A report published in the January 16 Morbidity and Mortality Weekly Report (MMWR) estimates that getting a flu vaccine this season reduced a person’s risk of having to go to the doctor because of flu by 23 percent among people of all ages.
Since CDC began conducting annual flu vaccine effectiveness (VE) studies in 2004-2005, overall estimates for each season have ranged from 10 percent to 60 percent effectiveness in preventing medical visits associated with seasonal influenza illness. The MMWR report says this season’s vaccine offers reduced protection and this underscores the need for additional prevention and treatment efforts this season, including the appropriate use of influenza antiviral medications for treatment.
“Physicians should be aware that all hospitalized patients and all outpatients at high risk for serious complications should be treated as soon as possible with one of three available influenza antiviral medications if influenza is suspected, regardless of a patient’s vaccination status and without waiting for confirmatory testing,” says Joe Bresee, branch chief in CDC’s Influenza Division. “Health care providers should advise patients at high risk to call promptly if they get symptoms of influenza.”
One factor that determines how well a flu vaccine works is the similarity between the flu viruses used in vaccine production and the flu viruses actually circulating. During seasons when vaccine viruses and circulating influenza viruses are well matched, VE between 50 and 60 percent has been observed. H3N2 viruses have been predominant so far this season, but about 70 percent of them have been different or have “drifted” from the H3N2 vaccine virus. This likely accounts for the reduced VE.
Flu viruses change constantly and the drifted H3N2 viruses did not appear until after the vaccine composition for the Northern Hemisphere had been chosen.
Another factor that influences how well the flu vaccine works is the age and health of the person being vaccinated. In general, the flu vaccine works best in young, healthy people and is less effective in people 65 and older. This pattern is reflected in the current season early estimates for VE against H3N2 viruses. VE against H3N2 viruses was highest — 26 percent — for children age 6 months through 17 years. While not statistically significant, VE estimates against H3N2 viruses for other age groups were 12 percent for ages 18 to 49 years and 14 percent for people age 50 years and older.
CDC recommends that people get a flu vaccine even during season’s when drifted viruses are circulating because vaccination can still prevent some infections and can reduce severe disease that can lead to hospitalization and death. Also, the flu vaccine is designed to protect against three or four influenza viruses and some of these other viruses may circulate later in the season. Flu activity so far this season has been similar to the 2012-2013 flu season, a “moderately severe” flu season with H3N2 viruses predominating.
Antiviral Supply Update
While manufacturers of antiviral medications have stated that there is no national shortage of antiviral medications at this time, and that there is sufficient product available to meet high demand, there are anecdotal reports of spot shortages of these drugs. CDC’s advice for patients and doctors is that it may be necessary to contact more than one pharmacy to fill a prescription for an antiviral medication. Pharmacies that are having difficulty getting orders filled should contact their distributor or the manufacturer directly.
For large institutional outbreaks this season, CDC is taking new measures to help match demand with supply, working with commercial partners to facilitate filling of large orders of antivirals for long-term care facilities or institutions having difficulty accessing antiviral supplies in outbreak settings. More information is available at http://www.cdc.gov/flu/antivirals/supply.htm.
Transcript of CDC Briefing (link)
Please Note:This transcript is not edited and may contain errors.
OPERATOR: Good morning and thank you for holding. The lines have been placed on a listen only mode until the question and answer portion of today’s conference. I would like to remind all parties the call is now being recorded. If you have any objections, please disconnect at this time and I would now like to turn the call over to Tom Skinner. Thank you, sir. You may begin.
TOM SKINNER: Thank you Elon. Thank you all for joining us today for an update on the 2014-’15 influenza season. With us today is the director of the centers for disease control and prevention, Dr. Tom Frieden who will provide opening remarks and he will be joined in the question session by Dr. Joe Bresee, spelled B-R-E-S-E-E, from our influenza division. Right now I’ll turn the call over to Dr. Frieden.
