Press Briefing Transcripts

CDC Briefing on Public Health Investigation of Human Cases of H1N1 Flu (Swine Flu)

May 5, 2009, 1:30 p.m. EST

• Audio recording (MP3)

 

>>> Good afternoon.  Thank you all for holding.  At this time, your lines have been placed on listen only until we open up for questions an answers.  Today's conference is being recorded.  If you have any objection, you may disconnect at this time.  I would I will now turn the conference over Mr. Glen Nowak. 

>> Thank you, to all who dialed in and those who are here for the daily briefing of the H1N1 flu.  Today we are honored to have with us today, Secretary Kathleen Sebelius of Health and Human Services, along with Dr. Richard Besser.  I will first turn the floor over to Mr. Besser.  Also the Secretary will be joining us for part of this press conference.  She'll be leaving at some point and Dr. Besser will answer questions.  So I will turn the podium over to Dr. Besser.

>> Thanks very much, Glen.  Thanks for joining us for today's press conference.  We're extremely honored to have Secretary Sebelius here in her first trip outside of Washington.  She made it a priority come here to understand what efforts are being undertaken at CDC to work to control the outbreak of H1N1 disease.  So we've provide her with a briefing, a tour of out of facilities and she's just come from an all hands meeting with CDC staff.  So we are thrilled to have her here with.  That I want to turn if over to her. 

>> Well, thank you, Rich.  It's my great delight to have my first out of Washington trip be here at the centers for disease control.  As Rich said, I just spoke at an all hands meeting and was able to thank them on behalf of the president and American people.  Great work going on here, not just on this H1N1 outbreak but day in and day out, to keep America safe and secure, a lot of that effort is coming out of CDC.  I know I bring the president's thanks, I'm proud of the staff and so is he.  Now, learning more about the H1N1 virus every day.  It's a dynamic situation.  Dr. Besser and others have made clear to the American public we're now over 400 cases confirmed, another 700 probable cases in 44 states.  We know there will be more cases.  Those numbers will go up, anticipate unfortunately they're likely to be more hospitalizations an more deaths.  36,000 people die a year from seasonal flu so we're likely to see a continued outbreak.  The good news is this virus does not seem to be as severe as we once thought it could be based on the very early studies in Mexico.  Throughout this outbreak, the administration and HHS have been guided by the science, the president made it very clear that safety and security of the American public was his top priority as commander in chief but he wanted the science to be the guide.  And Dr. Besser has done a great job with the team at CDC making us aware at the administration level across cabinet agencies and certainly to the president an his team what's going on in this very dynamic situation.  The issue of school closing has gotten a lot of attention.  There's a balance between the importance of making sure our children go to school every day and absorb the knowledge they need and safety and security of those children.  And the strategies of some of the public health departments across the country were when there was a known easy transmission child to child, we saw the outbreak run through the New York school system and didn't know enough about what the virus was likely to do to take children out of school, shut those schools down when they were affected.  The good news again is that while that guidance recognizes the fast transmission and we still know that's the case.  The virus transmits very quickly child to child, the end result has been a more mild version of the disease than was originally feared and the lethality seems at a much leg significant level.  So there's new guidance being put out as we speak that will recommend that schools cease closing with affected cases.  Having said that, know that it makes it even more important that parents and teachers and others pay attention to sickness as it is breaks out.  So we're urging parents to take steps if you're child is sick, please do not send your child to school.  Because your child will transmit the virus likely to additional children.  If a teacher is sick, please don't come to school.  And parents, don't turn around and keep your child home from school and send him or her to the mall, there are lots of people that are available.  This is really about staying home.  Staying home for a period of time until the infection can't be spread any further.  We work closely with education secretary Duncan on developing the new guidance for school districts and hope that this will alleviate some of the burdens on parents and workers that we were hearing about.  But again, the balance on keeping children safe and sound took the top priority until we learned a lot more about this disease.  I also should make it very clear, this is not an indication that we know enough yet about the course that this virus will take.  We don't know what will happen over the course of the summer and we certainly are don't know what will happen when we get back into flu season.  This is may.  Flu season is later this fall.  So our aggressive efforts to learn more, to study more, certainly to ramp up vaccine productions are going to be under way and let me just clarify what's going on right now with the vaccine because I think there's some confusion.  One of the first steps that was taken in in it's very aggressive effort to get out in front was to bring together the scientist from the citizens for disease control, the national institutes of health, together with the regulatory oversight from the food and drug administration to begin the development of a vaccine for H1N1 development.  You can't begin to develop a vaccine until you know what the virus strain looks leak.  So the strain has been identified that's been grown right now.  There will be testing phases under way to get to the right dosage and to make sure that we are administering this in the safest possible fashion and to be ready should the decision be made to go into production phase, be ready to go.  At the same time, seasonal flu vaccine, we know we're going to need.  Millions of cases every year, 200,000 hospitalization, 36,000 death, so the acceleration is under way for seasonal flu production.  Part of the reason we're accelerating that with our private partners is to make sure we can clear the decks so if the decision is made to actually produce a vaccine for H1N1 we're ready to go.  So the work is going ton simultaneously, we will have a seasonal flu vaccine up and ready for the millions of Americans who need to take their flu shots and if necessary, when he have a vaccine for H1N1 ready by flu season.  That work will continue.  So we're working as fast as possible again to stay ahead of this disease, I'm delighted with incredibly important work that CDC is doing.  In both, not only investigating what's happening but communicating to the American public and that's been a critical part of keeping Americans informed and I'd like to turn over to Dr. Besser for --

