PHGR Influenza and Beyond: Responding to Vaccine-preventable Diseases

National Satellite Broadcast & Webcast: 1/30/04 2-3pm EDT

Script Version 3 SHORT 1/29/04

	VIDEO	AUDIO
	13:30:00 SEGMENT 00 Pre-program Test 30:00
1.	14:00:00 SEGMENT 01 5:00
2.	TAPE: Cut – 1 Pre-Con /Open RT: 7:22
3.	CU BILL ROPER CG: William Roper MD, MPH	Roper: Hello, I'm Bill Roper. Welcome to another session of Public Health Grand Rounds, a collaboration of the Centers for Disease Control and Prevention, and the School of Public Health at the University of North Carolina at Chapel Hill.  In these LIVE interactive forums we focus on CURRENT public health issues. Today we find ourselves midway through an unusually bad flu season. And yet, as Public Health authorities know, NOT ENOUGH PEOPLE, especially those at HIGHEST RISK, are getting vaccinated against this potentially deadly disease.
4.	SS: U.S. Technical Help: (800) 728-8232 International Technical Help: (404) 639-1289	Now here are some important CONTACT numbers if you're having trouble receiving the program. For TECHNICAL assistance call: 800 7-2-8 8-2-3-2. That's 800 7-2-8 8-2-3-2 Or for INTERNATIONAL viewers, please call: 4-0-4 6-3-9 1-2-8-9 [PAUSE]
5.	CU BILL ROPER CG: William Roper MD, MPH	Roper: Flu is a disease that's SO FAMILIAR that many of us don't take it seriously. Yet each year, about ONE HUNDRED FOURTEEN THOUSAND people in the United States are hospitalized because of influenza. And approximately 36-thousand will DIE from this vaccine-preventable disease. In CHICAGO this situation has spurred the Health Department together with its community partners to TAKE ACTION.
6.	TAPE: Cut – 2 Tease RT: 1:33	OUTCUE: "… infants and young children."
7.	CU BILL ROPER	Roper: Treating influenza and other vaccine-preventable illnesses like pneumococcal disease costs Americans more than 10 BILLION dollars each year. The key to REDUCING the burden of these diseases is INCREASING IMMUNIZATION RATES, especially among those groups at increased risk for complications, such as seniors; anyone with chronic heart of lung problems; diabetes; or pregnant women. It's also important to reach RACIAL and ETHNIC MINORITIES who historically have had lower immunization rates than whites. Joining us today to discuss ways of reaching these goals is:
8.	CU WALTER ORENSTEIN	Dr. Walter Orenstein, Assistant Surgeon General and Director of C-D-C's National Immunization Program.
9.	CU KRISTIN NICHOL	We're also pleased to have with us Dr. Kristin Nichol, Professor of Medicine at the University of Minnesota and Chief of Medicine at the Minneapolis Veterans Affairs Medical Center.
10.	CU HUGH TILSON	And as always, we have with us my colleague at U-N-C, Dr. Hugh Tilson, Clinical Professor of Epidemiology and Health Policy. Hugh as usual will be keeping a close watch on our WEBSITE and will be sifting through QUESTIONS you send us on this timely subject.
11.	CU BILL ROPER SS: United States: Voice (800) 793 – 8598 Fax (800) 553 – 6323 TTY (800) 815 – 8152 SS: www.PublicHealthGrandRounds.unc.edu CU BILL ROPER	Roper: One of the real values of a LIVE INTERACTIVE program like this is HEARING directly from YOU, so please write or call in your QUESTIONS and COMMENTS. Our phone number is 800 7-9-3 – 8-5-9-8 Our fax number is 800 5-5-3 – 6-3-2-3 And, you can also submit a question at our website at www dot Public Health Grand Rounds dot U-N-C dot E-D-U. [PAUSE] And now let's take a look at our OBJECTIVES for today's program.
