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Press Conference - The Developing H1N1 Flu Virus Outbreak

Press Conference

Location: Washington, DC

Participants: Dr. Richard E. Besser, Acting Director, Centers For Disease Control And Prevention (Via Teleconference From Atlanta); Secretary Of Health And Human Services Kathleen Sebelius; Secretary Of Homeland Security Janet Napolitano

Moderator: Lark Mccarthy

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MS. MCCARTHY: Joining us now is Kathleen Sebelius, the newly confirmed secretary of the Department of Health and Human Services.


MS. MCCARTHY: The -- thank you so much for coming in.

SEC. SEBELIUS: Glad to be here.

MS. MCCARTHY: Also with us, Janet Napolitano, the secretary of Homeland Security. Madame Secretary, welcome as well.


MS. MCCARTHY: And joining us from Atlanta, Dr. Richard Besser, acting director of the Centers for Disease Control and Prevention. Welcome, Dr. Besser, to you as well.

DR. BESSER: Thank you.

MS. MCCARTHY: (Instructions for questioners not transcribed.)

So let's jump right in.

Secretary Sebelius, let's begin with you. What's the latest news, from the HHS perspective, about H1N1 today?

SEC. SEBELIUS: Well, I -- I'll tell you what I know, and then ask also to have Rich Besser join me in this dialogue. As you know and have just said, on a daily basis we're updating the American public on the information. So at 11:00 every day on the CDC website, -- www -- -- there is an update on numbers of cases and what's happening around the country. We're in a dynamic situation, so it does change every day.

Dr. Chan raised --

MS. : With the World Health Organization, right.

SEC. SEBELIUS: -- with the World Health Organization, increased the level to a level 5. And I just want to assure the American public who is listening and watching that we've anticipated that. That just means additional resources will be made available, additional opportunities will be there for us to reach out to state and local partners, but also around the world, which is Dr. Chan's information.

And we are aggressively trying to both contain and stop the spread of this influenza.

There are some schools who have taken individual action, closing districts. And I think most importantly people need to monitor and become informed about the spread of influenza. We know, in flu season, every year, we have millions of Americans get the flu. Hundreds of thousands are hospitalized. And unfortunately we have about 36,000 deaths with seasonal flu.

So we need to keep this operation in perspective in terms of, we don't know quite how serious this is going to be. We don't know how widely it's going to spread. And we don't know precisely the results. But we are well within the bounds of not only working aggressively to contain it but also beginning the process of developing a vaccine, which will be ready to inoculate.

MS. MCCARTHY: Obviously a lot is going on.

SEC. SEBELIUS: A lot is going on.

MS. MCCARTHY: All right. We're going to break down some of that throughout the broadcast. Let's just turn to Dr. Besser, because you raised a number of things.

Dr. Besser, you did just give your update a short time ago. When people hear that number, 109 confirmed cases in the United States, what does that mean?

DR. BESSER: Well, what that means is that we have 109 individuals who had flu-like symptoms and did what they should. They went and saw their doctor or called their doctor, got tested. And they are confirmed as having the H1N1 virus.

We have those individuals in 11 different states. And as we've all been saying, as we continue to look for cases, we expect that we're going to find them in more or more states.

We're working with state and local health departments. They're investigating cases in many more states than have confirmed cases. And we expect, as we move forward, to see a wider spectrum of disease, with some more severe cases as well.

MS. MCCARTHY: All right. Let's talk about, what does this change mean, from the World Health Organization, that we're now at 5? What does it mean to us in the United States and to us as individuals? And when the World Health Organization says they have 148 cases worldwide, what database are they using? That seems out of phase with what we know right now.

DR. BESSER: Right.

I was pleased to see that the WHO had made this move. In the United States, it does not have an impact, in that we have cases here within our borders. And we're taking aggressive action, to try and minimize the impact on people's health.

What it means for the world community though is that countries around the world that haven't started their efforts, around preparing for a new flu strain, it's time for them to wake up, pull out their plans and think about what they would do, if they had cases appearing in their own borders.

The number 5 means that according to the World Health Organization, a pandemic is imminent. And that means that this strain is spreading. And it is causing disease in more and more places. That's basically what that number means.

MS. MCCARTHY: So I know your message has been that the government is responding aggressively, regardless of what the designation is, correct?

DR. BESSER: That's right.

Whenever we see a new infection, whether it's flu or another one, we take aggressive steps to try and understand what's going on and implement rational, smart control measures. And those measures change, as we learn more. This is a situation like others, in that we take what we know. We implement measures and we adjust as we get more information.

Q Secretary Napolitano, let me ask you something that I've heard from people. I'm sure you've heard this.

Why isn't the United States closing its borders?

SEC. NAPOLITANO: Well, a couple of reasons.

One is, the epidemiologists, the CDC, the WHO all have said, there's no utility to closing the border.

The president last night likened it to closing the barn door after the horse already is out of the barn.

And therefore we're doing the things that make sense from a public health standpoint to protect the safety of the American people.

So the real focus needs to be now on what do we do to reduce the spread of the disease within our borders. But closing the borders, in and of themselves, won't have that kind an impact.

MS. MCCARTHY: Right. We should note, Secretary, that plan first -- for example, we've been doing these broadcasts for a year now, and some people may not appreciate the complexity of a lot of these decisions, because, for example, you mentioned the schools, that -- well, why would one school district close down while others are still open? Can you just briefly explain that?

SEC. SEBELIUS: Sure. Well, first of all, I think that the idea that we're here on this kind of broadcast is very important, because one of the things we're trying to do is get information to the public, to parents -- I'm a mother. I know that there are parents out there thinking: You know, what should I be doing?

MS. MCCARTHY: Absolutely.

SEC. SEBELIUS: Can I keep my children safe? How do I -- you know, how do I care for an elderly parent? What are the proper protocols?

So having this kind of dialogue, I think, is enormously helpful.

(Audio break) -- closing schools is primarily a local decision. And what the Center for Disease Control's Dr. Besser has done is to ask school districts, if a school has an identified case, a confirmed case, that that particular school is advised to close -- close for about a week, make sure that cases aren't spreading, try to contain it. But as he is good at pointing out, that doesn't mean send your kids to the mall. What we're trying to do is control group settings when there's a confirmed case, and we figure that students within an individual school may have come in contact with one another.

