This scenario presents a professional challenge due to the inherent complexities of translating novel pain management strategies from research settings into widespread clinical practice. Pharmacists must navigate the ethical imperative to adopt evidence-based innovations while ensuring patient safety, regulatory compliance, and equitable access to care. The integration of translational research, registries, and innovation requires a systematic and evidence-driven approach, balancing the potential benefits of new treatments with the need for rigorous validation and monitoring. The best approach involves actively engaging with and contributing to the established infrastructure for translational research and patient registries. This means pharmacists should seek out and critically appraise findings from peer-reviewed translational studies, participate in the development and maintenance of patient registries to track outcomes of novel pain management interventions, and collaborate with researchers and other healthcare professionals to identify and implement evidence-based innovations. This proactive engagement ensures that practice changes are informed by robust data, adhere to regulatory requirements for new treatments, and contribute to the ongoing refinement of pain management strategies. Ethical justification lies in the principle of beneficence, by seeking to provide the best possible care based on the strongest available evidence, and non-maleficence, by avoiding premature adoption of unproven or potentially harmful interventions. Regulatory compliance is met by ensuring that any new treatments or protocols are aligned with existing guidelines and approval processes for pharmaceuticals and medical devices. An incorrect approach would be to adopt a novel pain management therapy solely based on anecdotal evidence or marketing claims without independent critical appraisal of translational research or registry data. This fails to uphold the ethical duty to provide evidence-based care and could lead to patient harm if the therapy proves ineffective or unsafe. It also bypasses regulatory scrutiny designed to protect patients. Another incorrect approach is to ignore emerging translational research and registry findings, thereby stagnating practice and failing to offer patients the most effective and innovative treatments available. This contravenes the principle of continuous professional development and the ethical obligation to advance patient well-being through the adoption of validated innovations. Finally, implementing a novel therapy without establishing mechanisms for data collection and outcome monitoring, such as contributing to or utilizing patient registries, represents a failure to engage in the iterative process of translational research. This hinders the ability to assess the real-world effectiveness and safety of the innovation, potentially leading to suboptimal patient care and a lack of contribution to the broader scientific understanding of the intervention. Professionals should employ a decision-making framework that prioritizes evidence appraisal, regulatory awareness, and collaborative engagement. This involves: 1) identifying potential innovations through literature review and professional networks; 2) critically evaluating the quality and relevance of translational research and registry data supporting the innovation; 3) assessing the regulatory status and approval of the intervention; 4) considering the ethical implications for patient populations, including access and equity; and 5) developing a plan for implementation that includes robust monitoring and data collection, ideally contributing to or leveraging existing registries.

Scenario Analysis: This scenario presents a professional challenge due to the complex interplay between a patient’s genetic predisposition, the pharmacokinetic profile of a novel analgesic, and the potential for drug-drug interactions with a commonly prescribed medication. The pharmacist must integrate knowledge from clinical pharmacology, pharmacokinetics, and medicinal chemistry to ensure safe and effective pain management while adhering to professional standards and patient-centered care principles. The novelty of the analgesic adds a layer of complexity, requiring careful consideration of limited clinical data and potential off-label use implications. Correct Approach Analysis: The best professional practice involves a comprehensive review of the patient’s complete medication profile, including over-the-counter and herbal supplements, alongside their genetic information and the specific pharmacokinetic and pharmacodynamic properties of the new analgesic. This approach necessitates consulting up-to-date drug information resources, relevant clinical guidelines, and potentially engaging with the prescribing physician to discuss the rationale for the new therapy in light of the patient’s unique profile. This ensures that potential interactions are identified, appropriate dosing adjustments are considered, and the patient receives the most effective and safest pain management strategy, aligning with the ethical obligation to provide competent and evidence-based care. Incorrect Approaches Analysis: One incorrect approach would be to solely rely on the prescribing physician’s order without independent verification or consideration of the patient’s genetic data and the novel analgesic’s properties. This fails to uphold the pharmacist’s professional responsibility to act as a medication expert and a patient advocate, potentially overlooking critical safety concerns or suboptimal therapeutic outcomes. Another incorrect approach would be to focus only on the pharmacokinetic profile of the new analgesic without considering its medicinal chemistry interactions with the patient’s existing medications. This narrow focus ignores the potential for altered drug metabolism or receptor binding, which could lead to reduced efficacy or increased toxicity. A further incorrect approach would be to dismiss the patient’s genetic information as irrelevant to pain management with this specific analgesic, assuming standard dosing guidelines are universally applicable. This overlooks the growing body of evidence demonstrating the impact of pharmacogenomics on drug response and safety, failing to personalize therapy effectively. Professional Reasoning: Professionals should employ a systematic decision-making framework that begins with a thorough patient assessment, including their medical history, current medications, allergies, and relevant genetic information. This is followed by an in-depth evaluation of the proposed pharmacotherapy, considering its clinical pharmacology, pharmacokinetics, and medicinal chemistry. The next step involves identifying potential risks and benefits, consulting reliable drug information resources and clinical guidelines, and collaborating with the healthcare team. Finally, a personalized treatment plan is developed and communicated to the patient, with ongoing monitoring and evaluation.