12.	TAPE: Cut – 3 Objectives RT: :27	OUTCUE: ".. also known as READII."
13.	14:05:00 SEGMENT 02 Vaccine effectiveness 3:00
14.	CU BILL ROPER	Roper: Let's begin with that FIRST objective, the EFFECTIVENESS of VACCINES. And for perspective, let's remind ourselves once again of our ATTITUDE toward the flu, the main vaccine-preventable disease faced by adults. Whether it's through ignorance, denial or we're just too blasé, data show the public DOES NOT PERCEIVE INFLUENZA to be a SERIOUS ILLNESS, and is UN-SURE of the BENEFITS of vaccination. Walt, you've been in the immunization field a long time, WHY take this disease so seriously?
15.	CU WALTER ORENSTEIN	Orenstein: There are a number of really good reasons to take influenza very seriously. · We see outbreaks every winter · It's highly infectious. 10-20% infection rate · It puts over 100,000 people in hospital a year. About 50% of them are people age 65 or older. · Influenza is frequently associated with complications · It causes an average of 36,000 deaths a year. 90% of them in people over 65.
16.	CU BILL ROPER	Roper: So it's a disease which is MOST DEADLY for SENIORS but at the same time is VACCINE-PREVENTABLE. How EFFECTIVE is the vaccine?
17.	CU WALTER ORENSTEIN CG: Walter A. Orenstein, MD	Orenstein: The effectiveness depends on 3 things: · Whether a person has ever been exposed to the virus before · The match between the vaccine and circulating strains · A person’s age—the vaccine is 70 to 90% effective in preventing influenza in healthy, young adults, when there is a good match between the vaccine and the circulating strains. However in those who are 65 or older or are frail, the effectiveness of the vaccine against illness decreases to 30 to 40%. But for same group, the vaccine is 50-60% effective in preventing hospitalization and 80% effective in preventing death.
18.	CU BILL ROPER	Roper: So, given the facts about effectiveness, why should people get vaccinated?
19.	CU WALTER ORENSTEIN	Orenstein: Number one…Influenza is a serious disease associated with respiratory illness and it can exacerbate underlying health conditions such as diabetes, heart disease, and asthma. Number two.. your flu vaccine not only protects you, but it protect your loved ones as well And three…influenza is transmitted from people who are ill to people who are susceptible.  By getting vaccinated, you help break this chain of transmission.
20.	CU BILL ROPER	Roper: Thanks, Walt. Kristin, as an ex officio member of the Advisory Committee on Immunization Practices, IMMUNIZATION COVERAGE RATES are something you’re very familiar with. What can you ADD to what Walt said?
21.	CU KRISTIN NICHOL CG: Kristin L. Nichol, MD, MPH, MBA Is this correct for general pop?	Nichol: · Vaccine preventable deaths highest amongst adults. 99% versus 1% in children[n1] · Vaccination rates have become stagnant in the past 5 years. · Plateauing at just over 68% for people age 65 or older for the population as a whole. · When we look at African American and Hispanics the rate is significantly lower, around 50% So clearly there's a lot that needs to be done.
22.	14:08:00 SEGMENT 03 Identifying the Problem 8:00
23.	CU BILL ROPER	Roper: Thanks, Kristin. Now let's take a look at our CASE. In December Public Health Grand Rounds went to CHICAGO and spoke extensively with those Public Health and community groups who are actively engaged in trying to IMPROVE adult immunization RATES in the city. Hugh, what did you find out?
24.	CU HUGH TILSON CG: Hugh Tilson, MD, DrPH	Hugh: Bill, as you might expect it all began with the key tools of Public Health, surveillance and epidemiology. The Chicago Health Department set out first of all to identify the size and scope of the problem. They identified adult immunization patterns throughout the city and where the greatest gaps were, primarily in the African American and Hispanic communities. These needs dovetailed neatly with the national program C-D-C was launching known as READII. Here's how it happened.
