Press Briefing Transcript
CDC media briefing on healthcare-associated infections
March 26, 2014 at 12 noon ET
BARBARA REYNOLDS: Good morning. I'm Barbara Reynolds. We'll begin in just one minute. Following a brief video.
[Video script] On any given day, about 1 in 25 hospital patients have an infection caused by their medical care. Almost half of these patients are 65 or older.
There are 5 places where patients are most likely to get infections: in the bloodstream, the urinary tract, the gut, and the two most common places are the site of surgery and the lungs.
The germs most likely to cause healthcare-associated infections include: C. difficile, or deadly diarrhea, Staph, including the drug-resistant type known as MRSA, a family of germs known as Enterobacteriaceae, that include CRE the “nightmare bacteria,” Enterococcus, which can be resistant to an important antibiotic, vancomycin, and Pseudomonas, which can cause infections of the lungs and bloodstream.
One in every 9 patients who gets an infection will die during their hospitalization.
Over the last several years, great progress has been made in preventing some infections. For example, bloodstream infections in patients with central lines have been nearly cut in half in the last 5 years. But more work needs to be done. CDC’s goal is to eliminate all healthcare-associated infections. We work 24/7 to save lives and protect people.
BARBARA REYNOLDS: Again, welcome to CDC's media briefing on healthcare-associated infections. I'd like to welcome not only those, our guests in the room in media, but also those of us joining us webcast and satellite today. I'd like to introduce our two speakers. First speaking will be Dr. Michael Bell, an expert in infection prevention and patient safety. Dr. Bell traveled the world providing infection prevention consultation for outbreaks of common germs and exotic viruses like Ebola. Dr. Bell is currently the deputy director of the CDC's Division of Healthcare Quality Promotion. The division is responsible for patient safety issues in medical facilities. With Dr. Bell's leadership, the division creates infection prevention guidelines, researches new prevention strategies, investigates outbreaks in healthcare facilities and provides world class laboratory expertise for microbes that cause healthcare related infections, including antibiotic resistant threats. Joining us also today is Victoria Nahum of Atlanta, cofounder and executive director of the Safe Care Campaign. She has a compelling story to tell. And we are so pleased that Victoria is able to join us today to represent patients nationally who have been impacted by healthcare-associated infections. After their brief remarks we'll open it up for questions. Dr. Bell?
MICHAEL BELL: Good afternoon. Sooner or later everyone is likely to become a patient somewhere. We go to the hospital hoping to get better, and in many cases we do. But not always. As a doctor I want all of my patients to become well and stay healthy. But some things stand in the way, including healthcare-associated infections. CDC is known for handling outbreaks, but it's more important to be scanning the horizon for the next important threat that needs to be tackled. We undertook a major study to find out what kinds of infections are affecting patients in hospitals and understand just how big the problem is. The report shows that as a nation we are moving in the right direction. But there's a great deal of work still to be done.
Despite the progress we've seen, three quarters of a million patients every year end up with healthcare-associated infections. We found that on any given day, as you saw in the graphic, 1 out of 25 hospitalized patients has an infection. And of those people, as many as 1 out of 9 go on to die. This is not a minor issue. The comparisons you're likely to want to make I’ll just mention are with the 2007 report that was based on historical information going back into the late '90s. I want to caution you that this is not necessarily apples to apples. Even though it’s tempting to try to do that. It's more like apples to pears. You can definitely see there's a trend for things being better, but the minor details probably are not directly comparable. The report we're releasing today is important because it was intentionally designed to gather infection. I think the quality of those data are better than those we had to work with before.