Scenario Analysis: This scenario presents a professional challenge due to the inherent risks associated with compounding sterile products, particularly when a critical quality control parameter, such as the sterility testing result, is borderline or unexpected. The pharmacist must balance the urgency of patient need with the absolute imperative of patient safety and product integrity. Failure to adequately investigate a questionable sterility result could lead to the administration of a non-sterile product, posing a significant risk of infection to vulnerable patients. Correct Approach Analysis: The best professional practice involves a thorough, documented investigation of the sterility testing result before releasing the product. This approach prioritizes patient safety by ensuring that any deviation from expected quality is identified and addressed. The pharmacist should immediately halt the release of the affected batch and initiate a root cause analysis. This investigation would typically involve reviewing the compounding process, environmental monitoring data, raw material quality, personnel training, and the sterility testing methodology itself. If the investigation reveals a potential compromise in sterility, the batch must be quarantined and potentially destroyed. This aligns with fundamental principles of pharmaceutical quality control and regulatory expectations for sterile product manufacturing, emphasizing a proactive and investigative stance to ensure product safety and efficacy. Incorrect Approaches Analysis: Releasing the product based on a single, borderline positive result without further investigation is professionally unacceptable. This approach disregards the potential for a false positive or, more critically, a true positive indicating a breach in sterility. It prioritizes expediency over patient safety and violates the core tenets of sterile compounding quality control, which demand rigorous verification of sterility. Another unacceptable approach is to immediately discard the entire batch without a proper investigation. While caution is warranted, a complete lack of investigation means potential systemic issues within the compounding process or testing methodology may go unidentified and uncorrected, leading to future compromised batches. This is an overly reactive and inefficient use of resources and fails to learn from potential process deviations. Finally, relying solely on the manufacturer’s certificate of analysis for the raw materials without considering the compounding process itself is insufficient. While raw material quality is crucial, sterility can be compromised at multiple points during the compounding of sterile products, including environmental contamination, personnel technique, and equipment sterilization. A comprehensive quality control system must encompass all stages of the process. Professional Reasoning: Professionals should employ a systematic decision-making framework when encountering unexpected quality control results. This framework should include: 1) Immediate identification and containment of the questionable product. 2) Initiation of a documented investigation to determine the root cause. 3) Consultation with relevant quality assurance personnel and adherence to established Standard Operating Procedures (SOPs). 4) Decision-making based on the investigation’s findings, prioritizing patient safety above all else. 5) Thorough documentation of all steps taken and decisions made.