So it's really a social isolation a bit. It's taking a step back. Don't go to the movies. Don't -- you know, try and contain this. It doesn't mean that the district should shut down. That has happened a couple of --

MS. MCCARTHY: It has happened, yes.

SEC. SEBELIUS: -- a couple of school districts have decided that they would take broader measures. But that is not the recommended protocol at this point from CDC. And so we're telling parents that if there's a confirmed case, that's likely to happen.


SEC. SEBELIUS: And what parents can do is begin to think about what happens if you get a note coming home with Johnny from kindergarten that says he won't be coming to school for several days. What are the contingency plans? What's the backup plan? Because that's a piece of sort of personal preparedness that would be very helpful.

MS. MCCARTHY: Okay. All right.

We're starting to get lots of questions -- (chuckles) -- as you might imagine, from our viewers, and we do encourage you to keep e- mailing us throughout the program. It's

Please get them in quickly. And we're going to try to get them answered, as many answered as we possibly can. All right. So let's get to one. For Dr. Besser, this is from Ellen, who's in Michigan.

She says, my husband works in a factory. The parts come from Mexico. If touched, can he get sick, Dr. Besser?

DR. BESSER: No, that's not the case.

We do know that flu can be spread from things that they touch very quickly. So you know, if you're dealing with someone who has flu, and they hand you something, or you shake hands, that can be a means of passing the virus. But the virus doesn't survive that long.

The question though does raise the importance of borders and why we have to be very careful, when we talk about borders as a means of controlling disease. It's so important that there be free movement of parts, to keep that gentlemen in his job.

MS. MCCARTHY: Another question for you, Dr. Besser. This is from Muriel in Richmond, Virginia.

My family is planning a reunion in San Francisco in July. Do you suggest canceling it? My daughter and my father both have respiratory problems.

DR. BESSER: I don't recommend canceling it. Keep those plans in place. This is a rapidly changing situation. By July, we're going to know so much more than we know today. So keep those plans moving forward. It's a different story if you were having a reunion right now in Mexico, given the travel warning that's in place for non- essential travel to Mexico.

MS. MCCARTHY: All right. Let's just talk about travel, because that is.

What do you say about people that are about to get on a plane today or tomorrow? Is there any reason not to do that?

SEC. NAPOLITANO: Well, there's a travel health advisory for Mexico. And that means that the State Department is discouraging non- essential travel to Mexico. But beyond that there have been no other warnings issued that I'm aware of. And again part of this is, people need to be aware at all times. That may change over time. But right now we're talking about an outbreak of flu in Mexico, an outbreak around the United States.

And certainly we're not halting all travel within the United States, so.

MS. MCCARTHY: All right. Is there any reason for people to avoid mass transit -- the subway, the bus, the commuter train?



SEC. SEBELIUS: Again, I don't think so. And Dr. Besser has been asked this question a number of times. This is a dynamic situation, so the answer today is based on what we know and how rapidly this is expanding. And the travel advisory, as the secretary has just said, is really for nonessential travel to Mexico only. We're saying now to people --

MS. MCCARTHY: To Mexico, is the only warning out there right now.

Dr. Besser, you want to jump in? Want to be --

SEC. NAPOLITANO: Well, but I want to --

MS. MCCARTHY: Yeah, go ahead.

SEC. NAPOLITANO: I want to put one caveat on my --


SEC. NAPOLITANO: If you are sick --

SEC. SEBELIUS: Yeah. Right.

SEC. NAPOLITANO: If you have a fever, you should avoid travel. You should avoid perhaps exposing others to the flu. And so that's the one exception to the rule.

MS. MCCARTHY: Okay. All right. We're going to try to get to our next questioner. Dr. Besser, Rosemarie (sp) in Dallas: "If a person diagnosed with the -- with swine influenza has been in an office building, what sort of decontamination is needed?"

DR. BESSER: If you've come in contact -- if an individual has this infection and has worked in a work site, there really is not significant steps that need to be taken. If you're working at their workstation, you could wipe down the keyboard with some alcohol. Beyond that, there's nothing that you need to do.

MS. MCCARTHY: All right. And we should point out there is information on the CDC website about, you know, what sort of wipes and things to use.

SEC. SEBELIUS: There's guides for teachers, for parents, for workers, that's very helpful.


DR. BESSER: That's right.


All right, this is from Tyanna (sp). This is for Secretary Napolitano: "I'm the spouse of a TSA officer. What precautions will be taken to protect them and their families?"

SEC. NAPOLITANO: Well, we're issuing guidance for our own employees today, but it kind of depends on what kind of work they're doing. If they're not in contact with the public, as many of our workers are not on a regular basis, just normal.

MS. MCCARTHY: What about those front-line workers?

SEC. NAPOLITANO: Front-line workers, again, they may -- they may wear a mask. The ones who must wear a mask are those -- for example, we will have customs workers who may be within an isolation room with somebody who has been segregated because we think they have the flu. That person must wear a mask. So that guidance is going out today to our workers, and then I think general -- federal-employee-wide over the course of the next day or two.

MS. MCCARTHY: All right. And so we'll be looking -- but anyway -- and we have to keep emphasizing this is an evolving situation --

SEC. SEBELIUS (?): That's right.

MS. MCCARTHY: -- and that that's why you are going to be doing some sort of daily updates, and to check the websites.

SEC. SEBELIUS: And again, I think, Lark, it's important to remind people, when we hear 109 cases, that sounds a bit startling in isolation. We have hundreds of thousands of cases every year with seasonal flu. So we anticipate more cases. We anticipate some people in the hospital. And unfortunately, we anticipate some deaths. We have 36,000 seasonal-flu deaths every year. So I just think it's important for parents and others to understand this is a spike of a flu. We really don't know --

MS. MCCARTHY: But because it is this new strain, is --

SEC. SEBELIUS: Absolutely.

DR. BESSER: Right.

MS. MCCARTHY: Dr. Besser, an audience question for you. This is from Nehry (sp) in Bloomfield, Connecticut.

"My sister just returned from Mexico. Can she carry the virus even though she doesn't display symptoms?"

DR. BESSER: Well, every infectious disease has a -- something called an incubation period, a period from when you're exposed to this infectious agent and when you become sick.

Influenza's no different in that regard, and with influenza, we're seeing an incubation period of about two to seven days. So, you know, during that first week, it's possible that she could be brewing this infection. So she should watch for those symptoms during that period. After about a week, she can feel pretty comfortable that she's not going to get sick from that exposure.

