test samples, it limited its release of information to confirmed cases, as the United States had done from the beginning. The response of many countries to Mexico’s open and transparent reporting in this case may undermine WHO reporting requirements and encourage countries to be less open regarding future public health threats of international concern. Thus, the response of some countries to Mexico’s exemplary handling of this situation may increase the health risks to all people in future pandemics.

After the cure: managing AIDS and other public health crises

As alarming stories about new pathogens like Ebola virus or Mad Cow Disease fill today's headlines, scientists face a test of their abilities to contain them. But public health officials face a crisis of their own, because even when effective treatments become available, efforts to control disease often fall short. After Cure was written to improve prospects for effective management of AIDS and other public health crises. Martin Levin and Mary Bryna Sanger draw on cases of previous large-scale public health initiatives to show how management effectiveness can meet threats to public health. Focusing on AIDS as most compelling contemporary example of need for change, authors advocate a commonsense approach that seeks to minimize chances of failure. They encourage health officials to exercise strategic skepticism by developing plans that anticipate potential problems-such as scientific controversy over a vaccine's effectiveness or media sensationalism-which could arise from flaws in program design and implementation. Case studies involving polio, swine flu, childhood immunization, reemergent TB, and early AIDS experiences demonstrate variety of managerial problems that can confront such initiatives. By reviewing lessons of these cases, authors suggest how their approach can be applied to management of AIDS and future public health threats. They then present both a critique of early mismanagement of AIDS crisis and a scenario for the day after an AIDS vaccine is discovered. Because epidemics are likely to increase, After Cure clearly demonstrates importance of anticipating obstacles to their management through skillful scenario writing. Combining careful analysis with practical advice, it shows that in public health arena, management matters as much as medicine.