25.	TAPE: Cut-4 Identifying the Problem/Epidemiology RT: 2:34	OUTCUE: " to address this problem?"
26.	CU BILL ROPER	Roper: So LOCAL needs in Chicago converged with a NATIONAL initiative to RAISE adult immunization. Walt, tell us about the READII project that C-D-C launched along with other federal partners.
27.	CU WALTER ORENSTEIN (BUILD) SS: READII Project · 2002 HHS/C-D-C initiative in collaboration with CMS, HRSA, AoA & AHRQ SS: · Increase vaccination rates among Hispanic- Americans & African Americans SS: · Chicago, Milwaukee, Rochester, San Antonio and 19 counties in Mississippi	Orenstein: As we heard in the objectives, READII is short for Racial and Ethnic Adult Disparities in Immunization Initiative. It's an initiative that C-D-C and its federal partners LAUNCHED in 2002. We're trying to INCREASE VACCINATION RATES for influenza and pneumococcal disease among Hispanics and African Americans in FIVE communities. The five READII sites are Chicago, Milwaukee, Rochester, San Antonio, and 19 counties in Mississippi.
28.	SS: (BUILD) READII Objectives · Mobilize community organizations SS: · Motivate Healthcare professionals SS: · Increase awareness of vaccine benefits SS: · Get more minority seniors immunized.	The READII Project has 4 goals: Mobilize community organizations Motivate Healthcare professionals Increase awareness of vaccine benefits Get more minority seniors immunized.
29.		One of the unique things about the Chicago READII Project is that it's aimed at BOTH the African-American and the Hispanic communities.
30.	14:16:00 SEGMENT 04 Providers/Delivery Service 10:00
31.	CU BILL ROPER	Roper: Thanks, Walt. The READII Project in Chicago is now just over a YEAR old. Hugh, tell us what you discovered about HOW it's working.
32.	CU HUGH TILSON	Tilson: Certainly, Bill. Well, as Walt said, one of the goals of READII is to motivate healthcare professionals, providers in particular, to find ways to increase vaccination rates. We saw how Chicago under the leadership of the Health Department is approaching that challenge. Remember the lion share of immunizations in this country is administered by the private sector so there's a tremendous need to educate those private sector providers. And all providers need to know how to file for reimbursement not through Medicaid but through Medicare. While in Chicago we also saw some of the READII clinics operating in the 14 target communities. They're staffed by nurses from one of the community partners, the American Lung Association. So here's a look at what we found out about providers and the READII clinics.
33.	TAPE: Cut-5 Providers/ Service Delivery RT: 3:51	OUTCUE: ".. which we’re happy about."
34.	CU BILL ROPER	Roper: So clearly PROVIDERS play a CRITICAL ROLE in adult immunization rates. Kristin, how do we make things better in this area?
35.	CU KRISTIN NICHOL SS: (PP Slide #25) Disparities between Perception and Performance	Nichol: The first priority is of course turning PROVIDERS into BELIEVERS. Only 36 percent of healthcare workers report that they have GOTTEN the vaccine. It's critical that MORE healthcare workers get vaccinated against influenza.  We need to remember that healthcare workers see sick patients who may have the flu and can transmit it to the healthcare worker.  Healthcare workers can then TRANSMIT the disease to their susceptible patients.  By getting vaccinated, healthcare workers are protecting themselves, their patients, and their communities. Secondly, as the Chicago case shows, there's often this gap between PERCEPTION and PERFORMANCE among providers in terms of numbers of patients who receive an influenza vaccination. It can be a dramatic one as this chart demonstrates. On left, we see doctors reporting a better than EIGHTY PERCENT vaccination rate. However, on the right, when we conduct an AUDIT of their charts we find an ACTUAL rate of about FIFTEEN percent.