>> Thanks so much, madam secretary for those very kind words.  Let me give you an update on where we are today.  In terms of our cases, we're reporting 1105 probable and confirmed cases in 44 states.  There are over 700 probable cases and 403 confirmed cases.  The confirmed cases are in 38 states.  We expect that as we get these test kits out to state labs and as they get up to speed from some of the backlog they've had on testing will go away and we'll see a big bump in the number of cases.  That doesn't reflect transmission as much as it reflects we're catching up with the testing.  In terms of the age, the median age is 16 years.  The range of 3 months to 81 years.  There have been 35 known hospitalizations or confirmed hospitalizations with one death.  62% of the United States cases,s confirmed cases are under 18 years of age.  World health organization earlier today was reporting 1,124 cases in 21 countries.  We're hearing from Mexico they are seeing a plateauing in the number of cases there.  We are seeing and expect to continue to see virus transmissions both around the United States and around the globe.  And we would expect that we'll see cases in all states over time.  And given what we know from seasonal flu, we would expect that we would continue to see additional hospitalizations and it's likely we would see additional deaths.  In the news we've been hearing and as we've been talking to our public health colleagues, we've been understanding what's going on in various parts of the country.  New York City where they've reopened the school that had the large outbreak and that's very good news there.  So what are we seeing?  We're seeing some encouraging signs.  Again, the theme is this is a rapidly changing situation.  If you think back over the past four days where we were Friday and where we were Tuesday, we've seen an exponential growth in our understanding of what's going on.  But we're still in that period of major uncertainty.  We can look back and understand what's taken place but where this is going to go is hard to say.  But some of the encouraging signs as we've talked about.  We have some information about the virus that shows it does not contain some of the factors that are associated or were associated with previous pandemics.  We continue to gain information about severity in this country.And what we're seeing is severity that mirrors what we've tended to see with seasonal flu.  And that's not to diminish the impact of seasonal flu as the Secretary was saying, there's major burdens on people's health from the flu each year.  As we go forward, we are continuing to support state and local public health.  We have deployed 86 people from CDC around the country as well as in Mexico.  We have 16 people in Mexico working with the Mexican and Canadian team that is there.  And that is continuing to shed light on what we are seeing in this country as we learn more in Mexico, some of the things that look different at the beginning are no longer looking so different.  We're seeing more cases in Mexico of the milder disease.  That helps put in perspective what the initial reports were coming out of Mexico of very severe disease there.  The Secretary mentioned the guidance that will be coming, it will be posted later today around school closure.  And I'll be happy to take questions on that later.  The W.H.O. has this at a level five.  As we've talked about each day, they are looking to see on an ongoing basis whether there is sustained transmission in any area outside of the north American region.  That would be the indication that would lead them to consider whether there should be a change.  So it's not so much the number of countries, but whether the virus sets up shop in any of those countries like it has here and starts to spread person to person.  And given the number of countries that have cases, one would think that eventually that criteria would be met.  So in closing, as we go forward, we're going to be paying much attention to what takes place in the southern hemisphere.  They're entering their flu season.  That will be very important as we think about what we want to do in in this country in terms of vaccination.  That information will be important in terms of looking at whether any resistance develops in the virus and whether the virus changes overtime into something that would be more severe.  The points about personal preparedness are so important.  And personal responsibility.  The change in the school closure guidance reflects increased understanding about transmission that we're seeing widespread cases in terms of severity, that we're not seeing the most severe strains we were are initially concerned about and that is leading us to the change.  It does not change the importance of personal responsibility in terms of hand washing, in terms of alcohol gels if you don't have use of soap and water.  In terms of staying home, if you're sick from work for a good days and keeping your children out of school, if they're sick for a good seven days.  Those measures that can be taken by everybody will help reduce the likelihood that individual people will get sick and if they're sick that they'll transmit it to others.  So I'm going to stop there and we'll take questions.  Secretary Sebelius will not be able to stay long.  So if there are particular questions in that direction, that we could get to first, we'll start here in the room. 