TOM FRIEDEN: Good afternoon, everyone, and thanks for joining us today. There continues to be a lot of interest in flu and we want to keep you up to date. I’ll give you an update on the flu season, but I want to begin by providing what I hope is the take away message from this briefing. Antiviral flu medicines are underutilized. If you get them early, they could keep you out of the hospital and might even save your life. It appears that we’re right in the middle of flu season this year, and so far it’s shaping up to be a bad year for flu especially for older people and people with underlying conditions. We’ve seen a lot of flu. There’s a lot of flu out there now and there’s more to come. Flu season’s unpredictable in its timing and in other things, but on average it lasts about 13 weeks. We’re around seven weeks into this year’s flu season. So we’re about halfway there. This year; H3N2 viruses that particular strain of flu, continues to be the predominant strain. And flu is now widespread in almost the entire country. There are early signs that flu activity might be declining in some states where it started earlier in the season, and the percent of people going to the doctor who have flu-like illness came down a little bit this week, but it’s too soon to say whether we’ve peaked. And as I’ve noted, we still have weeks of flu activity ahead of us. Key flu indicators suggest that this year is shaping up to be a bad one, particularly for people 65 and older. That’s what we expect for a season where H3N2 is the predominant strain. H3N2 is a nastier flu virus than the other flu viruses and years that have H3N2 predominance tend to have more hospitalizations and, sadly, more deaths. In fact, hospitalization rates in the over 65 age group are rising sharply. Last week hospitalization rate was 52 per 100,000. This week in the over 65, it was up to 92 per 100,000 and that’s high but it’s typical of H3N2 seasons. Last year — the last season that we saw an H3N2 season, that was two years back, 2012-’13 the cumulative hospitalization rate for people 65 and older by the end of the season reached 183 per 100,000 and we wouldn’t be surprised to see something similar happening this year. Also sadly we’re reporting another five pediatric deaths bringing the total to 26 influenza-associated pediatric deaths this season, and we know from past investigations that the actual number of deaths from influenza among children is even higher than that reported number. Also, one of the systems that we would to track flu deaths in 122 cities is again elevated this week. About two-thirds of H3N2 viruses analyzed this season are different from the H3N2 virus that’s included in this year’s flu vaccine. Protection with vaccination against these drifted H3N2 viruses will probably be reduced. We’re running early numbers on this season’s vaccine effectiveness and we expect to have an update in the next week or two. Despite the likelihood that vaccine effectiveness will be lower this year because such a large proportion of the H3N2 viruses have drifted, we continue to urge people to get vaccinated. Vaccinations may still offer some protection and there are other strains of flu out there as well. Furthermore, in many flu years there is a certain proportion of cases late in the flu season from other strains of flu such as Influenza B and this year’s flu vaccine is well matched with the predominant strains of Influenza B circulated. For vaccinations it’s important to remember that not only is flu vaccination important but Pneumococcal vaccinations is important as well and to remind you last September CDC announced a new recommendation that all adults 65 years or older get two different pneumococcal vaccines. Pneumococcal disease causes Pneumonia, can be severe, and having the flu increases your chances of getting disease with Pneumococcus — with the pneumococcal organization, the best way to prevent pneumococcal disease is by getting vaccinated. We recommend for those particularly over 65 and in high medical risk groups to get vaccinated against the pneumococcal vaccine as well. Next and most important at this point in the flu season when from past trends we think at least 90 percent of people who will get a flu vaccine have already gotten it this year, I want to address the issue of influenza medicines. CDC has recommended the use of antiviral drugs as an adjunct to vaccination. They’re the only medicines that can specifically treat influenza illness, and in the context of an H3N2 predominant season with a less effective vaccine, treatment with anti-flu drugs is even more important than usual. CDC scientists have looked very carefully at the use of influenza drugs in the clinical setting, and the conclusion is clear, they work but they aren’t being used nearly enough. They can reduce symptoms, shorten the duration of illness, prevent serious complications; if you have influenza and get the medicines early, you may not need to be admitted to a hospital. In hospitals people are given medications early. They may not have to be moved to the intensive care unit, and prompt treatment with antivirals could even save your life. The consumer research that we’ve done shows that most people don’t know that there are prescription drugs to treat flu and, in fact, studies that look at physicians prescribing practices show that doctors aren’t using these drugs as recommended, and that’s why we want doctors, nurse practitioners and physician assistants, all clinicians to consider antiviral drugs. In fact, one recent study showed that fewer than 1 out of 5 high-risk out-patients who