36.	SS: Strategies to Improve Vaccination Rates · Increase demand Patient reminders Multifaceted program including education Regulation SS · Enhance access Reduce cost Walk-in clinics SS · Address provider barriers Reminder/Feedback Standing orders and policies	So what this tells us is that there's a need for providers to get organized and adopt a number of STRATEGIES to IMPROVE vaccination rates. · Increase demand Patient reminders Multifaceted program including education Regulation · Enhance access Reduce cost Walk-in clinics · Address provider barriers Reminder/Feedback Standing orders and policies. (Standing orders can boost immunization rates tremendously.)
37.	SS: Slide #13 Provider Recommendation (Highlight 2 "Negative Attitudes" columns)	Finally I would like to stress that the SINGLE MOST IMPORTANT STRATEGY for IMPROVING immunization rates is for the provider to RECOMMEND getting a flu shot. This chart of immunization rates for influenza and pneumococcal disease dramatically makes the case. Look at the NEGATIVE ATTITUDES columns. When a provider recommends a flu shot even when the patient has a negative attitude we still see an EIGHTY PERCENT immunization rate. When the provider gives NO RECOMMENDATION the immunization rate DROPS way down to TWENTY-SEVEN percent for INFLUENZA and FIFTEEN percent for PNEUMOCOCCAL disease.
38.	CU BILL ROPER	Roper: Thanks, Kristin. Anything you'd like to add about PROVIDER EDUCATION, Walt?
39.	CU WALTER ORENSTEIN	Orenstein: Bill, Kristin emphasized there's this tremendous GAP between provider PERCEPTION and PERFORMANCE in terms of immunization. C-D-C has in fact developed a very useful software package, called ACASA which is specifically designed to allow providers to go to their records and EVALUATE their immunization rates. It's easy to use and you can download it from C-D-C's website.
40.	14:26:00 SEGMENT 05 Community Outreach/Barriers 11:00
41.	CU BILL ROPER	Roper: Thanks Walt, We're now going to move on to look at the OTHER SIDE of the equation, the PATIENTS THEMSELVES. Hugh, what did you find out in the Chicago case?
42.	CU HUGH TILSON	Tilson: Bill, as Walt mentioned mobilizing community organizations and agencies is a key component of READII. And in Chicago, as we discovered, it's primarily these grassroots partners who are going out into the community, and coming up with effect ways to overcome the barriers and myths that prevent seniors from getting shots. Let's take a look.
43.	TAPE: Cut-6 Community Outreach/Barriers RT: 4:46	OUTCUE: " result from these illnesses."
44.	CU BILL ROPER	Roper: Walt, the case shows that there are a number of BARRIERS that PREVENT people from `getting vaccinated and they VARY among different communities. Could you summarize for us the MAIN REASONS WHY adults DON'T get vaccinated against flu and for pneumococcal disease?
45.	CU WALTER ORENSTEIN SS: PP Slide #25 Reasons for Not Getting Vaccinated	Orenstein: Bill, research from the 1999 Medicare beneficiary survey shows the FOUR LEADING REASONS seniors do not to get a flu vaccination are: First, people say they DID NOT KNOW they needed the vaccination; second, people INCORRECTLY believe the shot CAUSES flu; third, they INCORRECTLY believe the shot causes SERIOUS SIDE EFFECTS; and fourth they believe the shot DOES NOT WORK. And, as we saw in the Chicago case, these barriers do vary between populations. In the case of pneumococcal disease the three leading reasons are slightly different: First, respondents said they DIDN'T KNOW they needed it; second, they didn't think of it; and third, their DOCTOR didn't recommend it.
46.	CU BILL ROPER	Roper: And HOW LARGE are the DISPARITIES in coverage rates for different communities?
47.	CU WALTER ORENSTEIN SS: PP Slide #18 Influenza Vaccination Coverage SS: PP Slide #21 Pneumococcal Vaccination Coverage Levels	Orenstein: Bill, they're significant. If we take a look at influenza vaccination rates for those age 65 or older across racial and ethnic lines, we can see that while the white community is at SIXTY-EIGHT PERCENT coverage for influenza vaccine, the African American and Hispanic communities are just below FIFTY percent. So clearly there's a long way to go across the board to reach our Healthy People 2010 goal of NINETY percent coverage for the population as a whole. Pneumococcal vaccination coverage levels in those age 65 or older are even lower. Whites have about a 60% vaccination coverage level, while 37.2% of African Americans have received the vaccine and only 27% of Hispanics.