>> Thank you.  Secretary Sebelius, with respect to the question on the vaccine production, I want to flip the question around, how can you not go forward with production?  I say that in light of the time crunch that you're now up against?  You know that you have a novel influence strain in this country right now.  Perhaps nothing will happen with it next winter and it will go away but if it returns with a vengeance and don't have vaccine available, how can you possibly explain that to the American public? 

>> I think the goal really is to move forward.  But I wanted to clarify.  There are lots of people who have mistakenly believed there is a vaccine available right now.  There's some confusion between a viral discussion with Tamiflu and Relenza and a vaccine.  So I wanted to particularly clarify there is not a vaccine.  Development phase is very much under way and I think that every effort will be made to make sure that if and when the call is made by the scientists that production is ready to go by flu season follows the target, but again, in this disease from the outbreak, science has led the decision making.  We're going to be turning to scientists at NIH and here at CDC to say is this next step what's recommended?  Do we have a vaccine which can inoculate people in the future against H1N1?  If so, who are the target groups to receive that vaccine and I just wanted to make it clear that those decisions won't be made until there is a vaccine ready to go and we'll turn to the scientists to take the next step based on their recommendation.

>> Let's take one more in the room.

>> I'm Rebecca Schramm from CBS Atlanta News.  We have a case here locally because of a school that is closed down, confirmed case.  I'm wondering if you recommend that those schools and others like it will be open immediately.

>> There is guidance being posted I think as we're meeting today because there's concern about every day of school.  I will let Dr. Besser give the more detailed answer, but the overall conclusion having studied very carefully what's going on is keep the affected students home.  Please, for a seven-day period of time.  And if your child begins to come down with symptoms, keep him or her home, but that the schools should feel comfortable about reopening because this is presenting itself more like seasonal flu and in seasonal flu time, the only time a school would ever consider closing is if enough of the teachers and the population has frankly gotten the flu so they really can't function.  That's more the pant turn that we are going see right now. 

>> Let's take a question from the phones. 

>> Again, if you would like to ask a question, please press star one.  Our first question comes fromRobert Bazell, NBC News.

>> Thank you very much for taking the question.  When you talked about the 35 hospitalized cases, you said you didn't know the condition.  Obviously those cases are key to understand the mortality and morbidity rate of this illness in the United States and whether it's going to end up being the same as Mexico.  Do you have any more on that today or you just don't want to talk about? 

>> I don't have much more to add on that.  As we're doing additional testing and seeing how widespread this virus is, it's given a better handle on hospitalization rates.  And that's something that will be very useful and what we're seeing is rates of hospitalization that are similar to what we see with seasonal flu.  As we do additional testing, I think that we'll get a better handle on that and as the more detailed case investigations, we'll be able to address that as well. 

>> Here in the room. 

>> Thanks, Mike Stope from the A.P.  Doctor, can you talk more about the decision to change the guidance on the schools?  First of all all, which individual made the decision was it you?  Also any more information about what key information caused to you change it?  The Secretary just said keep kids home seven days.  Earlier, you said it sheds virus after 14 days.

>> Very good. 

>> When I think back to where we were won Friday, we were making recommendation about school closures.  We had a situation where we did not know much about Mexico.  We didn't know nearly as much about virus transmission in this country, we didn't have nearly the knowledge about the breadth of disease and the severity of disease.  So what do we know now that we didn't know then? 