Scenario Analysis: This scenario presents a professional challenge related to ensuring patient safety and adherence to regulatory standards in the context of pain management. The core difficulty lies in determining the appropriate level of verification for a pharmacist seeking to practice in a specialized area like global pain management, especially when their existing qualifications might not directly align with the specific requirements of such a program. Misinterpreting the purpose and eligibility criteria for a proficiency verification program can lead to either unnecessary barriers for qualified individuals or, more critically, the practice of pain management by individuals who have not demonstrated the required competencies, thereby jeopardizing patient care and violating regulatory mandates. Careful judgment is required to balance access to specialized care with the imperative of patient safety and regulatory compliance. Correct Approach Analysis: The best professional approach involves a thorough review of the pharmacist’s existing credentials and experience against the explicit purpose and eligibility criteria of the Comprehensive Global Pain Management Pharmacy Proficiency Verification program. This means directly consulting the program’s official documentation, which outlines the specific educational background, practical experience, and any prerequisite certifications or licenses required for entry. If the pharmacist’s current qualifications meet these defined criteria, they should be guided to proceed with the application process as outlined by the program. This approach is correct because it adheres strictly to the established regulatory framework and the program’s stated objectives, ensuring that only eligible candidates are considered, thereby upholding the integrity of the verification process and safeguarding patient welfare. Incorrect Approaches Analysis: One incorrect approach is to assume that any pharmacist with a general license to practice pharmacy is automatically eligible for a specialized pain management verification program. This fails to recognize that specialized programs often have distinct and rigorous eligibility requirements designed to ensure a specific level of expertise. This approach risks allowing individuals to enter a verification process for which they are not qualified, potentially leading to wasted resources and a false sense of preparedness. Another incorrect approach is to suggest that the pharmacist should simply enroll in the program without verifying their eligibility beforehand. This bypasses the crucial initial step of assessing whether the pharmacist meets the foundational requirements. Such an approach could lead to the pharmacist investing time and money into a program for which they are ultimately ineligible, causing frustration and potentially delaying their pursuit of specialized practice. It also undermines the structured nature of the verification process. A further incorrect approach is to advise the pharmacist to seek informal endorsements or recommendations from colleagues without consulting the official program guidelines. While professional networks are valuable, they cannot substitute for the formal, documented criteria established by the regulatory body or program administrators. Relying solely on informal opinions could lead to misinterpretations of eligibility and a failure to meet the objective standards set for the verification. Professional Reasoning: Professionals should adopt a systematic decision-making framework when encountering situations involving specialized practice verification. This framework should begin with clearly identifying the specific program and its governing regulations. Next, the professional must locate and meticulously review the official documentation detailing the program’s purpose, objectives, and, most importantly, its eligibility criteria. Any individual seeking to enter the program should then be assessed against these explicit criteria. If the individual meets the requirements, they should be guided through the formal application process. If they do not meet the requirements, the professional should clearly explain the specific deficiencies and, where possible, suggest alternative pathways for professional development that might lead to future eligibility. This methodical approach ensures adherence to regulatory standards, promotes fairness, and prioritizes patient safety.

Scenario Analysis: This scenario is professionally challenging because it requires balancing immediate patient needs with long-term medication safety and regulatory compliance. The pharmacist must navigate potential drug interactions, patient allergies, and the legal implications of dispensing a medication without complete information, all while under pressure to fulfill a prescription. The use of an outdated electronic health record (EHR) system introduces a significant risk of incomplete or inaccurate patient data, directly impacting medication safety and potentially leading to adverse drug events. The pharmacist’s responsibility extends beyond simply dispensing; it involves a proactive role in ensuring the safety and efficacy of the prescribed therapy within the established regulatory framework. Correct Approach Analysis: The best professional practice involves a multi-step approach that prioritizes patient safety and regulatory adherence. This includes verifying the prescription’s legitimacy and completeness, cross-referencing the patient’s known allergies and current medications within the available EHR data, and proactively contacting the prescriber to clarify any ambiguities or potential contraindications before dispensing. This approach directly addresses the potential for drug interactions and ensures that the dispensing decision is based on the most current and accurate information available, aligning with the fundamental principles of patient care and the legal obligations of a pharmacist. Specifically, this aligns with the general principles of pharmaceutical care and the regulatory expectations for pharmacists to exercise professional judgment to prevent harm, as often outlined in pharmacy practice acts and professional guidelines that emphasize the pharmacist’s role as the final check in the medication use process. Incorrect Approaches Analysis: One incorrect approach involves dispensing the medication immediately based on the available EHR data, assuming the prescriber has already accounted for potential interactions. This fails to acknowledge the limitations of the outdated EHR and the pharmacist’s duty to independently verify critical patient information. It bypasses the essential step of proactive communication with the prescriber, which is a cornerstone of medication safety and a regulatory expectation for pharmacists to ensure patient well-being. Another incorrect approach is to refuse to dispense the medication without any attempt to gather further information or contact the prescriber. While caution is warranted, a complete refusal without due diligence can negatively impact patient care by delaying necessary treatment. This approach fails to demonstrate the professional problem-solving expected of a pharmacist, which includes seeking clarification and resolving ambiguities rather than simply halting the process. A third incorrect approach is to dispense the medication with a verbal warning to the patient about potential side effects, without confirming the accuracy of the prescription or the patient’s profile with the prescriber. This shifts the burden of safety onto the patient and does not fulfill the pharmacist’s responsibility to ensure the medication is appropriate and safe for that specific individual, given their complete medical history. This practice is insufficient to meet regulatory standards for due diligence and patient safety. Professional Reasoning: Professionals should employ a systematic decision-making framework when faced with prescription ambiguities or potential safety concerns. This framework should begin with a thorough review of the prescription and available patient data. Next, identify any potential risks, such as drug interactions, allergies, or contraindications. The critical step is to then engage in proactive communication with the prescriber to resolve these identified risks. If clarification cannot be obtained or if significant safety concerns remain unresolved, the professional must then consider alternative actions, such as refusing to dispense while documenting the reasons and informing the patient and prescriber. This iterative process of assessment, identification, communication, and resolution ensures that patient safety and regulatory compliance are maintained.