MS. MCCARTHY: All right. Another question for you. Bob in Ashburn, Virginia: "If a member of my family becomes infected, what steps, precaution should the rest of our household take?"

DR. BESSER: Well, you know, what we're asking is, if someone has this infection, that they try and isolate themselves at home so that they're not going out and infecting others while they are sick.

People who live in the household can do a number of things. Frequent hand-washing is important whether you're in the household or whether you're out. If you're going to have direct face-to-face contact with the person who has that infection, either that -- the patient can wear a mask or you can wear a mask in that setting. And that can reduce the likelihood that you're going to get the infection.

MS. MCCARTHY: Secretary Sebelius, something you've already touched on. This is from Dee Dee (sp) in Hyattsville, Maryland. "Why is this swine flu so much more concerning compared to seasonal flu?"

SEC. SEBELIUS: Well, we don't know that it is. It's -- because it's a brand-new strain, we'll know a lot more at the end of this cycle than we do right now. So we know what happens year-in and year- out with seasonal flu; what we don't know is if this is going to be more virulent or milder. But it's a new strain, so the vaccine is being developed. We know that there are some antiviral drugs, the Tamoxifen (sic/Tamiflu) and Rezelen (sic/Relenza), that will work, and so --

DR. BESSER: The --

MS. MCCARTHY: Tamiflu and Relenza. (Laughs.) Tamiflu and --

SEC. SEBELIUS: I mean -- I'm sorry, Tamiflu and Relenza --


SEC. SEBELIUS: -- are effective, and we know that that's helping. So if someone does begin to get symptoms, that helps to contain the symptoms. And so we --

MS. MCCARTHY: Well, it's a perfect segue, without you even knowing it, to our next question. This is from Julie (sp) for Dr. Besser. "Should a -- high-risk organ-donation patients be taking Tamiflu to avoid getting swine flu?" And then I have a follow-up on Tamiflu. Dr. Besser? This is from Julie (sp).

DR. BESSER: Well, that is a great question, and it points to the fact that when it comes to an individual patient, the best way to get information about your own care is with your doctor.

And so we want to refer individual patients and -- to their physicians.

We have guidance up on the website. We have guidance for individuals, and we have specific guidance for health care providers. That's not something that you personally should take off the Web. You should talk to your provider to make sure that the guidance fits your particular situation.

MS. MCCARTHY: What about side effects from people who are prescribed Tamiflu or Relenza? Should they be worried about side effects? And again, do you just discuss that with your physician?

DR. BESSER: Correct. You know, with any medication, there are potential side effects. Discuss that with your physician, and when you're prescribed a medication, you can also talk to your pharmacist to get advice.

MS. MCCARTHY: All right. Thank you so much.

All right. This question to anyone on the panel. This is from Tanya (sp) in Nelsonville, Ohio. "I'm a mother of two small children. Should I stock up on food and nonperishable items?"

Madame Secretary, do you want to start?

SEC. SEBELIUS: Well, my experience as a mother is, children eat -- (laughter) -- day in and day out. So having a food supply is always a good idea.

I do think that what we're recommending that people think about is some contingency plans. Does that mean stockpile food and water? No. Does it mean that you should remind your children to cover their faces when they cough or sneeze? Absolutely. If your child appears to be getting sick, keep them home from school, and have a contingency plan for a more -- a school shutdown, a day care shutdown, figuring out how not to put them in a group setting once again.

MS. MCCARTHY: Right. Or if you, Mom, are sick, about at least having a few days' food, water on hand.

SEC. SEBELIUS: Absolutely.

MS. MCCARTHY: Or dads --

SEC. SEBELIUS: So having some family preparations is always a good idea, and parents certainly taking care of that. But we're certainly not recommending that people rush out and stockpile food and water.


DR. BESSER: You know, if I could add something on that topic, it --


DR. BESSER: -- this is the time when people should just think about overall preparedness. And whether it's for a hurricane or tornado or a new infectious disease, it's important that people think about preparedness, and that goes to the issue of making sure you have food in your house. There's nothing special about this event that says that you should have food in your house.

But communications, understanding what the communication plan is within your household, what -- who you would call if your school notified that your children had to go home, whether you have arrangements with others to help you provide that -- that's a general preparedness principle that is always in play.

MS. MCCARTHY: Secretary Napolitano, you want to follow up on that?

SEC. NAPOLITANO: Well, I was going to add that the one thing we have stockpiled are the antivirals, the Tamiflu and the Relenza. And one of the things that has been occurring over the past few days is to move those stockpiles out to the states, prioritizing the states where we already have confirmed instances of the flu, but to all states by the 3rd of May.

MS. MCCARTHY: All states by the 3rd of May.


MS. MCCARTHY: All right.

SEC. SEBELIUS: Twenty-five percent of the stockpiles will move.

MS. MCCARTHY: That's good news. Headline news. We like that. (Chuckles.)

Secretary Napolitano, I want to you to take this one. Annette in Lexington, Kentucky, is -- you've touched on it, but I think this is a big concern to people.

Is it safe to fly within the USA at this time?

SEC. NAPOLITANO: Yes, it is. And it is safe.

The one caveat is that if you are sick yourself or showing signs, don't contaminate others by getting into a plane, a bus, a train, an enclosed space. But we are not discouraging travel in the United States at this time.


A related question. This is from Carolyn in Des Plaines, Illinois.

Under what circumstance would the U.S. consider closing the border to Mexico? What would have to happen?

SEC. NAPOLITANO: Well, that -- it would be -- you know, we don't play what-ifs. In this circumstance, there has been no scientific, epidemiological or any other suggestion that the border should be closed.

That being said, we have issued guidance, to our workers at the borders, on what to look for, in case somebody does look like they have the flu, and what personal protection they should take.

SEC. SEBELIUS: And I think one of the differences, Lark, between this outbreak and SARS, a couple of years ago, this is in the North American corridor. We have cases already here.

So the notion is, you can't contain something from coming into the United States. It's already here. So what we're doing is focusing the resources, the medical attention, the supplies on containing it, within the United States, trying to keep people out of group settings, if they are ill.

That's why the recommendation is to close a school, if a child in that school has a confirmed case. So there are measures we can take and focus on. But the flu outbreak is already in the United States.

MS. MCCARTHY: Dr. Besser, a question from Hassan in California.

Why does the fatality rate appear higher in Mexico? What's the cause?