clearly should have gotten treatment — treated with antivirals actually did. We’ve done some initial studies to understand this better, and these suggest that there are many different factors involved here. Clinicians may not be aware of the CDC guidance. There may be a perception that the drugs don’t work. Some doctors and other clinicians are waiting for a positive test before prescribing medications or may not prescribe antivirals after a two-day window after which the benefit is often. These are areas where we’re working to improve clinician awareness. Right now we’re expanding all of our efforts to reach clinicians with reminders about the value of these drugs. Earlier this morning CDC released a health advisory on this topic and our message to clinicians is clear, be aware that flu remains widespread and have a high index of suspicion for flu. In fact, in many of the areas where we do studies, more than half of the people with flu-like illness have confirmation that they have flu on detailed studies, but don’t wait for confirmatory testing. While antiviral drugs work best when given early, its treatment benefit may be present even if given later but early treatment is important and it’s not essential, it’s not necessary to get the tests done before you treat the patient. In fact, doing so may delay. If those treated with Tamiflu don’t have influenza, the benefit is going to be much higher. After all, doctors treat a variety of infections with antibiotics that aren’t actually infections with bacteria. If more individuals, particularly the elderly and those with underlying health conditions such as asthma, sickle cell disease, renal disease, diabetes, if people with those underlying conditions who have flu or flu-like illness got treated, we could prevent potentially tens of thousands of hospitalizations and possibly thousands of deaths. It may be useful for providers to implement phone triage lines to enable high-risk patients to discuss symptoms over the phone and to facilitate early initiation of treatment an antiviral prescription can be provided without testing and before an office visit. Certainly for all hospitalized and high-risk patients with suspected flu, treat as possible. If you’re at high risk for flu, 65 or older, your child is younger than 2, pregnant women, people with diabetes, asthma, lung disease or another chronic condition, check in with right away with your doctor, nurse practitioner, physician assistant or other clinician if you get flu symptoms. Antiviral treatment can mean the difference between a milder illness and a stay in the hospital or intensive care unit or even death. Finally, use common sense. If you’re sick, cover your cough. Don’t go to school or work. Don’t go near others so you don’t make them sick, too. That’s particularly important to help protect people who are most vulnerable to the flu in our families and communities. Finally, just to summarize, this flu season is shaping up to be a severe one, especially for older people and young children and people with underlying health conditions. Antiviral flu medicines save lives but they’re unfortunately underutilized. We’re encouraging clinicians to prescribe them for more severely ill and high-risk patients; even if those high-risk patients have mild flu illness. And it’s not too late to get a flu vaccination because the vaccine may still offer some benefit. If you’re at high risk for serious flu illness and have symptoms of the flu, see your health care provider promptly. Thank you very much.
TOM SKINNER: Elon, I think we’re ready for questions, please.
OPERATOR: Thank you. At this time if you would like to ask a question, please press star 1 on your touch tone phone. You will be prompted to record your name and record your name clearly when prompted. One moment please. Our first question today is from John Roberts.
JOHN ROBERTS: Good afternoon, Dr. Frieden; a couple of things. First of all, you’re encouraging practitioners to use antiviral medications in greater frequency than they have before. At the same time, over the years CDC has been putting out the message about not over using antibiotics, and particularly don’t use antibiotics unless you have a clear indication that they are necessary. But here you’re giving a completely opposite message to clinicians saying use these even if you don’t have a firm diagnosis. So how do you square those two things, particularly considering that antiviral medications can give rise to resistant viruses? And then as a second question, what’s the latest on the Ebola exposure in the laboratory there?
TOM FRIEDEN: So, first off, in terms of a medication like Tamiflu, the key thing as with antibiotics, if you’re prescribed it, take the full course. It’s one pill twice a day for five days and that course of antivirals will have a benefit and we have not seen the widespread emergence of resistance to Tamiflu. So unlike the situation where we’re very concerned and we want to actually have better stewardship and conserve the antibiotics used for bacterial disease and we’re working to reduce resistance, for the flu season we want to see more antivirals used. The risk is of progressive illness, hospitalization and death. The risk here is not of widespread emergence of resistance at this point. And in terms of laboratory incidence, the one individual who might have been exposed has not become ill and we’re continuing our investigation and we’ll have that completed by the end of the month.
JOHN ROBERTS: Great. Thank you.
TOM SKINNER: Next question, Elon.
OPERATOR: Thank you. Our next question is from Mike Stobbe.
MIKE STOBBE: Hi. Thank you for taking my question. Right. Yeah. There’s — clearly there’s an emphasis on more physicians more often prescribing antivirals for high-risk patients. Doctor, you talked about there’s one of the reasons that maybe it’s been low is there may be this perception out there that it doesn’t work. Of course, there was the report last year. I was wondering if you could speak a little bit more on that. Is it correct that per the FDA the drug does not make claims about effectiveness concerning reduced hospitalizations or complications like pneumonia? And I understand the argument it’s the best thing out there, but given the CDC’s emphasis on evidence-based medicine, are there plans by the FDA or other federal agencies to do more research on that question and maybe make more members of the physician community comfortable with how effective or not effective this — these drugs are in preventing hospitalizations and pneumonia?
TOM FRIEDEN: You’d have to refer questions about the FDA to the FDA, but our scientists have looked very carefully at all of the data associated with oseltamivir and influenza, and the data is quite consistent. We think in doing a summary of studies it’s very important to weight the studies as according to the strength of the methodology of different studies and to look at a range of outcomes and what we see quite consistently is particularly when given early, in the first 48 hours after onset of illness, there is an impact on reducing how long people are sick and how sick they get. Clearly, for example, one study that treated people for hospitalized showed that they were much less likely to end up in the intensive care unit. So there’s a clear and consistent set of data. To put it very simply, if I or one of the members of my family got flu or a flu-like illness, I would get them or me treated with Tamiflu as quickly as possible. Dr. Bresee, would you like to add to that?
JOE BRESEE: I would just say, Mike, that’s a good question. As you know or as you might remember, the FDA licensure process really included studies that were relatively small and looked at uncomplicated influenza as the primary outcome. The more severe outcomes like hospitalizations, like ICU, like death are less common, much more rare; you really rely on observational studies. These are studies done after the licensure of the product and therefore are considered in the product licensure package. The studies that have been done after the licensure of these drugs shows that these drugs work well to prevent complications in high risk individuals.
TOM FRIEDEN: Just because it does come up, I will say overall manufacturers have reported that they have sufficient product on hand to meet the projected high demand this season. There are spot shortages and delays in some parts of the country and in some pharmacy chains. In our discussions with manufacturers they have informed us that they are aware of these spot shortages and they’re taking measures to improve the supply situation, but what that means for doctors and patients is you may have to call around to a couple of pharmacies to make sure you find one that has the Tamiflu in stock now. Overall there’s no overall shortage at this point.
TOM SKINNER: Next question.
OPERATOR: Our next question is from Denise Grady.
DENISE GRADY: Thank you very much. I’d like to ask two questions please. One is you were mentioning young children, babies as high risk. Are they — is CDC recommending the Tamiflu be used in children? And if so, is there some lower age limit where it’s not appropriate for them? And the other thing I would just like to ask is do you have estimates of numbers of cases, say cases now — total cases in any given year? Thank you.
TOM FRIEDEN: I’m sorry, Denise. I missed the last question you asked, the last sentence.
DENISE GRADY: Oh, I just asked if you had estimates on numbers of case, number of cases so far this year and maybe overall numbers of flu cases in any given year, about what we see.
TOM FRIEDEN: So in terms of the lower age group, really there’s no — for oseltamivir, for Tamiflu there’s no lower age. For flu vaccination we say to begin at six months of age, but for treatment of an ill baby, in fact, infants under the age of two are at particularly high risk for severe influenza, so earlier treatment in that group is particularly important, although all children younger than five are considered at high risk — higher risk for complications of flu. The highest risk is for those that are two years or younger or younger than two years of age. In terms of the number of cases of flu, studies suggest that anywhere from 5 to 15 percent of the entire country gets flu in an average flu year. So you’re talking about tens of millions of cases of influenza, and in terms of hospitalizations, it can be hundreds of thousands of hospitalizations per year. Dr. Bresee?
JOE BRESEE: That’s right. Our estimates would say just the same, it’s that millions of cases of flu, millions or tens of millions of doctor’s visits for the flu. Each year we get well over 100,000 and often up to 400,000 of hospitalizations from flu and tens of thousands of deaths each year. I should say tens of thousands of deaths on the average year. The deaths can vary quite dramatically, as can the severity of flu. We did a study a couple of years ago that estimated that over about a 20-year period, deaths occurred, about 5,000, 50,000 deaths occurred in those years. There’s quite a big range of severity of the flu season each year.
TOM SKINNER: Next question.
OPERATOR: Thank you. Our next question is from Bertha Coombs.
BERTHA COOMBS: Hi. Thanks for taking my question. This time of year is when you start looking out for next year’s flu vaccine. Given what we are seeing this year, what is your analysis and what are you looking at and how are you tweaking that formulation?
TOM FRIEDEN: The selection of the flu strain for the next year relies on an international collaboration. We work with countries all over the world to track flu strains, so that we know what’s spreading in the Southern Hemisphere and we make the most educated guess possible about what will spread in the Northern Hemisphere. It’s too soon to say what the committee will recommend. We’ll see that in the coming month or so. What we know from last year is by the time the committee recommended it so that the manufacturers could gear up and produce it, this particular drifted strain of H3N2 had not been identified anywhere in the world. By the time the choice was made, the die was cast, if you will, for this year’s flu strain and then the variant strains or drifted strain emerged and then gradually over the summer and fall became the predominant strain.
BERTHA COOMBS: Right. Do you think it’s going to influence the process this year given what you’ve seen?
TOM FRIEDEN: What influences the process is the epidemiology. What strains are spreading in the community? We would expect if this variant strain of H3N2 continues, that will be in next year’s vaccine.
TOM SKINNER: Next question.
OPERATOR: Our next question is from Matthew Glasser.
MATTHEW GLASSER: Yes, hi. We’re starting to see a lot of influx people into emergency rooms. We’re seeing hospital diversions of ambulances. What’s your guidance in terms of people who start getting sick and the first thing that they do is go over to an ER or urgent care center?
JOE BRESEE: That’s a good question. Oh, I’m sorry, this is Joe Bresee again. That’s a very good question. This time of year, with flu, especially in severe flu years, we see this sort of situation where there are crowded doctors’ offices, crowded hospitals. I think it’s a difficult thing. We want to see in clinic, especially people with high risk conditions that might be at risk for severe flu and even death. Those people we’d like to call their doctor before they come over probably, but we don’t want people to avoid seeking health care if they have flu and if they have high-risk conditions especially. But I think that — I think that nurse triage lines are a good idea, but, Dr. Frieden, any other advice?
TOM FRIEDEN: No. I think it’s very important that patients be in touch with their clinician. On the one hand if it’s uncomplicated flu and someone has an underlying condition, the doctor may be able to call in a prescription without or before an office visit. On the other hand, if someone’s having trouble breathing or there’s a concern that they may be severely ill, it’s important that they seek care. One of the things that we are working on intensively with different areas around the country are what are some newer ways to get treatment out more promptly. We may have more information for you on that next week.
MATTHEW GLASSER: Thank you so much.
TOM SKINNER: Next question.
OPERATOR: Our next question is from Robert Lowes.
ROBERT LOWES: Yes, Dr. Frieden. Thanks for taking our calls. Do you have any preliminary figure or information on the effectiveness of this year’s vaccine?
TOM FRIEDEN: In another week or two we will. Not right now though, but thanks for asking and thanks for your interest. We do anticipate that it will be less effective. You know, even in a good year the flu vaccine isn’t as good as most of our vaccines. Its efficacy is around the 60, 65 percent range, which is, you might say, passable, but not what we would like, where we have 90, 95 percent efficacy of other vaccines. This year since two-thirds or more of the strains are drifted we anticipate it to be significantly lower, but we’ll see and as soon as we have that data we will share it.
ROBERT LOWES: Thank you.
TOM SKINNER: Next question.
OPERATOR: Thank you. Our next question is from Jennifer Emert.
JENNIFER EMERT: Thank you for taking my question. You said, you know, because the vaccine isn’t as good of a match this year. Is the CDC seeing less vaccinations then. Do you track that? What will happen with what’s left over? Does the CDC track how much of that flu vaccine goes unused? Why or why not?
TOM FRIEDEN: We do track vaccine use. There have been 145 million doses distributed. We’ve seen uptake rates that are very similar to previous years, not high enough. We work closely with the manufacturers. There’s always a balance between producing enough and not increasing the risk of manufacturers having too much on hand, but we haven’t seen a shortage of the vaccine and we have seen a similar uptake in past years. You know if you look at the people who deal with flu the most, nurses and pharmacists, were at 90 percent plus on vaccinations. I got my flu shot, I think everyone who’s sitting with me in this room did. It remains the single most effective way we can prevent the flu.
TOM SKINNER: Next question.
OPERATOR: And our next question is from Adam Smeltz.
ADAM SMELTZ: Hi, doctors. Thank you very much for taking our calls and for hosting this session. This goes back to the flu vaccine again. Dr. Frieden, I think on a call maybe in December you had indicated, if I recall, that close to 50 percent of the H3N2 strains that have been confirmed or cases, rather, that have been confirmed at that point involved a drifted strain. I hear you using the two-thirds figure now. Does that mean that more of the confirmed reported cases that you’re seeing are drifted than was the case in December?
TOM FRIEDEN: Yes, that’s exactly the case. What has happened since the spring is that the drifted H3N2 has steadily increased as a proportion of all of the H3N2s and H3N2s remain the predominant strain. So it has steadily overtaken the vaccine strain.
ADAM SMELTZ: Thank you.
OPERATOR: Thank you. Our next question is from Claire Hughes.
TOM FRIEDEN: Just before your question, it is possible that some of that drift is a result of what we call pressure or — from the vaccine itself so the influenza viruses out there may be selected for vaccine strains that are less amenable to the vaccine strains, so as the population had influenza spreading, the people who got the vaccine would have increasingly gotten the drifted strain and that may be one of the reasons that that has become the predominant strain. In other words, it’s a reflection — it may be a reflection of some level of the efficacy of the vaccine for the prior strain, but we’ll have to wait for next year to have a vaccine that covers this strain. Next question please. (Editorial note – All influenza viruses change over time. One factor that leads to changes in influenza viruses is the effect that population immunity plays. High levels of immunity in the population against a flu virus may make it easier for new strains to emerge and spread. Population immunity is the result of previous exposure to the viruses primarily through prior infections, but also through vaccination. As population immunity to older viruses’ increases in the population, the circulation of these older viruses is suppressed and antigenically drifted viruses predominate. The emergence of the drifted H3N2 virus this season is a good reminder that flu viruses are always changing, and continued efforts toward strengthening surveillance, updating and improving vaccines is critical.)
CLAIRE HUGHES: All right. Thank you. My question had to do with the supply of the antivirals, which you partly answered, but I wondered if you could say more about the regional shortages and spot shortages and where they are. Also, I would like to ask you to repeat part of a question, part of an answer I didn’t quite get, which is about whether there are children who are considered too young to receive antiviral medications.
TOM FRIEDEN: I would just reiterate on the spot shortage issue that the bottom line is you may have to call around. It’s not one particular part of the country. We’re seeing less flu now in the southeast. We’re probably still seeing increases out in the west. It’s variable in different parts. Our FluView has that in detail on the web, but the bottom line is that to get antiviral medication you may have to call around to more than one pharmacy. In terms of the age, there’s no age at which someone is too young to get treatment if they’ve got influenza.
CLAIRE HUGHES: Thank you.
OPERATOR: And we have just — we do have time for one final question. Our final question today is from Kristi Nelson.
KRISTI NELSON: Thank you for taking my question. The cost of prescription antiviral drugs can vary widely, especially when people are self-paying. Do you think that means a lot of lower income people are choosing to forego it, even though lower income people are more likely to have the underlying unmanaged chronic health conditions that can complicate the flu and land them in the hospital?
TOM FRIEDEN: We do recognize that costs can be a barrier for influenza vaccination. That barrier has come down with coverage, as well as lack of co-payments, but for antiviral treatment it’s an issue. Fortunately millions more Americans have health insurance that covers the cost of care and, of course, although there are co-pays, the co-pays for a prescription are far less than the co-pays for a hospitalization or time lost from work. Bottom — so thank you all for joining. I’ll just repeat the bottom line here. It is shaping up to be a bad flu year. We’re right in the middle of it now. We’ve got many more weeks of flu season to come. Antiviral flu medications are greatly underutilized, but if you get the flu and if you get medicines early, they could keep you out of the hospital, they could keep you from having to go into the intensive care unit and they might even save your life.
TOM SKINNER: Thank you, allain, and thank you all for joining us today. A transcript from this briefing will be available on the CDC media relations web page later this afternoon and should you need additional information, please call the CDC press office at 404-639-3286. Thank you.
OPERATOR: Thank you. And this does conclude today’s conference. You may disconnect at this time.