The report sounds the alarm about the threats we need to be addressing. It tells us, as you saw lung infection, gut infection, infections related to surgery, infections related to urinary catheters are at top of the list of things that are causing problems for hospital patients. It also shines the light on several important pathogens, these are the germs that are responsible for many of these infections. At the top of the list is Clostridium difficile or C.diff it causes antibiotic resistant diarrhea. And in the past, going back 20 years or so ago it was more of a nuisance than anything else. But today the type of bacteria is spread in this country has such a strong toxin, that it’s a very severe infection requiring colon removal in some cases and that deadly diarrhea is contributing to an unacceptable number of infections. Staph infections continue to be a problem, including antibiotic resistant type MRSA. And finally we're seeing a lot of infections related to the Enterobacteriaceae. This is a family of bacteria that includes e. Coli, many common organisms that live in the gut and need to be there for us to be healthy. The challenge that we see is that some of those bacteria, the nightmare bacteria are now completely untreatable. That means that as a doctor, I have nothing left I can offer a patient who has an infection like this in the hospital. The microbes we're talking about now are also in last year's antibiotic resistance threat report. That is the report we released looking at how much of a problem antibiotic resistance is. They're also at the center of the President's FY-15 budget initiative, where he's trying to drive progress by cutting some of these infections by 50 percent or more in five years. This is a major and important investment in making sure hospital care remains safe.
It's not all bad news. Some of the successes we're seeing are in protecting the most fragile patients, the patients in intensive care units. We've seen good progress preventing blood stream infections related to central lines. Central lines are the plastic catheters that go in the skin in through the neck and into the major vessels of the heart. These are very important tools, we need them to provide good medical care to provide medication, they're also a freeway for bacteria to get into the blood stream. So, making sure we handle those catheters perfectly every time is a major push that we've made. We have seen that the number of these infections have gone down by almost half since 2008. This is great progress. There's more work to be done. Similarly we’ve seen progress in infections related to surgery. Of the group of 10 surgery types that are captured in this report, we’ve seen about a 20 percent reduction in infections after surgery also since 2008. Is 20 percent enough? I don't think so, but the progress is moving in the right direction. In contrast, urinary tract infections related to catheters in the bladder are being more stubborn. We are not seeing the same kind of rapid progress. In a way, maybe that's not a big deal because they're not as severe an infection. People don't tend to die immediately from a bladder infection like they do from a blood stream infection. But the problem is, bladder stream infections are a major driver of broad spectrum antibiotic use. When broad spectrum antibiotics are given, it wipes out those normal bacteria in the gut and opens up for much bigger problems for C.diff. So you think you're having a trivial infection of the bladder, then the next thing you know you're fighting for your life because of deadly diarrhea. So we take catheter-associated urinary tract infections very seriously. And the fact that we’re seeing a stalling out of progress is something that we're working on very specifically.
The challenge with antibiotic resistance really can't be overstated. We’ve found that over half of hospitalized patients end up getting an antibiotic at some point. This is a huge amount of antibiotic pressure. We're focusing on improving the prescribing of antibiotics specifically because these nightmare bacteria and deadly diarrhea are such a threat to patient health. We want to see every hospital in this country having a strong antibiotic stewardship program so they can make sure all prescriptions are as sound and appropriate as possible. So how else do we use the information that we're reporting? The data we provide at CDC drives action. At the state and federal levels we use this data to find the facilities that are struggling with one or more types of infection. Then we try to target resources towards those areas. Using this targeted approach, we have seen several successes at the state level. For example, in Florida, there's a 35 percent reduction of those catheter-associated urinary tract infections. This is great. Similarly in Georgia, right here at home, we have cut blood stream infections in babies in ICUs by almost a half. So this targeted approach is a way to use limited resources because no one is flush with money right now. As effectively as possible, targeting the biggest part of the problem.