The audit findings indicate a potential discrepancy in how the Comprehensive Global Pain Management Pharmacy Proficiency Verification exam’s blueprint weighting, scoring, and retake policies are being communicated and applied. This scenario is professionally challenging because it directly impacts the fairness and transparency of the assessment process, potentially affecting the career progression and confidence of pharmacists. Ensuring adherence to established policies is crucial for maintaining the integrity of professional verification. The best approach involves a thorough review of the official examination handbook and the most recent policy updates from the relevant professional body. This handbook serves as the definitive guide for all aspects of the examination, including the detailed breakdown of content areas and their assigned weighting on the exam (blueprint), the methodology for calculating passing scores, and the specific conditions under which a candidate may retake the exam. By consulting these primary sources, the audit team can accurately assess whether current practices align with the established framework. This ensures that the examination process is standardized, equitable, and defensible, upholding the professional standards expected of pharmacists. An incorrect approach would be to rely on anecdotal evidence or informal discussions among candidates or proctors regarding the exam’s weighting or retake rules. This method is unreliable and can lead to misinterpretations of policy. The absence of official documentation means there is no verifiable basis for the information, potentially leading to unfair assessment or the application of outdated rules. Another incorrect approach is to assume that the scoring or retake policies are static and have not been updated. Examination bodies periodically revise their policies to reflect evolving professional standards or to improve the assessment process. Failing to check for the latest revisions means that decisions might be based on obsolete information, which would be a failure to comply with current regulations. Finally, an incorrect approach would be to prioritize candidate convenience or perceived fairness over established policy when addressing retake situations. While empathy is important, the retake policy is designed to ensure a consistent and rigorous standard for all candidates. Deviating from this policy without explicit authorization or a clear, documented rationale based on exceptional circumstances would undermine the integrity of the verification process. Professionals should employ a decision-making framework that begins with identifying the authoritative source of information (the official examination handbook and policy documents). They should then compare current practices against these documented policies, seeking clarification from the issuing body if any ambiguities arise. Finally, any proposed changes or interpretations of policy must be formally documented and approved to maintain transparency and accountability.