DR. BESSER: You know, that is a critical question. And we are participating as part of a trinational team, in Mexico, to try and understand that better. We were very happy to announce today that Mexico now has laboratory capacity to be able to diagnose H1N1 infection. And that will help speed along these studies.

There are many possibilities. It could be subtle changes in the virus. It could be differences, in terms of when people present for treatment. It could be differences in how people are treated. Or it could be that we are earlier in this introduction, and that we may see progression.

All of those are on the table. None of them have been ruled out. But answering that question is so vitally important to how we move forward, with managing and minimizing the impact of this outbreak on our population here.

MS. MCCARTHY: Dr. Besser, a question from Deanna in Walker, Iowa.

Can you guarantee there are enough antivirals, especially for those who are immune-compromised?

DR. BESSER: You know, what I can tell you is that we have been stockpiling, in the event that a pandemic occurred. And we have 50 million courses of antivirals, and that those are moving across the country, not because there are shortages for taking care of patients, around the country. But in the event that this were to change, from what we're currently seeing, we wanted to ensure that states had the drugs that they needed, to be able to care for their populations.

MS. MCCARTHY: Dr. Besser, another question for you. Jennifer (ph) wants to know: I have a baby who is exclusively breast-fed. What should I do if one of us gets sick with swine flu?

DR. BESSER: You know, that's one of those questions that you should ask your doctor. We have information on the website. One of the most important things you can do -- I'm a pediatrician and a parent, and one of the important -- most important things you can do is breast-feed your -- your children, in terms of preventing infectious diseases. So talk to your doctor about those concerns. If you develop flu-like symptoms, please call your physician and have that conversation.

MS. MCCARTHY: All right. Thank you so much, Dr. Besser.

Secretary Napolitano, this is from Carmen (ph) in Florida: What happens if we get to Level 6?

SEC. NAPOLITANO: Well, from the public's perspective, not much, because our preparations have anticipated that we will at some point be at Level 6. And so the stockpile, the movement of the stockpile, the information on the website, all of those sorts of things, the movement of masks and other protective equipment, all have been done as if we are going to be at Level 6.

MS. MCCARTHY: Secretary Sebelius, do you want to address that?

SEC. SEBELIUS: Well, I think I would agree with Secretary Napolitano, and remind the viewers of what Dr. Besser said earlier. We -- we have anticipated this. And within the United States, we are treating this as if -- while we are in a pre-pandemic stage, it doesn't change here in the country.

What I think Dr. Chan of the World Health Organization -- what the warning level did was to alert countries where the outbreak hasn't presented itself yet that this really may be a worldwide situation and that they should begin to think about it.

So we are already taking steps. We are very aggressively addressing cases here, containment here; trying to move rapidly. But there are countries that are now going to focus on the warning that haven't really paid a lot of attention.

MS. MCCARTHY: Dr. Besser, do you want to weigh in on that? What happens if we get to Level 6?

DR. BESSER: Well, the only thing I'd like to add is that when people think about a pandemic, to many people, all they have in their mind is 1918, which was a devastating pandemic around the world. Pandemics occur, and there's a wide range in terms of severity. And so there are some pandemics that look very much like a bad flu season. And we've experienced bad flu seasons over the -- over the past five years, and they are -- they are very troubling and difficult to manage, but they're nothing like 1918. In terms of our activities in this country, we are doing exactly what we would be doing whether this were called a three, a four, or a six.

MS. MCCARTHY: All right. We do want to just note that we're getting lots of e-mail questions and we're -- so if we seem to be going rapidly, that's why. We're trying to get to as many as possible. In fact, I'm told we've received about 1,500 so far. So we probably won't get to all of those, but let's keep going.

Dr. Besser, this is from Linda (ph): Is it possible that this virus is being carried into North America by migrating birds from Mexico?


MS. MCCARTHY: Okay. (Laughter.) All righty!


MS. MCCARTHY: He's with the program. That's getting to it quickly.

All right. We'll move on.

This is from Krista (sp), Dr. Besser, or anyone else can jump in on this one. At what point should officials advise staying at home and avoiding crowds whenever possible to prevent transmission? At what point. Dr. Besser, does that make sense?

DR. BESSER: If you have the flu, if you have a fever or flu-like illnesses or you're starting to feel a flu coming on, you should not go out into the workplace or you shouldn't send your children to school, because that's how these infections can be spread. We are nowhere near the point of taking the kind of drastic measures for the population in general. We are taking aggressive action right now that meets the situation as it exists.

MS. MCCARTHY: All right. Secretary Napolitano, this is from a Dr. Gache (ph).

Oh, you want all to answer? Okay. All right. Round robin on that one, all right? At what point should officials advise staying at home and avoiding crowds whenever possible?

SEC. SEBELIUS: Well, again, I think you've just heard from the scientist. And what we're trying to do is let the science drive the protocol, not what might be, could be, people's fears. Dr. Besser is the experienced scientist who really is guiding a lot of the community mitigation, and that's what we're talking about.

MS. MCCARTHY: All right.

Dr. Besser, another question for you. This is Dina in Maine. Are the N95s effective if the person has not been fit-tested? And this has to do with the mask. So Dr. Besser, you want to address that?

DR. BESSER: Well, N95s are most effective when they are fit- tested. And if you are in an occupation where using an N95 is part of your job, it's very important that you have that fit-testing to ensure that you're protected. That pertains in large part to health-care workers.

MS. MCCARTHY: Is that health-care workers? Yes.


MS. MCCARTHY: All right. We're trying to whip through these questions here, so bear with me for just one second as we get to the next one. I think they gave me all 1,500 at once. No, here we go.

All right. Dr. Besser or Secretary Sebelius, this is from Sue in Clinton, South Carolina.

Are there recommendations for health-care workers -- we've just been talking about that in terms of the mask -- to take prophylactic Tamiflu? Dr. Besser?

DR. BESSER: Here I would refer health-care workers to our website,, where there are specific guidelines on what health-care workers can do.

MS. MCCARTHY: All right. So we'll leave that one there.

Twenty-six. Okay, hold on. Bear with me, folks. We've got numbers on the questions. We're trying to put them in some sort of logical order.

Dr. Besser, this is from Eva. How long does it take to get results -- and I know this came up at your briefing earlier, but people are very concerned about this - from the H1N1 test? How long does it take?

DR. BESSER: Well, that is a good question. And some of that has to do with the increased burden on testing that's taking place now. As we look for cases, that puts some increased burden on testing. And as this virus moves in communities and more people are ill, there are more people for testing.