48.	CU BILL ROPER	Roper: Aside from funding to the sites, C-D-C also offers TECHNICAL ASSISTANCE to the READII sites. Tell us about that.
49.	CU WALTER ORENSTEIN	Orenstein: Staff from the National Immunization Program, and from our contractor, the Academy for Educational Development, provide TRAINING and TECHNICAL ASSISTANCE to the sites in many areas. Some of these include how to mobilize a community, dealing with the media, evaluating program effectiveness, using data for decision making, working with faith communities, working with provider communities, and methods for conducting provider-based interventions.
50.	CU BILL ROPER	Roper: Thanks, Walt. Kristin, what about improving immunization rates through VACCINATING in NON-TRADITIONAL SETTINGS? What can you tell us about those approaches, particularly in the context of MINORITIES?
51.	CU KRISTIN NICHOL	Nichol: As we saw in the case, going to where the people are can be very effective. So we need to discuss community vaccination clinics, working with community and faith leaders to build trust, and promoting the vaccination to build consumer demand Potential advantages · Cost · Access/convenience · Increased public awareness and demand · New providers and new strategies
52.	14:37:00 SEGMENT 06 Public Awareness 5:00
53.	CU BILL ROPER	Roper: Thanks, Kristin. Let's return to our Chicago case. One of the other key strategies for improving adult immunization rates is by INCREASING PUBLIC AWARENESS as a whole. Hugh, what did CHICAGO do in this area?
54.	CU HUGH TILSON	Tilson: Bill, as with any major public health initiative enlisting the support of the local media, both large and small, played a significant role in getting their message out to the public at large. Here's how they went about it.
55.	TAPE - Cut #7: Public Awareness/Media RT: 2:17	OUTCUE: "… and they’re going to want."
56.	CU BILL ROPER	Roper: Walt, I believe YOU participated in the media event to launch Chicago's Adult Immunization Awareness Week. Tell us about that.
57.	CU WALTER ORENSTEIN	Orenstein: That's correct Bill. I got MY SHOT there in front of the television cameras. I got my shot because vaccination is recommended for me, and because I believe it is a safe and effective vaccine. I get vaccinated annually and I recommend that my family members do as well. Another reason I was vaccinated is that I am a doctor and vaccine is recommended annually for health care workers to protect them from developing influenza and to prevent health care workers from transmitting influenza to their patients.  Remember, health care workers frequently come in contact with flu patients who are infectious. Infected health care workers can, in turn, transmit the virus to patients with underlying conditions that put them at high risk of complications from influenza.
58.	CU BILL ROPER	Roper: In WHAT OTHER WAYS has C-D-C supported the READII communities in their effort to get out the message?
59.	CU WALTER ORENSTEIN SS: PP Slide #42 &43 READII Communications Materials	Orenstein: Bill, C-D-C has created a number of POSTERS and BROCHURES which community partners can distribute. The materials are designed specifically for the MINORITY SENIORS and their families. All of the materials were PRE-TESTED with seniors and use text and images that resonate well with them. The materials picture physicians, seniors, and grandchildren and we have both ENGLISH AND SPANISH versions.
60.		Roper: Thanks Walt. Generating public awareness is obviously key to raising immunization rates to the NINETY PERCENT level we're aiming for in our Healthy People 2010 goals. Kristin, what are YOUR THOUGHTS on USING the MEDIA and educating the public?