Scenario Analysis: This scenario presents a professional challenge due to the inherent complexity of managing chronic pain, the potential for opioid misuse or diversion, and the need to balance patient autonomy with public safety and regulatory compliance. The pharmacist must exercise sound clinical judgment, adhere to strict dispensing regulations, and maintain open communication with the prescriber to ensure appropriate and safe patient care. The risk of dispensing a prescription that is either inappropriate for the patient’s condition or potentially being used for illicit purposes necessitates a robust decision-making framework. Correct Approach Analysis: The best professional practice involves a multi-faceted approach that prioritizes patient safety and regulatory adherence. This includes a thorough review of the prescription for any red flags, such as unusual dosages, quantities, or formulations, and cross-referencing this with the patient’s known medication history and any available prescription drug monitoring program (PDMP) data. If any concerns arise, the pharmacist should engage in direct communication with the prescribing physician to clarify the medical necessity and appropriateness of the prescription. Documenting all interactions and decisions is also crucial. This approach aligns with professional ethical obligations to act in the best interest of the patient while also fulfilling legal responsibilities to prevent drug diversion and misuse, as mandated by pharmacy practice standards and relevant drug control legislation. Incorrect Approaches Analysis: One incorrect approach involves dispensing the prescription without further inquiry, assuming the prescriber has acted appropriately. This fails to meet the pharmacist’s professional responsibility to verify the legitimacy and safety of dispensed medications, potentially leading to patient harm or contributing to the opioid crisis. It disregards the pharmacist’s role as a gatekeeper and overlooks potential red flags that could indicate diversion or inappropriate prescribing. Another incorrect approach is to immediately refuse to fill the prescription without attempting to contact the prescriber. While caution is warranted, an outright refusal without seeking clarification can negatively impact patient care, especially if the prescription is legitimate and the patient is experiencing uncontrolled pain. This approach bypasses a critical step in the decision-making process and can damage the patient-prescriber-pharmacist relationship. A further incorrect approach is to fill the prescription but then anonymously report the prescriber without any direct communication or attempt to resolve concerns. This action, while seemingly protective, is unprofessional as it avoids direct engagement with the prescriber to address potential issues and can be perceived as an abdication of professional responsibility to resolve clinical discrepancies collaboratively. It also bypasses the opportunity to educate the prescriber or patient if a misunderstanding exists. Professional Reasoning: Professionals should employ a structured decision-making framework when faced with potentially problematic prescriptions. This framework typically involves: 1) Initial assessment of the prescription for obvious errors or inconsistencies. 2) Risk identification by considering patient history, PDMP data, and known prescribing patterns. 3) Information gathering through direct communication with the prescriber and, if appropriate, the patient. 4) Decision-making based on the gathered information, weighing patient needs against safety and regulatory requirements. 5) Documentation of the entire process and the final decision. This systematic approach ensures that decisions are informed, ethical, and legally defensible.

This scenario is professionally challenging because it requires balancing a patient’s expressed desire for a specific pain management regimen with the pharmacist’s professional responsibility to ensure the safety and efficacy of that regimen, especially when it deviates from standard practice or involves potentially high-risk medications. The pharmacist must navigate potential conflicts between patient autonomy, clinical judgment, and regulatory obligations to dispense safely. The best approach involves a comprehensive assessment of the patient’s request, including a thorough review of their medical history, current medications, and the rationale behind their proposed regimen. This includes engaging in a detailed discussion with the patient to understand their experiences, expectations, and any previous treatments. Crucially, this approach necessitates consultation with the prescribing physician to clarify the rationale for the proposed therapy, discuss potential risks and benefits, and collaboratively determine the most appropriate course of action. This aligns with the professional duty of care, the principles of patient-centered care, and the regulatory expectation that pharmacists exercise professional judgment in dispensing medications, ensuring they are safe and effective for the individual patient. It upholds the collaborative nature of healthcare and prioritizes patient well-being through evidence-based decision-making. An incorrect approach would be to immediately fulfill the patient’s request without further investigation. This fails to uphold the pharmacist’s professional responsibility to ensure the medication is appropriate and safe for the patient, potentially leading to adverse drug events or suboptimal pain management. It disregards the need for clinical validation and physician collaboration. Another incorrect approach would be to outright refuse the patient’s request based solely on the deviation from standard practice, without engaging in a discussion or seeking clarification from the physician. This undermines patient autonomy and the pharmacist’s role as a healthcare partner, potentially damaging the patient-pharmacist relationship and preventing the patient from receiving appropriate care. Finally, an incorrect approach would be to dispense the medication as requested but provide only minimal counseling, assuming the physician’s prescription is sufficient. This neglects the pharmacist’s duty to proactively identify and address potential issues, such as drug interactions, contraindications, or the need for specific monitoring, which are critical components of safe medication use. The professional reasoning process for similar situations should involve a systematic evaluation: first, understanding the patient’s request and their perspective; second, reviewing all relevant clinical information; third, consulting with the prescriber to ensure alignment and address any concerns; and fourth, making a collaborative, informed decision that prioritizes patient safety and therapeutic outcomes, adhering to all applicable professional standards and regulations.