>> We know that in communities that in seeing cases in the school.  They're already seeing cases in the communities.  So a strategy of trying to stop the transmission by approaching it as a school phenomenon is not very appropriate.  We know much more about severity.  We are not seeing the rates of severe disease that had been reported initially out of Mexico.  We know more about the virus itself in terms of it not containing the genetic elements that were associated with severe disease and when you put these things together and look at, all right, going into a pandemic, before there's a pandemic, what condition is school closure warranted?  Well, there, if you're seeing a very high mortality event.  And there's a pandemic severity index that is in our community mitigation guide.  For very severe pandemic, the potential benefits of school closures outweighs the risk, especially if there's not widespread transmission in a community.  When you get to situations that are approaching that of seasonal flu.  Then the down sides start to outweigh the benefits that you might get in your community.  Then focusing on the measures of children not going to school when they're sick.  Teachers looking to see if kids in their classroom are sick and sending them home.  The hand washing efforts, those become a much more appropriate strategy.  We are in constant contact with our state and local public health colleagues and what we hear from them is how incredibly difficult and burdensome school closure is.  If we felt there was the benefit there, then we would be continuing to recommend school closures.  But when we hear of the difficulty involved of children who are dropped at libraries because there's nowhere for home care, of people who could lose their jobs because they don't have sick leave, these factors are really real.  And we need to really feel that the public health benefit of that makes it warranted.  So here it's a time based decision but it involves a lot of judgment.  For a decision of this magnitude, CDC informs the decision with the science but it goes to the highest levels of government. 

>> -- Reuters.  Secretary, the administration has been accused of not filling top posts quickly enough.  I wonder when you expect to name a director for the CDC.  At the same time, this quite a separate issue, what should states do with the Tamiflu which has been shipped to them?  Are they expected to use that off and if not, what should they do with that?  So two questions.  Thank you.

>> What we know about Tamiflu and Relenza is they are very effective antiviral treatments for flu cases.  So the reason that the stockpile 25% of the stockpile was pushed to the state was to have those available.  And we expect that as cases present themselves and as we say, we're at about 1,000 now, we expect many, many more cases of this flu to present itself around the country.  So the antivirals are now at the state level and that's very appropriate.  They can push them out infected patients.  So we do anticipate they will be used.  In terms of the leadership positions, I think there's no question in our agency alone, there are over 20 positions that require information, that the protocol is no one is confirmed before the secretary is confirmed.  So while there are lots of folks in the pipeline that I was not confirmed until last Tuesday night.  And I think we're seeing an accelerated agenda where the assistant secretary has had his hearing, confirmation vote, hopefully will take place very soon.  The head of the food and drug administration, the nominee.  Dr. Peggy Hamburg will have a confirmation hearing on Thursday and confirmation hearings are under way to fill the leadership positions in the centers. 

>> Thank you very much, I actually wanted to ask a question about quarantine.  As you probably know there's some quarantines that have been in the news far from our shores.  Mexican citizens.  Hotel guests in Hong Kong.  I wondered if the U.S. government -- U.S. public health is involved at all in discussions over whether this is appropriate and talking with those governments about whether this is the right thing to do.  And secondly, what should -- this kind of situation could arise more and more if we see more epidemics and pandemics.  What should the U.S. government's public health be in? 

>> I'm going take the 30,000 foot view and then turn to the science doctor.  I can tell you that since I have been in this position, there has been a very dynamic and prior to my arrival, there's been a very dynamic discussion with Dr. Margaret Chan, the head of the world health organization, daily briefings between her staff and the staff at the department and CDC and homeland security.  There have been active discussions between President Obama and President Calderon as recently as five days ago.  There are lots of international conversations are taking place about proper protocol, about what CDC is learning about the disease, about how to move forward, about what is happening potentially in viral stockpiles.  What can happen if a vaccine becomes available.  So those conversations are likely to continue and I would turn to Dr. Besser about, I'm not aware of the specific treatment protocol which may be under way in discussions.  I've had those conversations about possible medications, making sure that we're all sending the same message on the same page on a regular, Dr. Besser could answer. 