61.	CU KRISTIN NICHOL	Nichol: Bill, the MOST IMPORTANT QUESTION we have to address is "What does the PUBLIC KNOW about influenza and other vaccine-preventable diseases?" From there we move to the important details. Do people fully appreciate the RISKS of these diseases? Do they understand the SAFETY of immunization? WHERE can they go to get immunized? What NON-TRADITIONAL IMMUNIZATION SITES are available to them? In general we need to make sure the public has access to ACCURATE and UP-TO-DATE INFORMATION that is grounded in good audience research.
62.	14:42:00 SEGMENT 07 Lessons Learned 5:00
63.	CU BILL ROPER	Roper: Thanks, Kristin. Let's go back to our case once more. Hugh, what have the Chicago Health Department officials and their community partners LEARNED from this whole effort to raise adult immunization rates?
64.	CU HUGH TILSON	Tilson: Bill, the lessons learned are always the most fascinating part of any Public Health Grand Rounds case for me. Here's what they had to say about their experience so far.
65.	TAPE: Cut-8 Lessons Learned RT: 3:21	OUTCUE: "... accomplish our mission."
66.	CU BILL ROPER	Roper: Walt, from your standpoint what are the KEY POINTS the audience should take home from today’s broadcast?
67.	CU WALTER ORENSTEIN	Orenstein: Bill, I think it is important for the audience to remember several key points: · Influenza and pneumococcal disease are SERIOUS. Both diseases cause UNNECESSARY hospitalizations and can cause death. · Influenza KILLS an average of 36 thousand people per year and pneumococcal kills approximately 5,700 people per year. · The influenza and pneumococcal vaccines are both SAFE and EFFECTIVE and getting vaccinated is the best way to PREVENT these diseases. · We need to strive to INCREASE vaccination coverage rates among those at HIGHEST RISK for complications, such as seniors and those with chronic health problems. Reminding people that getting a flu shot not only protects them, but protects THEIR LOVED ONES can be very motivating. · We also need to ensure that more HEALTHCARE WORKERS get vaccinated. · And last, I think we can learn a lot from the READII Project sites about how to ENGAGE community leaders, healthcare providers and others in activities that PROMOTE adult vaccination. and increase vaccination coverage rates.
68.	CU BILL ROPER	Roper: Thanks, Walt. Kristin, what are the KEY LESSONS for you?
69.	CU KRISTIN NICHOL	Nichol: Bill, there's clearly an urgency to do better. · VACCINE PREVENTABLE DEATHS are particularly HIGH among adults · IMMUNIZATION RATES are TOO LOW · We know a lot about FACTORS associated with LACK OF IMMUNIZATION · We know a lot about STRATEGIES to improve immunization rates · Physicians must RECOMMEND vaccinations · We must take a SYSTEMS APPROACH to get organized and get serious.
70.	14:47:00 SEGMENT 08 Discussion 6:00
71.	CU BILL ROPER SS: United States: Voice (800) 793 – 8598 Fax (800) 553 – 6323 TTY (800) 815 – 8152 SS: www.PublicHealthGrandRounds.unc.edu	Roper: Thanks, Kristin. In a moment it'll be YOUR turn to ask questions about ADULT IMMUNIZATION and how to better reach your community. Please tell us too about YOUR EXPERIENCES and BEST PRACTICES. Again, you can TELEPHONE us at: 800 7-9-3 – 8-5-9-8 Our FAX number is 800 5-5-3 – 6-3-2-3 And, you can also submit a question at our WEBSITE at www dot Public Health Grand Rounds dot U-N-C dot E-D-U.
72.	SS: Discussion Forum www.PublicHealthGrandRounds.unc.edu	Also, I'd like to remind you about our Discussion Forum on the WEB. Content experts from C-D-C and U-N-C will facilitate the on-line discussion. THAT will start TODAY and run through February six. That's another opportunity to ASK questions and SHARE your best practices. Just go to w-w-w dot Public Health Grand Rounds dot u-n-c dot e-d-u and click on the "Discussion Forum".