This scenario is professionally challenging due to the inherent complexity of managing pain across diverse patient populations and disease states, coupled with the critical need to adhere to stringent regulatory frameworks governing pharmaceutical practice. The pharmacist must navigate the nuances of acute, chronic, and rare disease pain management, ensuring patient safety, efficacy of treatment, and compliance with all applicable laws and guidelines. Careful judgment is required to balance therapeutic goals with potential risks and to make informed decisions that prioritize patient well-being within the legal and ethical boundaries. The best professional approach involves a comprehensive assessment of the patient’s condition, including a thorough review of their medical history, current medications, pain characteristics, and any co-existing conditions. This assessment should inform the selection of appropriate pharmacotherapy, considering evidence-based guidelines for pain management in acute, chronic, and rare diseases, while also taking into account the patient’s age, organ function, and potential drug interactions. Furthermore, this approach necessitates ongoing monitoring of treatment efficacy and adverse effects, with a willingness to adjust the therapeutic regimen as needed. This aligns with the fundamental ethical obligation to provide competent and individualized patient care and adheres to regulatory requirements that mandate pharmacists to exercise professional judgment in dispensing and managing medications. An incorrect approach would be to solely rely on the prescriber’s initial order without further patient assessment or consideration of alternative therapeutic options, especially if the prescribed regimen appears suboptimal or carries significant risks. This fails to uphold the pharmacist’s professional responsibility to ensure the appropriateness of medication therapy and could lead to suboptimal patient outcomes or adverse events, potentially violating professional standards of care and regulatory expectations for pharmacist oversight. Another incorrect approach would be to prioritize the most readily available or familiar pain management agents without a thorough evaluation of their suitability for the specific patient and their condition. This overlooks the critical need for individualized therapy and the potential for more effective or safer alternatives, thereby failing to meet the standard of care expected in comprehensive pain management and potentially contravening regulatory guidelines that emphasize patient-centered care. A further incorrect approach would be to defer all decision-making regarding pain management to other healthcare professionals without actively contributing clinical expertise or raising concerns about potential issues. While collaboration is essential, the pharmacist has a distinct role and responsibility in medication therapy management, and abdicating this responsibility undermines the interdisciplinary approach to patient care and the pharmacist’s contribution to patient safety. The professional decision-making process for similar situations should involve a systematic approach: first, thoroughly understand the patient’s clinical presentation and pain profile; second, critically evaluate the proposed pharmacotherapy against established guidelines and patient-specific factors; third, engage in collaborative communication with the prescriber and other healthcare team members to optimize treatment; and fourth, implement a robust monitoring plan to ensure ongoing safety and efficacy.

This scenario presents a professional challenge due to the need to balance public health objectives with individual patient autonomy and the practical limitations of a community pharmacy setting. The pharmacist must act as a gatekeeper for public health initiatives while ensuring equitable access and accurate information delivery. Careful judgment is required to navigate potential misinformation, resource constraints, and diverse patient needs. The best approach involves proactively engaging with public health directives by developing a comprehensive in-pharmacy immunization program that prioritizes accessibility and education. This includes establishing clear protocols for vaccine storage, administration, and record-keeping in compliance with national immunization guidelines and pharmacy board regulations. Furthermore, it necessitates a robust patient education strategy, utilizing pharmacists’ expertise to address community concerns about vaccine safety and efficacy, thereby fostering trust and increasing uptake. This approach aligns with the pharmacist’s role in population health by directly contributing to disease prevention and herd immunity, while adhering to ethical obligations of beneficence and non-maleficence. An incorrect approach would be to solely rely on passively waiting for patients to inquire about immunizations. This fails to meet the public health imperative of proactive disease prevention and misses opportunities to reach underserved populations who may not actively seek out vaccination information. It also neglects the pharmacist’s responsibility to promote health and prevent disease within the community. Another incorrect approach would be to implement an immunization program without adequate staff training or proper cold chain management. This poses a significant risk of administering compromised vaccines, violating patient safety regulations and ethical principles of non-maleficence. It also undermines public confidence in the pharmacy’s ability to provide safe and effective healthcare services. A further incorrect approach would be to dismiss patient concerns about vaccine safety without providing evidence-based information or referring them to appropriate resources. This demonstrates a lack of empathy and professional responsibility, potentially alienating patients and contributing to vaccine hesitancy. Pharmacists have an ethical duty to address patient concerns with respect and provide accurate, unbiased information. Professionals should employ a decision-making framework that prioritizes public health goals while upholding individual patient rights and safety. This involves staying abreast of current public health recommendations, assessing community needs, and developing practical, evidence-based strategies for service delivery. It also requires effective communication, patient counseling, and collaboration with public health agencies.