>> The world health organization is pretty clear in terms of recommendations on travel and lack of value of shutting down -- of attempting to shut down borders.  Influenza is a virus that spreads very easily and people can spread the virus through the day before they're actually showing symptoms.  So trying to maintain a flow of people, trying to maintain a flow of commerce is important.  Where we looked at our overall pandemic plans, if this had started on a distant shore rather than here, we would have look the at what would be the value of intensive entry screeners.  Modelers have looked at that and there are a number of different models, but what it's basically shown is you may gain a few weeks in terms of entry into your country.  You're knot going to prevent a virus like influenza from crossing borders.  Microbes don't respect board, but you might get a few weeks to set up some of your preparedness efforts.  You know, countries that don't have this should be preparing now.  And they should we're at a W.H.O. level five thinking what should I do when it comes to my border, more than what should we do if it comes.  Secretary Sebelius has to catch a flight back to Washington, but I'm happy to take more questions here in the room and then we'll go back to the phones.

>> Health officials gave us an update here in Georgia on the latest cases.  For example in cob county, a child, mother, father, two siblings including a 2-month-old old and relative are all symptomatic and on antivirals but they are not confirmed cases.  Health officials said we are probably seeing this around the country.  I'm wondering how off are we -- I know want to get from number, but how often are we in numbers?  You are going to have this situation in households and can you comment on 2-month-old receiving antibiotics?

>> In terms of numbers, it's really impossible to know how many cases of H1N1 disease there are.  That's because there's a spectrum of disease.  Until we do serologic studies, studies of the blood, we won't know if there are a number of people infected who had no symptoms at all.  Many infectious diseases can be totally asymptomatic.  So very hard to say be at numbers.  We look at the diagnosis more as a way of track disease around the country and getting an understanding of the curve of the disease than coming up with an absolute number.  In terms of the young child who is getting Tamiflu, I'm a pediatrician, what I do with a young child is I look really carefully at what are the recommendations, what is the underlying medical condition of a child, are they at a particular risk?  Then I weigh the benefits of treatment with a drug that may have not have gone through thorough testing in children.  Any drugs we use in children don't go through those studies, so I would look at that and weigh the benefits of treatment versus any potential risk. 

>> Let's go to the phone. 

>> Julie Steinhassen of Reuters, your

>> Thank you, Dr. Besser, what I want to know is what does this age distribution say?  We're still seeing cases of this virus affecting young healthy or population of younger adults, any hints of why this is affecting healthy adults and older children and what does that say about a how the public should behave? 

>> Thanks for the question.  Age distribution can tell us a lot and drive some of the studies that we're doing.  So you see an infectious disease in a particular population.  Here we're seeing it primarily in younger adults.  Well, is that because those are the individuals who were initially exposed?  We know that many people acquired this infection traveling to Mexico.  So is this a population who on spring break went to Mexico and we're seeing it there first and it will move into other populations?  Or is there something about that population themselves?  So could they lack protective factors that are in another population?  Is it possible that the elderly because each year they're exposed to flu, is it possible they have some level of protection from that annual exposure?  Those are important questions.  Those are questions that are being studied, they will factor into decisions around vaccination, should we decide to go down that route.  But it is a very active avenue of study.  Another question from the phone.

>> Thank you.  Ellis park, "time" magazine, please go ahead.

>> At the ye, thank you, just wanted to ask you about your opinion on some of the new flu tracking, surveillance service out there.  I know that the CDC has worked with Google flu trends, for example, can you talk a little bit about how helpful that type of information is particularly now to get a better sense of the dynamics of the outbreak, you know, where it might be increasing or what the ebb and flow of it and is it getting worse, is it tapering off, can you comment a little bit about how useful those kind of methods are.

>> In terms of our ability to detect emerging infectious disease, new infectious diseases, we're constantly looking for what we call situational awareness.  I mean what's going on out in the communities.  And we're looking at you know, many, many different sources of information.  The Google flu tracking information, there was a study done with Google in conjunction with CDC to look at can you use that information, can you use people going on the web to find information about flu as an indication of where flu is taking place?  And the first year looking at that in terms of looking back, it was very helpful.  The question is looking forward can you see that?  As of two weeks ago, Google hits on flu on H1N1 are just off the charts.  And so our website gets 8 million hits a day.  So looking for a signal of increased activity on the web in a particular place isn't very useful.  But we're open and are continually looking at various approaches to early detection because the sooner you can detect a problem, the sooner you can understand it and implement appropriate control measures.  Another question from the phone? 