So we're undertaking steps to try and reduce some of that testing burden. Initially, this testing was only available here at the Centers for Disease Control and in Canada and some other countries where we'd shared the virus. We are now -- we've moved out a research test kit to New York and California. As long as the test kit works well there, as of Monday we'll be rolling out test kits to every state to try and reduce the time required for those confirmatory tests.

MS. MCCARTHY: Okay. So obviously that's something that we'll keep on top of.

Secretary Napolitano, this is from Dawn (sp) in Evansville, Indiana: "In the case of public employees like local government or libraries, who makes the call to shut down in case of a pandemic?"

SEC. NAPOLITANO: Well, it's locally driven. It's primarily your local school district, it's your mayor, it's others locally. But it can be informed by what the Center for Disease Control and others say about when is it called for, what are the kinds of guidance that are out there. But primarily those decisions are made locally.

MS. MCCARTHY: They are made locally. You want to weigh in on that?

SEC. SEBELIUS: Well, I absolutely support what the secretary says. And often the key person at the local level is the local health official, who -- what we're seeing is state and local partners doing a great job, being, again, very aggressive, very informed. And really, they're the first-line responders.

So they begin the identification; it passes up the chain; but the local folks have a great collaborative partnership in this, because clearly Dr. Besser can't identify cases and find them. It's really done at the local level.

And the local health officials are getting regular updates. They've been training for this and planning for this for a series of years, and I think all those exercises that people participated in, this is exactly what they were anticipating.

MS. MCCARTHY: Good point to make, that the planning really has been going on for years here.

SEC. SEBELIUS: Absolutely.

MS. MCCARTHY: Vaccine question. When will we have a vaccine? Dr. Besser, you want to start off on that one?

DR. BESSER: Sure. We're taking all the steps that are necessary to begin production of a vaccine. And what you initially need to do when you have a new infection is you need to identify the virus that you're going to use to make a potential vaccine. We've done that; we're growing that up.

And then there's all kinds of work going on across the department and through interaction with industry, so that, should we decide a vaccine is warranted and that we're going to want that for the fall, we'd be able to ramp up production.

MS. MCCARTHY: Yeah, can you give us a(n) earliest timetable, just sort of a range? So people want to know how quickly, and then how soon do you know whether or not it's effective, whether you've targeted the right strain?

DR. BESSER: So after you grow up this virus, you'll initially do some studies to look at, does this strain induce immunity, does it allow you to make the protective factors that you'll need. If those steps, moving forward, look good, then we would be able to share those strains with industry and produce the vaccine.

The target would be to have this vaccine ready for the fall flu season, so that in addition to being vaccinated for the flu, you'd be able to be vaccinated for this strain. But that decision as to whether we should vaccinate the public hasn't been made, and we won't know that until this goes much further and we see whether this infection becomes more severe or goes away.

SEC. SEBELIUS: Well, Lark, I would just add that the -- there is a balance between speed and safety.

We want both. So the Food and Drug Administration is working very closely with the National Institutes of Health.

One is the scientific group identifying the strain responsible for growing the virus, looking at the proper doses. Food and Drug Administration has the overall safety of the American public at the forefront. And they are good partners in this.

The worst of all worlds is to, you know, do something that --

MS. MCCARTHY: You don't want to rush a vaccine a) that's not effective or that has too many side effects.

SEC. SEBELIUS: Absolutely you don't want to. Or the wrong dosage, so all of those components will be part of this process.

But the good news for the American public is, that can be done in a speedier and safe fashion than ever before.

SEC. NAPOLITANO: It's important to recognize the difference between an antiviral and a vaccine.


SEC. NAPOLITANO: The antivirals that have been stockpiled that are being distributed are for people who have gotten sick, to take care of their symptoms.

(Cross talk, laughter.)

And the vaccine of course is to prevent from getting ill to begin with. But all of us -- not all of us, many of us remember the swine flu issue in 1976. And we want to make sure we don't repeat some of the lessons learned on that one. So history can be our judge as well.

MS. MCCARTHY: (Inaudible.) So just tell me what Janine wants to know, and I'll repeat her question. Okay.

Janine in Florida wants to talk about flu outbreaks coming in waves, because we do know there have been past epidemics where it started mild and then months later came back in a very virulent form.

So what have we learned? And what do we know so far, about this particular strain, in terms of, oh, we could breathe a sigh of relief a week from now and then in four months?

So who wants to start on that?

SEC. NAPOLITANO: That's a good one for Dr. Besser probably.

SEC. SEBELIUS: Well, we know also that this is not typical flu season. So the typical flu season is fall into winter. And what we don't know is what exactly H1N1 will look like, by the time we get into the flu season ramping up. But Dr. Besser can talk a little bit about what may be the waves.

MS. MCCARTHY: Dr. Besser, please, because it's an important question that a lot of people are worried about, that we could get through this and four to six months later, something would happen.

What do you tell people?

DR. BESSER: That is a great question.

In 1918, what was seen was a fairly mild outbreak of flu in the spring and then no cases for a while. And then when the virus came back, it was much stronger and caused more significant disease.

You never know. This is a new infection. And each virus has its own course. Some viruses appear briefly. People get infected. And then they go away, never to return.

Normally from flu season to flu season, we see slight changes in the strain of influenza that's causing disease. And that's why actually we have to change the vaccine, each season, to make sure that it's as effective as we hope. But there's some judgment that's involved here.

You never know whether the virus you're seeing now is the one you'll see next year. And so we will engage with the broadest range of the scientific community, across our department, across the country and really across the world, to think about the question of, is this a virus that will come back, and do we need to be concerned that it could come back stronger?

MS. MCCARTHY: Either of you want to weigh in on that, or you were just agreeing with Dr. Besser? Okay. All right.

All right. Let's -- give me a number here. I'd say we've -- I must say we really -- we are gratified that so many people are writing in. So our system wasn't quite designed to handle so many at once. (Laughter.)

So -- all right. So, Paula, from Dallas, is -- tell me what Paula wants to know. Here we go. Paula is traveling to Florida, and she says -- oh, she has COPD, so obviously she's got a respiratory issue going on. "Do I need to be concerned?"

So someone traveling to Florida, and she has COPD. Does she need to be concerned?

Dr. Besser, you want to start?

DR. BESSER: Well, as someone with a underlying condition that is at greater risk for flu, you do have to pay attention.

But we are asking everyone to pay attention to those things that are -- that we all do to reduce the likelihood infection. You know, the frequent hand-washing can reduce your risk.

But I would take your trip. I'd talk to your doctor and say, "What should I do if I get sick while I'm traveling? And just be aware that this is a period of uncertainty, and if you get flu season symptoms, if in the past you'd let them go for a little while, I wouldn't do that here. I would connect with your doctor as soon as you became ill.

MS. MCCARTHY: All right. Thank you, Dr. Besser. Appreciate it.

This is for anyone on the panel, from Becky in Roanoke, Virginia. "My son went to Mexico on a cruise for spring break. He is not showing signs of being sick. Should I be alarmed or take him to the doctor?"

Went to Mexico, not sick.

SEC. NAPOLITANO: When did he go?

MS. MCCARTHY: She said spring break.

SEC. SEBELIUS: Spring break.

MS. MCCARTHY: So let's assume, you know, past few weeks.

SEC. NAPOLITANO: It sounds like he's well beyond the incubation period and not to worry --

MS. MCCARTHY: Should be fine.

SEC. NAPOLITANO: -- would be my medical advice. (Laughter.) But Dr. Besser, would you confirm that for me? MORE

MS. MCCARTHY: Do you want to weigh in? Because sure, it's a concern, yeah. Dr. Besser, what would you say to Becky in Roanoke?

DR. BESSER: Secretary Napolitano got it just right. (Laughter). Once you're past that incubation period, you don't need to keep worrying about that. But --

MS. MCCARTHY: And you would consider that period to be how many days?

DR. BESSER: Around a week.


DR. BESSER: Again, this is a new virus, but what we know from -- traditionally from influenza is, it's about a week. So seven days -- when you're past that, you can feel much more comfortable that you're not going to come down with the flu.

MS. MCCARTHY: A related question, Dr. Besser: This is from Anne (sp). "I live in a college dorm. I'm worried!" What do you say to Anne?

DR. BESSER: Well, college campuses are places where people have a lot of close contact. And so it is a place where you should practice proper procedures and practices for reducing risk. We are putting out later today revised guidance for colleges and universities. We have guidance that's up there now, around --

MS. MCCARTHY: I'd just say, as the mother of a college student, I'm going to take the moderator's prerogative, say: Spell out a couple of specific things, Doctor, right now! (Laughter.)


MS. MCCARTHY: (Laughs.)

DR. BESSER: All right. Here's what you could --

MS. MCCARTHY: (Laughing.) Okay.

DR. BESSER: Here's what you can do.

MS. MCCARTHY: All right.

DR. BESSER: Wash your hands, okay, or use alcohol gels. Get some rest. Don't run yourself down. If you start to feel sick, visit your campus clinic. And pay attention. If you've got classmates who are sick, tell them to go get checked out, so that they're not sharing that around the dorm.

MS. MCCARTHY: Okay. I think the doctor was saying less partying. Is that what I heard in there? (Laughter.)


SEC. SEBELIUS: More homework.

MS. MCCARTHY: Or more homework.

SEC. SEBELIUS: That and less partying.

(Cross talk.)

MS. MCCARTHY: All right. Thank you. Thank you, Dr. Besser. Thank you for -- I appreciate that.

All right. This is from Beth in -- Dr. Besser, for you as well. She says: How confident are we that we have found Patient Zero? And does it really matter?

Dr. Besser?

DR. BESSER: Finding Patient Zero is not that important for what we're doing now. But it is important as we look to see how did this occur in the first place. Influenza viruses that cause pandemic -- pandemics are novel. They're new. And they usually involve interaction between strains of flu that typically infect humans and strains of flu that infect animals.

This particular strain has elements from humans, birds and swine. And so if we can understand where the first case took place, maybe it will help us in our efforts to prevent the emergence of future pandemic strains.

MS. MCCARTHY: So helpful to know. So are we confident that we have found Patient Zero, that the child that's been identified is Patient Zero?

DR. BESSER: We have not identified a Patient Zero. The work going on in Mexico --

MS. MCCARTHY: In Mexico.

DR. BESSER: -- is trying to look to see --

MS. MCCARTHY: They're trying.

DR. BESSER: -- where could this have started.

MS. MCCARTHY: Okay. Because, you know, there have been some reports.


MS. MCCARTHY: So you're saying that you're -- there's no official designation at this point.



At some point, would there be? What would give you confidence to make that kind of designation?

DR. BESSER: I would be very skeptical of any decision that one individual person was THE first case, especially with an emergence like this.

MS. MCCARTHY: So more important to identify sort of the cluster of where it begins is what you're focusing on?

DR. BESSER: That's right. Trying to understand the setting in which it took place. Did -- you know, many times -- what we're seeing time and time again is that infections are emerging at the interface between animals and humans. And so whether we're talking about SARS or we're talking about influenza, those interfaces, the -- that interaction can teach us a lot about where the next emerging infection will come from.

MS. MCCARTHY: A question from Steve, Dr. Besser: Do we know how long this virus can live outside the body?

DR. BESSER: You know, those are some of the studies that we need to do. We expect that this would be like other influenza viruses and would be allowed to live outside the body for a short period of time.

MS. MCCARTHY: All right. Thank you so much.

Secretary Napolitano, this is for you, from Robert in Houston: If you won't close the border generally, can we at least prohibit infected persons from coming in -- coming to the U.S. to seek medical attention?

SEC. NAPOLITANO: We are providing guidance at the ports to identify those who may be sick and have a public health official screen them before they come into the country.

MS. MCCARTHY: All right. Anything to add on that?

SEC. NAPOLITANO: Obviously we can't keep out an American citizen who's trying to reenter the country.

MS. MCCARTHY: Who's trying to reenter -- okay. So that wouldn't happen. I mean --

SEC. NAPOLITANO: So that would -- no, somewhat of a difference, yeah --


SEC. NAPOLITANO: Yeah. We could have American citizens who are coming back, but we can get them and make sure they're advised to quickly go see a doctor.

MS. MCCARTHY: Okay. All right.

(To staff.) So tell me the next number. All right. Number 37. (Laughs.) All right. Let's see if we can find -- just tell me what the question is and we'll just relay that one.

Ah. How many days should a swine flu patient remain quarantined? So let's say you've got a confirmed case, Dr. Besser. You know it. What do you do? How many days should you stay away from people?

DR. BESSER: Okay. Just to clarify one term, or two terms --


DR. BESSER: -- we talk about isolation --

MS. MCCARTHY: Yes, yes. Mm-hmm.

DR. BESSER: -- and we talk about quarantine. We talk about isolation when someone's sick, and so if an individual is sick, we're recommending that they self-isolate at home for seven days or at least one day past when their symptoms go away.

The idea of quarantine is telling some people who may have been exposed to stay away from other people.

And here, we're suggesting that family members of a -- of an infected person consider that. Not that they have to stay on full quarantine in the house, but try and decrease their contact with others until they really know whether they are going to get sick.

MS. MCCARTHY: All right. And it is important to deal with those terms, isolation versus quarantine. And you do suggest a lot of self- isolation if you're ill.

This is from Jen (ph) in Wisconsin to everyone: What can be done to protect babies and toddlers, especially those who go to day care? Secretary Sebelius?

SEC. SEBELIUS: Well, I think it's -- it's, again, a vulnerable population, we know that, in flu season. But again, I think the same kind of precautions, that parents need to be alert. If there are any symptoms that either another child in the day care center or certainly the provider has any signs of illness, some kind of discussion quickly to get the case identified, and ask that the center be shut down; at a minimum, remove your child.

But again, I think it's critical to anticipate this, if this spreads, that kind of preparation: What is the plan to have an alternative caregiver for your child? What happens if your child care provider comes down, or the center closes? How do you get to work? How do you manage that?

DR. BESSER: Right.

SEC. SEBELIUS: That kind of personal planning, as Dr. Besser said, is important for any kind of disaster or any kind of planning. But having a family plan of what is the continuity of getting to and from work for moms and dads, how do you keep going and where are your children going to be safely cared for.

MS. MCCARTHY: Dr. Besser, do you want to add anything, as a pediatrician we should note. This question is: What can be done to protect babies and toddlers, especially those going to day care?

DR. BESSER: I think Secretary Sebelius hit it -- hit it right on the money. Having the plans in place; not sending your child to day care if your child is showing some early signs of being sick. Those are very important things that -- that you can do.

MS. MCCARTHY: Secretary Napolitano, this is from Brian (ph) in Indiana: Do we have enough stockpiles of the antiviral medication to withstand a serious pandemic?

SEC. NAPOLITANO: We have, based on the projections that we have, yes, 50 million courses of the Tamiflu and Relenza. And that's in addition to another 23 million or so courses that various states have set aside. And that's in addition to another 7 million that the Department of Defense has set aside. And recognize that if those estimates change, the manufacture of that can be ramped up and those stockpiles replenished on a -- on a fairly rapid basis.

MS. MCCARTHY: Well, that's good to know. Yes?

SEC. SEBELIUS: And there's a very -- I think, to follow up on Secretary Napolitano, there's a very close interface between the manufacturers and the scientists at this point. They are kind of standing ready. There has been a lot of emphasis within the Department of Health and Human Services on making sure that there's a continuity of preparedness that moves right through to both not only the production of antivirals, but certainly when we get in -- if we decide to get into vaccine production.

So that capacity over the last five years has been increased dramatically, and there's a very close relationship between the research going on and the ability to turn that research into rapid production.

MS. MCCARTHY: Okay. Let's go to -- Dr. Besser, this is from Clark (ph) in Indiana: Is there any other new strain of influenza that the CDC is tracking at this time?

DR. BESSER: We're constantly tracking new strains of diseases. As people have been hearing in the news over the past number of years, we've been very focused on a strain called H5N1, which is a bird strain, and we continue to track that. And it raises another point. While we are very busy and aggressively reacting and responding to this outbreak, we are keeping our eyes open for any other health issues that could be going on around the country or around the globe.

MS. MCCARTHY: All right. I guess there are a lot of people that are worried that we may be so focused on this that you lose sight of the other viruses that you have been tracking.

Secretary Napolitano, this is from Julie (ph): Is it safe to eat fruit and vegetables from Mexico?

SEC. NAPOLITANO: Yes. This is not a food-borne illness. And it's particularly safe to eat pork. And I think it's important to reemphasize that. This has the name "swine flu," and there is a swine strain in it, but it is not borne by pork products and it is safe to eat pork.

MS. MCCARTHY: And maybe we should just take a brief moment to mention that's why the switch, trying to emphasize more H1N1 now, because swine flu was -- mischaracterized, shall we say. Is that --

SEC. NAPOLITANO: Well, it's a nickname, but it's -- but it denotes something that really isn't accurate. And all of a sudden, we had farmers who grow pigs and whatever -- that whole aspect of our economy was taking a hit for something that absolutely has no relation to them of the safety of the food products there. So that's why we are, again, as we go through this, always trying to refine and communicate clearly what this is and it is not. This is not pork- borne.

MS. MCCARTHY: It's not pork-borne.



SEC. SEBELIUS: And it's not food-borne at all.

MS. MCCARTHY: At all. All right. So I hope that it -- I know that it's commonly known now as "swine flu," but understand it really is not a pork-borne illness.



SEC. SEBELIUS: That's right.

MS. MCCARTHY: -- is why we're making that switch. So we had a question about pets, and so why don't we just talk about that? Are pets at any risk from this? Dr. Besser?

DR. BESSER: You know, influenza strains tend to be species- specific, and we haven't seen any evidence that this strain of flu can infect anyone but humans.

MS. MCCARTHY: Okay. I appreciate your being short.


MS. MCCARTHY: Yes, I do. But that's a very good question. I mean, we have so many pet owners out there, right? Okay.

Ah, so this is for anyone on the panel.

This is from Sherry.

Does this new strain not contain the avian flu?

Excellent question, Dr. Besser. Do you want to start off on that?


As I mentioned previously, this strain is a reassortment of four different strains. One of the pieces of that originated from a bird. But this is not related to the H5N1 strain that we're following in various parts of the world.

MS. MCCARTHY: (Off mike.) Okay, we'll leave it there.

SEC. SEBELIUS: I think Dr. Besser got it right on.

MS. MCCARTHY: All right.

We'll go to Joanne from Andover.

Dr. Besser, this is for you. How will the manufacturing of seasonal influenza vaccine be affected by H1N1 swine flu vaccine development?

DR. BESSER: Well, it is very important that we have an adequate, ample supply of seasonal flu vaccine, given the information that Secretary Sebelius shared earlier, about the impact of that disease. So the plan is to finish production for seasonal flu before ramping up production for an H1N1, if we decided to go down that road.