73.	SS: Resources www.PublicHealthGrandRounds.unc.edu	You can also to access our ON-LINE Resources Page, which has LINKS to useful resources on the web.
74.		Hugh you've been checking our website. Do you have ANY QUESTIONS for us? Tilson: [QUESTION] Roper: We have a call from [STATE]. Go ahead, please.
75.	14:53:00 SEGMENT 09 Wrap-Up 7:00
76.	CU BILL ROPER	Roper: Unfortunately that's all the time we have now for our discussion. MANY of you, I'm sure, will have ADDITIONAL questions and comments. So please join us at our website discussion forum. If you're looking for information, check out our Resource Page. And now I'd like to ask each of our guests to share a few FINAL WORDS about our topic today, responding to influenza and other vaccine-preventable diseases. Let me start with you, Walt.
77.	CU WALTER ORENSTEIN	Orenstein: BRIEF FINAL WORDS
78.	CU BILL ROPER	Roper: Kristin, what's your TAKE HOME MESSAGE?
79.	CU KRISTIN NICHOL	Nichol: BRIEF FINAL WORDS
80.	CU BILL ROPER	Roper: And Hugh, what words would you like to leave us with?
81.	CU HUGH TILSON	Tilson: Well, Bill, I couldn't miss the chance to THANK our wonderful PUBLIC HEALTH GRAND ROUNDS team. THANKS too to all the good people in Chicago. They truly are taking a community-based approach to raising adult immunization rates and it's working. And I'd like to give THEM the FINAL WORD on this important challenge for public health.
82.	TAPE: Cut-9 Final Words RT: 1:30	OUTCUE: ".. out there with the people."
83.	CU BILL ROPER	Roper: We pay attention to the exotic – SARS, MONKEY POX, WEST NILE VIRUS. But as for the perennial threats to our health, like INFLUENZA and PNEUMOCOCCAL disease, we often grow IMMUNE to the warnings when we should be getting immunized. As Public Health professionals we need to aim for the same level of success with ADULT IMMUNIZATIONS as we have already achieved with CHILDHOOD immunizations. By doing so we can save many of the 36-THOUSAND lives we currently lose to the flu each year. We hope today's case study from Chicago will help you RAISE adult immunizations rates in YOUR community.
84.	SS: Website Address www.PublicHealthGrandRounds.unc.edu SS: E-mail GrandRounds@sph.unc.edu	Before we go, my thanks to all our guests for joining us today. I'd also like to thank you, our viewers, for being with us. We know you represent the FULL SPECTRUM of community public health partners, from grass roots community workers to public health directors. Let us know what YOU think of today's program by going to our website and filling out the online evaluation form. If you want to receive continuing education credit, you must complete an on-line EVALUATION form. If you have any difficulties, please e-mail us at GrandRounds at S-P-H dot U-N-C dot E-D-U.
85.	SS: Website Address www.PublicHealthGrandRounds.unc.edu	Again, when you visit our WEBSITE, take advantage of our Resource Page and the DISCUSSION FORUM where you can get additional questions answered and share your own ideas about our program. This forum will be open between now and February sixth.
86.	SS: Public Health Grand Rounds Highway Safety March 26, 2004 2:00pm – 3:00pm ET For more information visit: www.PublicHealthGrandRounds.unc.edu	Public Health Grand Rounds will be back on March 26th when examine the important issue of HIGHWAY SAFETY. So please, be sure to mark that date on your calendars.
87.		On behalf of everyone at C-D-C, the Public Health Training Network and the School of Public Health at the University of North Carolina at Chapel Hill, I'm Bill Roper wishing you a GOOD DAY from Atlanta.
88.	SS: Production Credits SS: Partners SS: A Special Thanks To: (1) SS: A Special Thanks To: (2) SS: A Good Day From Atlanta	Music

---

[n1]CHECK THE ACCURACY OF THIS—we don’t think it is correct.