>> Thank you.  Larry Abramson, National Public Radio, please go ahead.

>> Thank you.  I would appreciate it if you could give us some more details on exactly what the guidance is going to say on schools?  Does this mean that all schools can now reopen?  How many cases do schools need to have before they now need to consider closing? 

>> Thanks very much.  Yeah, the guidance you'll be able to find on our web just some information on that.  The big focus is on identifying children who are ill and so it's asking individuals who are sick to stay at home, parents have a responsibility to look at their children in the morning and see if they're ill and not send them to school if they are.  We have information on children who have flu-like symptoms staying home for seven days.  That's important.  We have information on there so that if a school is having a large cluster and that cluster is affecting attendance and staffing to the degree that the school really can't function then locals can consider closing school in that situation.  So what we saw in New York City in that one school where there were hundreds of people, hundreds of children who had the flu, New York may still have made the decision to close that school with what we know now.  But that's a local decision.  Anyone that closed their school based on a previous recommendation, we no longer feel that school closure is warranted.  We feel we have enough scientific evidence that schools can be open that were closed for that reason. 

>> One more from the phone and then we'll go back to the floor.

>> Thank you.  Helen Branswell, the Canadian press.

>> Thank you for taking my question.  Dr. Besser, I was wondering if you could elaborate a little bit about how the picture in Mexico is becoming clearer.  You mentioned that mild cases are coming to the surface, I'm wondering is is that because of backlog specimens being tested or is it some syndromic surveillance how is it that people are sort of going about sort of establishing how big the rest of the iceberg is? 

>> Thanks for that question.  You know there's a large team in Mexico looking at the situation.  One of the first things that Mexico requested was the establishment of a lab that could do the testing there.  And this was a trinational effort to get that up and running because until you know whether a case is a case, it's very hard to sort out the situation.  And so the initial focus was on looking at the severely ill and individual whose who died to determine which were truly cases.  And so that effort has been under way.  In addition to that, with additional staffing and as the burden on the most acutely ill has gone down, it's allowed the establishment of more surveillance around the country.  And so what I'm hearing from my el colleagues in Mexico is that they are seeing some leveling off in places like Mexico City but there are seeing additional cases in other areas.  And when you talk about an epidemic or a pandemic, I mean it's not that everywhere gets hit at the same time, it's really a series of smaller outbreaks.So just as here we report cases in one state and then cases in another state, and then it moving around, that's the type of picture we're hearing about from Mexico.  What we're hearing is that there were a lot of people who had milder flu-like illness.  I don't know that we'll ever get confirmatory testing on all of those but the picture there is not as different as what we're seeing here.  One last question from the floor.

>> Hi, Sandra Endo from CNN.  Given the new guidance, schools should remain open or cease to be closed.  What guidance would you give just the general public, we see so many people walking around in fear, washing their hands is a good idea, but do people need to be wearing face masks and avoiding large gatherings, what guidance would you give the general public? 

>> I know people are concerned and some people are afraid.  I really wanted to see if we can try and channel that into planning and into action.  And the more we can channel people into actions that we know will be beneficial.  And so I say it again and again and again, hand washing is critical.  Viruses love to be transmitted by hands.  Hand washing or use of gels is number one.  Covering your cough with your sleeve is number two.  And then staying home, if you're sick or your child is sick is critically important.  The change in school guidance is not in any way diminished those factors.  Other things that you're describing like wearing masks in public.  There isn't the evidence base for that now if someone is peeling more comfortable for that I'm not going to tell them to take off their mask but we don't have the science base to show that's an effective measure and we do have the science to support the measures that we've been actively promoting.  In terms of planning, it's always good for families and individuals to have an emergency preparedness plan.  We're going into hurricane season around the country, tornado season in the midwest.

>> Make sure you have a plan to know what you'll do in an emergency.  That's something that will pay off in the long run.  Thanks very much. 

>> Two announcements.  One as Rich alluded.  The school guidance is now post and we do have B roll to the secretary's visit to the CDC emergency operations center.  If you're interested in the B roll -- it's available through the feed that you're currently getting right now.  So we're putting it up on the satellite.  So you'll be able to get it through the satellite.  Thank you for your interest.  And we'll talk to you soon. 

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES