June 11, 2009
Operator: Good afternoon, everyone. Thank you all for standing by and welcome to today's conference call. At this time your place lines have been placed on listen-only for today's conference. During the question/answer portion, please be sure to press star 1 and record your name at the prompt so that you may be introduced to ask your question. The conference is also being recorded and if you have any objections, you may disconnect at this time. I will now turn our conference over today to Mr. Glen Nowak. Sir, you may proceed.
Glen Nowak: Thank you for coming here and dialing in for this update on the H1N1. This will be directed by Dr. Anne Schuchat, Dr. Frieden who will make opening remarks, then turning the podium over to Dr. Schuchat. We'll then turn it over to questions and answers. I'll now turn it over to Dr. Frieden.
Tom Frieden: Thanks very much, Glen, and thank you all for being here. I want to welcome the media and also our partners on the telephone including health departments from around the country. It is wonderful to be back at CDC. I worked for CDC for 12 years and this Monday began my term as director. It is just great to be part of such a wonderful organization. Since the beginning of H1N1, I was health commissioner in New York City and was able to interact on a daily basis with the experts at CDC and have just tremendous respect and admiration for the great work that has been done here. I also want to recognize the leadership of Dr. Rich Besser, Anne Schuchat and Steve Redd through this period. They will continue to be part of CDC's leadership team in this response. I'm honored to be leading the nation's experts in this response to the Novel H1N1 virus.
As you know, W.H.O. has officially declared us to be in a pandemic, phase 6 of the global pandemic description. This is not a surprise. It was expected based on the data. W.H.O. waited until they were certain that they had documentation that on multiple continents it was person-to-person sustained transmission and this basically meets our definition of a pandemic. If a strain of the flu virus to which most of us don't have immunity, which is spreading from person to person in many parts of the world. This does not mean that there is any difference in the level of severity of the flu. This is not at this point a flu that's anywhere near as severe as the 1918 pandemic, for example. The declaration of a pandemic does not suggest that there's been any change in the behavior of the virus, only that it is spreading in more parts of the world. And really for all intents and purposes, the U.S. government has been in phase 6 of the pandemic for some time now. This, however, is important because it does send the strong message that the virus is here, it's in all likelihood here to stay, and it's important that we continue our aggressive efforts to prepare and respond. Our key goals are to determine where the virus is spreading and to reduce its impact, particularly on those who are most vulnerable -- people with underlying health conditions and infants as well in this case. I'd now like to turn the podium over to Dr. Anne Schuchat who will provide you with an update on cases around some of the action that's been taken.
Anne Schuchat: Good afternoon, everyone. I'd also like to welcome Dr. Frieden to the Centers for Disease Control and Prevention and this press conference. I'm going to give you a quick update on the situation, talk a little bit more about the W.H.O. declaration today, some clinical information, and then summarize some of the actions we're taking here at the Centers for Disease Control and Prevention with partners around the world.
Our U.S. situation, we are continuing to see ongoing transmission of this novel virus. The virus has reached every state in the country. Many of the states are seeing decreases in illness but there are a couple of areas where influenza-like illness is still above the baseline for this time of year. Our case counts, we've been increasing them every week at this point and we're trying not to focus on them but I can give you the situation. There are over 13,000 cases reported to us here in the U.S. There are over 1,000 people who have been hospitalized that have been reported to us. And our last update on the counts of death are 27, but we'll be updating that soon and I do, unfortunately, expect that number to rise. The regional trends that we've been seeing on our website, we're showing that information, we're tracking the influenza-like illness from our 4,800 sentinel providers around the country. What we're seeing is that region 1 and region 2 still see increases above what they'd expect. Region 1 is New England, and in particular Massachusetts is having some challenges. And region 2 is the New York/New Jersey area, and they're also above baseline but plateauing above baseline. I think it's important to recognize that we have to keep our eye out for this, that people think that it's over, flu season is over. But you know, we do expect that there may be continuing transmission over the weeks ahead and we need to remain vigilant. We're looking for that and we know that a number of health departments are still working very intensively.
Let me mention a few things about the pandemic alert level or the pandemic phases. As you know, Dr. Chan, the Director General of the World Health Organization, declared phase 6, announcing that it is a pandemic now. I want to go a little bit into detail about what that means for individuals and what does that mean for countries and our global community. This phase 6 means a pandemic is under way. We've been talking about this for years, we've been planning for it, and of course here in the United States we've been reacting as though we were in a pandemic already in terms of our intensive efforts to prepare individuals and respond as a nation. This means, just as we've been talking with Americans, it is important to remember the personal steps you can take to reduce spread of infection and to keep yourself and your family healthy and safe. Important to cover your cough or sneeze, important to stay home if you're ill, not traveling when you're ill, and to really be prepared for greater amounts of illness in your community or your school. What does this mean actually for others? It means that for countries that weren't already seeing the kind of community transmission that we have here in the United States, they really do need to dust off those pandemic plans, make sure they know how they're going to react as illness increases in their own communities, and take aggressive steps to follow what's going on.
We say that influenza is unpredictable, and I know it is really frustrating because we wish we could tell you exactly what's going to happen, but we can't. So we have to be prepare for changes in the amount of illness, the severity of illness, the characteristics of the virus, and the reactions of our communities. And what this really means, this spread to multiple regions that is what defines a pandemic, an actual pandemic, what it means is that the virus is spreading, not as Dr. Frieden said, not that it has changed in the apparent severity. Now severity's been something a lot of people have been talking about. We can think about the severity to the individual and we already know that this virus can cause very mild self-limited disease that gets better without treatment, but it is also able to cause very severe illness for an individual, hospitalization, intensive care unit, or even death. And we try to look at the spectrum of how much of that severe to mild illness is there. Right now the world health organization is characterizing this as a moderately severe pandemic. They're not saying it is the same thing as that 1918 devastating pandemic, but it's something we have to take seriously and we need the countries to be paying attention to. Of course, the same virus can cause very different patterns in different countries. We know some countries have limited health structures and health services, and some communities have more people who are vulnerable to life threatening infections with the same kind of virus that would cause a mild illness in others. So I think we really need to work together. We're really all in this together around the world. Here in the U.S., the phase 6 declaration isn't going to change our day-to-day activities. We continue to take this seriously, continue to work with state and local health departments and the provider community, and continue to want Americans to be aware of this and be thinking ahead. You know, taking those safe precautions of covering your cough or sneeze, but also thinking about if things got worse in my community, how would I cope with that. We're not restricting travel outside -- to particular countries. We're not changing those types of things. This is not what the meaning of the declaration is. It's just really important to remember that a pandemic is a global thing. It means that the whole world is united around this condition now. For a while there it looked like it was just the Americas.
A couple points about the clinical picture. We continue to see a disproportionate amount of illness in hospitalizations. Younger people compared with the elderly. With seasonal influenza, in a typical year we see a lot more disease in the elderly. But in some ways this Novel H1N1 virus is behaving somewhat like the seasonal H1N1 viruses which tend to affect younger people and not the elderly so much. The H3 viruses, the influenza H3 viruses tend to affect the elderly and often are quite severe there. In other respects, of course, this virus isn't like the seasonal H1N1 because we don't think there's general population protection. It is a very new virus. 57% of the cases that we're having reported to us occur in people 5 to 24 years of age, and 41% of the hospitalizations are in that same age group -- the older children and young adults. But I also want to tell you about the rates, the cases per 100,000 population, and let you know that the highest rates of hospitalization are actually in children under 5. And the next highest rates are in those people 5 to 24. So it looks like this is a virus that's disproportionately affecting younger people but there are still lots of infections and hospitalizations in older persons. According to the U.S. statistics, 71% of the hospitalized patients have occurred in people who have an underlying condition -- respiratory illness like asthma or conic obstructive pulmonary disease, immune deficiencies, and so forth. As we have noted, there's been a disproportionate amount of pregnant women among those who have had infection.
Let me turn last to the actions that we're taking. There are two categories I want to cover. One is understanding the problem and the other is preparing for prevention. To understand this problem we're now intensively focused on the southern hemisphere. We still have spread here in the U.S. but we're looking to the southern hemisphere which is just beginning their influenza season. We of course at CDC have people stationed around the world working on a number of conditions and they're helping us know what's going on with influenza. We also have deployed staff to selected countries in the southern hemisphere to get a little more of the ground truth. We are hearing reports officially from several southern hemisphere countries about increases in disease and those have also been in the media. Australia's going into their flu season. They've reported a lot of cases so far. Chile has also reported a lot of cases. They've been very open and transparent about their circumstances and congratulate them for that. The second area of actions is about vaccines. As we've been talking over the weeks, vaccines are a very important potential prevention opportunity for a pandemic of influenza. It is important to separate a couple things. We think about vaccines in terms of vaccine development, vaccine manufacturing, and vaccine administration or delivery. At this point the government has launched an effort to develop a vaccine against this strain and we are in the early stages of manufacturing. There has not been a decision to actually vaccinate people, and that's a very separate decision that will be made later on, quite a bit later once we have more information. At this point what I'd like to do is turn things back over to Dr. Frieden. I think he and I will take questions.
Tom Frieden: Thank you, Dr. Schuchat. In summary, we know that the virus is circulating widely now, not only in the U.S. and neighboring countries, but also in many parts of the globe. The unfortunate news is that it seems to spread faster, at least in schools-aged children than we've been accustomed to seeing. The good news is that so far, we've not seen lots of disease among the elderly who tend to be the more severely affected by seasonal influenza. Given the continued transmission and the uncertainty about the course that had will take, our role will be to continue intensive preparations and planning for the coming months. We can expect to see continued and increased urgency and visibility of planning efforts. We can expect to see continued efforts to develop a vaccine and we hope and anticipate that that may be in place by the fall. Again, a decision of whether or not to use the vaccine is a separate decision from whether or not to make the vaccine. But obviously we need to make it in order to make the decision of whether or not to recommend it and use it. There's been excellent cooperation with the World Health Organization and with countries around the world. This is one of the many conditions that reminds us that we are all connected, and many of our decisions in the U.S. will rely on good information from countries in Latin America, in Africa, in Asia, Australia and elsewhere. So very important that we confront this jointly. Of course, state and local health departments are at the forefront of responding to H1N1 and facing many very difficult and daily decisions.
We're faced with a situation of uncertainty. We wish we could foresee the future. We wish we could know what course it will take. But what we're doing now is getting information as effectively as we can so that we can take the steps that are most sensible now to reduce the number of people severely ill or tragically, who may die from H1N1 influenza. One of the key steps is that for anyone who does have a fever, a measured fever, take your temperature, over 100, along with either cough or sore throat an also has an underlying condition, whether you have asthma, diabetes, or are pregnant, or an infant under the age of 2, see your doctor right away to see if you should be treated for influenza with antiviral medication. There will be increased discussion and planning with school officials, faith organizations, community organizations, the business community, on how to address flu when it comes back in the fall and winter. Moving forward, we'll have to address two different challenges -- seasonal flu, as we have each year, and Novel H1N1 influenza. We'll be looking at those separately and how they relate to each other. This is a shared responsibility -- government, health care providers, the private sector and the public. All of us are in this together to respond to what can be a challenging situation. Up until now we have been fortunate that we have not seen a level of severity that's greater than seasonal flu, and the fact that it has not, until now, affected seniors heavily is fortunate and we'll be tracking to see if that remains the case. At this point I want it thank everyone for being here and we'll turn to questions.
Mike Stobbe: Hi, doctor, Mike Stobbe from the AP. Regarding the W.H.O. announcement, there was speculation or even expectation that might happen for weeks and weeks and weeks. Now that it's finally happened, was that delay in some way beneficial in terms of the public understanding that it wasn't as severe as it might have been at the beginning? Can you comment on that?
Tom Frieden: I think for some time maybe if we had it to do over again a few years back when we set the six phases of influenza activity, we might have had a different way of doing that that also would incorporate the level of severity. This is at this point nowhere near the level of severity of the 1918 pandemic which many of us think of when we think of a pandemic. I think what's W.H.O. wanted to do was make sure, verify, get set so that we could understand it. But really the practical implications are not significant. We have been acting as if it's a pandemic for some time, and of course in the U.S. and in the Americas, we have already had wisely continued transmission for some time. So this doesn't change any of our actions.
Mike Stobbe: Could we avoid some hysteria as a result of the delay?
Tom Frieden: Well, I think as time goes by we better understand the particular strain. At the same time, we're concerned that people not become complacent because this is a Novel strain of influenza, it has spread rapidly. So we have to balance our response. We have to be prepared, we have to ensure that when people are sick they stay home, encourage people to cover their cough when they cough and cover their sneeze when they sneeze, take medications if they have an underlying condition and have fever with cough or sore throat. And at the same time, recognize that this isn't a situation that is such that we would take broader actions at this time.
Operator: Our first question comes from David Brown with the Washington Post.
David Brow: Thank you very much. I have two unrelated questions. One is, Dr. Frieden, could you just repeat the advice to consumers about the age and clinical symptoms that warrant going to see the doctor? And my second question is, how many doses or what is the current size of an order that HHS has put in to various flu vaccine makers for production of vaccine?
Tom Frieden: In terms of recommendations to the public, if you have symptoms of flu -- and by "symptoms of flu," we mean a fever that you measure and that's at least 100 Fahrenheit, along with either cough or sore throat, and you also have an underlying condition, such as asthma, which has been the most common underlying condition we've seen, or you are pregnant, or for an infant under the age of 2, see your doctor to see about treatment. In terms of vaccine order, I'll turn that over to Dr. Schuchat.
Anne Schuchat: Our HHS Secretary Sebelius announced May 22nd that nearly $1 billion was going towards vaccine development and manufacturing. That included resources for the clinical trials that are being carried out through NIH and through the manufacturers in collaboration, of course, with the FDA and with the part of HHS that works on these pandemic matters. It also included resources to assure manufacturing capacity for both antigen, the component of the vaccine that gives you that immuno response, and the additional chemical that can sometimes increase the immune response that's more specific to the antigen. So the actual amounts -- or I can give you dollar figures rather than not ghost information -- there are five different manufacturers that the HHS has contracted with and there's been a procurement order for a total of $650 million worth of antigen, and $287 million worth of adjuvant. It is posh to say there are a lot of steps important in the clinical development of a vaccine and the testing and we can't predict today how much antigen would be needed. For the H1N1 vaccine we need a lot of antigen to get the response but with adjuvant you could get a different response. We need to be able to manufacture vaccine in case there is decision to use vaccine we have it on hand. Even if the decision to use vaccine is not made, these orders permit the chemicals to be stored in bulk where they could later be formulated if they needed to be. We've done this in a way that's giving us a lot of options for the future.
Glen Nowak: Thank you, Anne.
Operator: Our next question comes from Alice Park with Time Magazine. Ma'am, your line is open.
Alice Park: Yes, this is also a question about vaccines for either Dr. Schuchat or Dr. Frieden. At this point do we have any better information for how well this vaccine is going to be matched to whatever strain we might be in the fall, and how quickly would we be able to adjust this vaccine if we were to see a slightly different variant of this H1N1 become more prevalent in the fall?
Glen Nowak: I'll have Dr. Schuchat answer that question.
Anne Schuchat: The good news so far is we have tested a number of isolates from around the world, including different countries and many different states here in the U.S. Characteristics of the virus are the same, suggesting that the strains that are being used for vaccine development are matching the strains that are continuing to circulate. But with influenza, we need to keep looking. So we'll be testing strains through the course of the weeks and months ahead and learn more from that about whether whatever may circulate here in the fall or winter is still the same as what has been circulating so far. So at this point we have no reason to think that the strains that are being used to develop vaccines have any kind of diversion from what's circulating. Now, of course you've asked the question about how well will this work. That's the million dollar question because we don't know yet. We're going to need to do those clinical studies to see whether a vaccine that's developed gives a good immune reaction in different people, whether vaccine with or without adjuvant and whether there are different doses people need to get a good response. Those are studies we'll carry out over the next several months and we'll look forward to seeing results from them.
Glen Nowak: Is there a question in the room? Okay, operator?
Operator: Helen Branswell with the Canadian Press.
Helen Branswell: Thank you, very much. I would ask two unrelated ones, as well, if I could. The first is about the fact that authorities, both the U.S., internationally, everywhere, seem to be often saying that most of the people who get sick or require hospitalization are people who have underlying health conditions. Thing is though that many of the conditions creates a very, very broad umbrella. And I think that many of the people who are standing under that umbrella may see themselves as healthy individuals, you know, people with asthma may not sort of see themselves as inherently unwell. I'm wondering if you have some concerns that there may be people who don't think they're at risk because they don't view themselves as having co-more bid conditions. That's the first question.
Glen Nowak: Let me address that first question. I'll have Dr. Frieden answer that first question.
Tom Frieden: This is a valid concern. We want to make sure that what we're trying to do at this point in the U.S. we don't have a vaccine. So the most effective thing we can do to reduce the impact of H1N1 in the U.S. in communities where it's continuing to spread, first, stay home if you're sick. You're not doing yourself or the community any favor by going out and possibly infecting other people and not feeling as well yourself. Second, of course, cover your mouth when you cough. And then, for those who become sick, if you have an underlying condition, seek care promptly, because quick treatment does make a difference. And it is important to recognize that if you have asthma, that means you may have a lot more trouble breathing if you have an infection like flu. That's an important time to consider going to the doctor to get evaluated. If you're having trouble breathing, go to the hospital very promptly. So it is important that people recognize they are in a group that may be at higher risk so if they do develop a measured fever that's high, along with flu-like symptoms, they can promptly receive care. You don't even necessarily have to go to your doctor. In most jurisdictions you can call your doctor and he or she may be able to provide a prescription over the phone or if you're very ill, direct you to go in to get seen immediately in a place that can provide more intensive care.
Helen Branswell: Thank you, could I ask a second question?
Glen Nowak: Sure, go ahead.
Helen Branswell: Thanks very much. Early evidence in the southern hemisphere points to this new virus potentially crowding out the seasonal flu viruses which is something that's been seen in previous pandemics. I'm wondering if anybody is giving any consideration to the notion that, come fall, you're not going to want to be using up resources administering seasonal flu shots.
Glen Nowak: I will have Dr. Schuchat respond to that question. Anne?
Anne Schuchat: The pattern of illness of the inch influenza strains in the southern hemisphere is an important issue that we're tracking. And of the information we have so far, in some places they're seeing this Novel H1N1 virus earlier than your usual flu season and it is the main thing circulating. And in other countries we've heard reports that it's the minority strain, the other usual seasonal flu strains are more common. We'll be looking at that over time. Seasonal flu vaccine production is well under way and we're expecting as much as we can ever predict, we're expecting a good supply of seasonal influenza vaccine to be available. And we are continuing to expect to be administering the seasonal influenza vaccine and making sure people get it. Now there's a couple things to remember. Seasonal influenza can be a bad thing. About 36,000 people die from that every year, and it's disproportionately a problem in the elderly and the vaccines that are available can really reduce illness as well as some of the complications. We are expecting to be using that seasonal flu in the fall. Another thing to consider is that, when you have circulation of the seasonal flu strains in this new Novel H1N1 virus, we're concerned about the possibility of the mixing of the strains. Seasonal H1N1 virus that we've had this past year is resistant to Tamiflu. And we really don't want this Novel H1N1 virus to become resistant to Tamiflu as well so there can be some benefit from trying to reduce these other infections even in the circumstance of a Novel strain. I think it's really premature for us to make any definitive conclusions about the seasonal influenza vaccine, but based on what I know today, I'm not expecting us to change our recommendations about that.
Glen Nowak: Operator, I'll take another call from the phone.
Operator: Our next call comes from Stephen Smith with the Boston Globe. Your line is open, sir.
Stephen Smith: Hello, good afternoon. I, too, would like to pose two unrelated questions. The first is, I'm hoping that you might be able to explore -- certainly Dr. Frieden, from your previous perch in New York, you have a particular insight on this point -- why we are seeing continuing elevated activity in New England and the New York/New Jersey areas and what's being done to better understand that. And my second question is, from what has been reviewed to this juncture, what in your estimation are some of the supply chain issues going forward that need to be addressed and refined?
Glen Nowak: I'll let Dr. Frieden ask the first question and Dr. Schuchat the second question.
Tom Frieden: Influenza is one of, if not the most, unpredictable of all infectious diseases. And why it acts the way it does, why it goes away in the summer, usually, why it has been more intense in some areas than others is very hard to predict or very hard to explain. What at least we can do is to track it carefully. We do know that there are parts of the country where we still see lots of influenza-like illness. Some of that may have to do with people being more sensitized. Going in for care more commonly. But some of it clearly reflects increased community activity of influenza and the reasons for that are very hard to determine. We'll be looking at that. We're working with groups of researchers who can try to understand that better, but the implications really aren't any different. There's flu around, so take it serious I had, particularly if you have an underlying condition.
Anne Schuchat: Could you just repeat that second part of the question?
Stephen Smith: Certainly. What's been experienced vis-a-vis these supply chain issues whether it has to do with antivirals, whether it has to do with getting masks out -- because there have been shortages across the country, transient shortages. I'm just wondering what sort of lessons have been learned about -- it's often discussed we live in a just-in-time economy. I'm wondering, as you now have seven or eight weeks experience with H1N1, the sorts of lessons that have been learned from that and how that might lead to some tinkering with supply chains as we move into the fall and the prospect of having two strains in circulation.
Anne Schuchat: Thank you. Those are terrific questions. Before this Novel H1N1 virus was recognized, of course the U.S. government and our partners at state and local levels were actively working on preparedness plans for just such an eventuality and they did involve things like procurement and stockpiling through our strategic national stockpile of antivirals and personal protective equipment like masks, and exercises where we would practice how would we move them around and state and local exercises to figure out how would we further distribute them, and we really tried to get as ready as we could. This past several weeks has been an opportunity to test those plans in action, and there have been some challenges. What's going on right now is an intense effort working with state and local governments to try to gather those lessons learn and to understand what worked well, what didn't work well, how can we take those lessons and really get more ready for the fall. So the association of state and territorial health officials is hosting a series of regional meetings that's really going to try to pull together that kind of lessons learned, not just about supply chain issues but really about all of the components of our response. I think this will be vital information for us to reaction better in the fall an potential information to share with our colleagues in the southern hemisphere who are just facing this concern right now.
Glen Nowak: We have time for two more questions.
Operator: Our next question comes from Craig Schneider with the Atlanta Journal Constitution.
Craig Schneider: Hello. I just wanted to ask if this new level of -- for the pandemic is expected to create any kind of changes for state or local governments?
Glen Nowak: I will have Dr. Frieden answer that question.
Tom Frieden: The new W.H.O. level really makes no practical difference for state and local governments around the U.S. We've already been in a situation where there is widespread person-to-person spread of a virus to which most of the population does not have immunity. So there are no practical implications for most state and local health departments in the U.S.
Glen Nowak: Operator, one final question.
Operator: Our final question comes from Shannon Pettypiece with Bloomberg news.
Shannon Pettypiece: I was wondering, based off the information you have so far from the statistics, is there any way to say this flu strain right now appears to be less severe than the seasonal flu as far as fatalities and hospitalizations. I was also wondering just on the vaccine question, I know we talked about it a lot, but is it still a question of concern about whether we're even going to have a vaccine available and through all the testing and clinical trials by the time flu season comes around?
Glen Nowak: I'll let Dr. Schuchat answer those questions.
Anne Schuchat: The first question was about the severity of this virus compared to seasonal influenza. And at this point I think it's premature to conclude that it is less severe than seasonal influenza. We're certainly seeing pretty severe illness in individuals who are young, including some people who are young and otherwise healthy, unfortunately. So from that perspective, we're seeing this range, this spectrum where the vast majority of people have an illness that gets better on its own and this much smaller proportion of people have quite severe illness. So I think we're really looking to larger numbers and to understanding more detail the potential severity over large population. The second question was about whether we have a vaccine. That's a really good question. You know, we have mechanisms in place to develop a vaccine and to test it and to study it, and we're going to need to look at the results. We're going to need to study the results. We cannot assume that everything is going to go perfectly. There may be some bumps in the roads, there may be some really big bumps in the road. I think we need to be prepared for the possibility that a good vaccine may not be created or that we may not have it in sufficient time before we have a lot of disease. And that's why it's so important for individuals and communities and governments to continue to prepare. Vaccines aren't the only tool that we have in the tool box. We have other efforts like appropriate use of the antiviral drugs, mitigation efforts like social distancing or school dismissals as appropriate. There's a lot we can do individually and in our communities and I think we have to be ready for the idea that we may not get a vaccine as soon as we'd like it, or we may not get a vaccine that works as well as we would like it, or we might not even get a vaccine. We're really taking all the steps we can to make sure that we have one if we need it. But I think there is uncertainty in that just like there is uncertainty in the nature of the influenza virus.
Glen Nowak: Thank you all for coming here and participating in this press briefing. The transcripts will be up in the next few hours. If you have any additional questions, please contact CDC's division of media relations. Thank you.
Operator: That does conclude today's conference call. We thank you all for participating. You may all now disconnect and have a great day.