MS. MCCARTHY: Thank you so much. I'm sure that's on a lot of people's minds. So, and would this be a good season, Dr. Besser, just in general, for people to get, if it's recommended for you, to get your seasonal flu shot? Is it believed that in general that will help?

DR. BESSER: Well, it's always a good season to get your flu shot. And that's something that hopefully people will keep in mind, as they think, moving forward, what can I do to prevent infection; what can I do to prevent severe consequences from flu?

Each year, we work hard to increase the number of people who get the flu shot. And a lot of people say, oh, it's just the flu. I hope people think about what they can do, to prevent themselves from getting sick.

MS. MCCARTHY: Dr. Besser, let's stick with you for a moment. This is Dorothy from Pittsburgh.

If this current flu strain is new, why has it been designated as H1N1? And is that the same designation as the 1918 Spanish flu viral strain?

DR. BESSER: This strain is very different from any previous strain that we've seen. The H1N1 are technical designations that refer to various parts of the virus itself. And so in 1918, there was a virus that had specific designation. This H1N1 is a new, novel strain that's unrelated to the previous strains.

MS. MCCARTHY: So it's unrelated, so just help us out. Understand that the naming it, it's a technical thing. It doesn't have to -- in other words, it won't be necessarily H6 or something like that?


The H refers to hemagglutinin, and the N to neueraminidase. And that's probably as far as we need to go on that one.

MS. MCCARTHY: Okay. We'll stop it there today. But it's an excellent question.

(Cross talk, laughter.)

People do want to know, what does that mean? And is it named like hurricanes or something? You know, so no is the answer.

All right. Let's talk about soap and water versus, you know, these -- the disinfectants. Is soap and water just as effective as these antibacterial soaps?

Dr. Besser.

DR. BESSER: Well, it depends how you wash your hands. And it's very important, when people think about washing their hands, to remember what we teach young children, either singing "Happy Birthday" or singing "Twinkle Twinkle." Those will be -- those will ensure you're washing your hands long enough.

I heard one of the radio stations was trying to come up with a better song for adults to sing. If you aren't going to be doing your song, and you're hands aren't dirty, alcohol-based hand gels are very effective in killing viruses and are a way to go. I keep one in my pocket. And that way, if I'm not near a sink, I've got something that I can use to clean my hands.

MR. MCCORMACK: All right. Well, I won't put you to the test, but you're carrying it right now, is that what you say? (Laughs.) All right. There he is, practicing what he preaches. All right. So the bottom line, if you're using soap and water, sing the birthday song while you're doing it, or use the alcohol-based hand sanitizers.

SEC. SEBELIUS: And finish the song.

MS. MCCARTHY: And finish.

SEC. NAPOLITANO (?): Wash the whole time you sing the birthday song.

MS. MCCARTHY: The whole time. That's a good little thing to remember. All right.

Give me a number where we're going to next? Fifty-one. Amy. And Amy wants to know -- can you put it up on the screen? Go -- right there. Oh, people with diseases such as -- and I can't read that at all. Go ahead.

All right. "Are people at -- with certain diseases such as diabetes at higher risk of getting the flu?" And we have so many diabetics in the country right now. And would severity be higher for them if they actually do get it?

DR. BESSER: They're not at increased risk of getting the flu, but they're at increased risk of having severe complications from the flu. And so they're in that risk group where, if they are developing symptoms of the flu, they should speak with their doctor.

MS. MCCARTHY: All right. Any other groups in particular that, you know -- with certain illnesses that you'd want to point out here today, or any general warnings?

DR. BESSER: Yeah. I would say that, you know, if you have diabetes, if you are undergoing treatment for cancer --


DR. BESSER: -- those are areas where you would need to be concerned. If you're on any medication that could impact on your immune system, if you have respiratory problems like the person before with COPD, those are conditions that put you at greater risk for severe complications. But talk to your doctor, because if you don't know if you should be getting seasonal-flu vaccine, it's important that you do know.

MS. MCCARTHY: All right. Thank you for that, Dr. Besser.

Secretary Napolitano, this is from Gerry (sp) in Kansas: "I am traveling this weekend. Should I wear a mask on the plane, or should I cancel my trip?" Now, she doesn't say where she's traveling, but let's assume it's domestic travel. Should she wear a mask?

SEC. NAPOLITANO: That's not called for. And again, we're not restricting travel right now, and we're asking for self-awareness. If you're sick or you're coming down with the flu, don't get on the plane. But beyond that, there are no travel restrictions.


We do want to let our viewers know that we're out of time for questions, because we wanted to leave just a moment to give -- our panel members to give your final thoughts, what you most want to emphasize. I know the president, for example, has emphasized it is the time for concern, not panic.

Secretary Sebelius, your first week here on the job, and people are looking for assurance. They want to know --

SEC. SEBELIUS: Actually, I've just had 24 hours on the job. (Laughs.) But it seems like a week!

MS. MCCARTHY: (Laughs.) So --

SEC. SEBELIUS: I do think that the concern can be turned into action.

We've talked a bit about steps everyone can take: Have a plan for yourself and your family. Certainly, although it seems very simple, you know, washing hands on a frequent basis, covering mouths after a sneeze or a cough, and paying attention if you have flu-like symptoms in yourself or family members or somebody you're in contact with in the office and taking steps. Those are really important as we move forward.

And this is a dynamic situation. It will change.

MS. MCCARTHY: Secretary Napolitano?

SEC. NAPOLITANO: Well, and the other thing is, is to say that at the government level, we're doing everything we can to make sure that the situation is managed; people have the right information; we're moving the antiviral stockpiles out, the treatments and so forth out, so that they're accessible to communities throughout the United States. And we'll keep doing that as we go through this outbreak.

MS. MCCARTHY: Dr. Besser, we'll give you the last word.

DR. BESSER: Yeah, the other thing I would add is, make sure that you stay informed, understand where to get local information to help you decide best what to do to ensure your health and the health of your family.

MS. MCCARTHY: All right. Thank you all so much. We really do appreciate it.

SEC. SEBELIUS: Well, thanks to you.

MS. MCCARTHY: And we do want to thank all of our viewers for your many questions, and we hope we have given you some answers and certainly some resources. So you can get more of your questions answered, go to

I'm Lark McCarthy. Thank you for joining us today for "Plan First."


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