Lastly, I’d like to say a word about what can you do as a patient. I'm always asked what is it that I can do to protect myself in the hospital or a loved one? The short answer is ask questions. It's hard, but you have to ask questions. And the questions to ask are things like have you washed your hands? It sounds basic, but it's important. And you can ask it in a nice way. You can say I’m sure you just washed your hands it would mean a lot to me and my mother if you would wash them again. Because we're very worried about infections in the hospital. You can ask questions about the catheters you have. If you have a catheter in place, ask every day can the catheter come out today? In fact, before you have a catheter put in, when you're talking to your surgeon, ask her how long will I have to have a catheter after my procedure? If she says two days, starting day two, start asking can the catheter come out today? They said it would come out today. Finally ask about testing. Are you doing tests to make sure I’m on the right antibiotic? If so, you know, tell me about it. These questions are very hard to ask if you're a patient receiving care. You have plenty to think about. I think it's a good idea to bring a friend or family member whose main job it is to be the persistent asker of those questions. Because at the end of the day, the doctors, the nurses, the entire medical team wants you to get better. Even though it might be annoying for a minute, it's a helpful reminder to have hand washing, catheter removal and appropriate antibiotic use be at the top of their minds. There's a huge amount of information in these reports we're releasing today. I don't want to lose sight of the fact that every number you see in the report is a person. These are patients who went to the hospital to receive care, and in some cases they got infections that kept them in the hospital longer and in a few cases they died. This is something that drives the efforts at CDC to eliminate healthcare-associated infections. I wish I could be introducing our next speaker under different circumstances, but I’m honored to share the podium today with Mrs. Victoria Nahum. She is the cofounder and executive director of the Safe Care Campaign. She and her husband Armando are strong and timeless advocates for patient safety. Her story brings home the importance of the issue, and frankly it’s why we’re all here today.
VICTORIA NAHUM: Thank you, dr. Bell. Good afternoon. In an 11-month period between November of 2006 and October of 2007, three different members of my family representing three different generations of my family were infected by healthcare-associated infections in three different hospitals in three different states. So at the end of that time we lost our son Joshua to a drug resistant gram negative infection that surrounded his brain and it was so virulent it pushed part of his brain into his spinal column. In doing so it effectively rendered him a permanent ventilator dependent quadriplegic. So two weeks later, Joshua died from his infection. He was only 27. So, in our grief in trying to understand, you know, how and why these infections were so frequently appearing all over the country, my husband Armando and I we reached out to the CDC for answers in Atlanta. They were close by. I want to tell you graciously they met with us. In the eight years since our original meeting, they have become great partners and mentors and encouragers in our work to prevent other families from experiencing similar fates. Our organization, Safe Care Campaign, works with hospitals and healthcare systems to help them do just that. So these new infection numbers, the data today represents a forward stride in our shared work. Components including guidelines turned into checklists and data transparency in public reporting as well as pay for performance initiatives have all helped prevent infection, unnecessary harm, and many tragic deaths. While inwardly I breathe a small sigh of relief that annual infections and mortalities are diminishing, I want to tell you that I remain extremely cautious regarding the growing threat of antibiotic resistance and the dire impact of its potential danger to American healthcare. Today I want people, healthcare workers and patients alike to understand they have the power. You guys have the power to prevent healthcare-associated infections. Professional caregivers can make the definitive difference by practicing compulsive hand hygiene and always following other best practices at the bedside. Patients, patients can actually prevent their own infections and potential infections in loved ones by doing easy things like Dr. Bell suggested when he was up here a few minutes ago. Things like asking questions, insisting on proper hand hygiene every time by anyone who touches them, even their family members. And especially their doctor. And educating themselves on how to safely receive medical care -- this is really important. You don't just slap down and say take care of me. You have to kind of navigate what will happen to you. In doing so, that can save your life. Thankfully we are realizing once and for all we're all in this together yet our singular and very personal roles and how we deliver as well as receive care leaves us accountable for our own actions. Thank you so much.
MICHAEL BELL: Well, I hope you appreciate as much as I do the courage and conviction that it takes to share that story, and continue to work for such an important cause. It's certainly why CDC has made this such a high priority. Diane, on the phone, if you could give instructions to callers, I will take questions now from the room.
OPERATOR: Thank you. If you would like to ask a question, please press star 1. You will be prompted to record your name. To withdraw your request, please press star 2. One moment, please, while we wait for the first question.
BARBARA REYNOLDS: Erin from NBC.
ERIN SYKES: The statistic of one in nine patients who die, I’m assuming that's as a result of the hospital-acquired infection, it wasn't another comorbidity that occurred?
MICHAEL BELL: That’s a perfect question. No. Of all the patients who had infections one out of nine of them went on to die during their hospital stay. There's a possibility that something else was contributing to that death, but it's difficult to tease that out. So we've simplified the numbers one in nine.
ERIN SYKES: Were there any states that stood out as performing well with reducing infections? Any states that performed worse? Do you have that comparison?
MICHAEL BELL: I wish there were. If there was a perfect state, we could copy everything they're doing and spread it across the other 49. If there was one that was particularly terrible, we could put all of our resources there. As it turns out, state by state, some places are having success with some infections, not others. It's a very mixed picture. Other questions in the room? Diane, do we have a question on the phone, please?
OPERATOR: Yes, we do. We have a question from MICHAEL Stobbe, Associated Press. Your line is open.
MICHAEL STOBBE: Thank you for taking my question. Your announcement today could be taken by some as good news--
MICHAEL BELL: Diane, we just lost MICHAEL on the overhead. Perhaps we lost Diane as well.
OPERATOR: One moment. We'll get him right back on the line again.
MICHAEL BELL: Okay.
OPERATOR: Bear with me. Your line is open, MICHAEL.
MICHAEL STOBBE: Okay, can y'all hear me?
MICHAEL BELL: Yes.
MICHAEL STOBBE: Okay, great. Thank you for taking the question. This -- what you presented today could be seen by some as good news. These are numbers that suggest-- estimates that suggested that there were nearly two and-a-half times as many hospital infections in a year as the numbers you presented from the 2011 survey. I guess I was wondering if you could talk a little bit more about the context of this data? Where are we in the evolution of data collection? You said a little bit about that, but you talked about the apples and pears, but are these really the most solid numbers we've had? And if there have been improvements in fighting hospital infections, could you say a little more about what generally type of measures have accounted, for example, the improvement in blood stream infections that you mentioned? If you could address that. Thanks.
MICHAEL BELL: Sure. So, first and foremost, this is probably the best quality of data we've had in a very long time to look at the burden and type of infections we're seeing in health care. The previous estimates, I think, are useful in a very big pictured, non-granular kind of way to say that it used to be bigger, now it seems to be smaller, but they definitely are not the same methodology. I wouldn't compare them directly. But I think there seems to be a trend. The reason for doing this became clear when we did the original publication in 2007, where we had to use all sorts of different publications and data sources to cobble together a picture. That led to the process that allowed us to do the survey that we were publishing today. But it took a pilot in 2009, followed by expansion in the next year, and that process was a direct response to the difficulty of getting a burden estimate from the previous publication. Having said that, this is more than just that burden estimate. The places where we have seen success are things -- infections like central line associated blood stream infections, ventilator associated pneumonias, things that happen in intensive care units. Originally this was the place where the sickest patients were, these were the infections that had the greatest threat to patient wellbeing, and those were the things that we focused on up front. These are also the things we follow month by month, year by year, in the National Healthcare Safety Network. We track these things, and that's part of what populates the progress report that was also released. At the same time we need to be thinking about what we're not measuring in that system. And this prevalence survey allows us to look at every infection happening on that day and figuring out what else is out there. Some of that “what else” is the pneumonias, for example. Of the pneumonias that made up almost 25 percent of infections, a lot on the ward. Well what are those? We're in the process right now of teasing that apart so we can understand what the next level of prevention is. In the intensive care unit we know that if you raise the head of the bed, do meticulous oral care so there's less bacteria building up there, and reduce sedation so you can get people off the ventilator as soon as possible, these things are associated with preventing those pneumonias. What is the equivalent bundle of practices for a patient who’s not on a ventilator? Is it perhaps related to sedation? Could it be these people are using tranquilizers, because hospitals are, let's face it, noisy places. Right? But maybe the down side to getting good night’s sleep is that you're more likely to accidentally inhale saliva or stomach contents and get a pneumonia. We don’t know if that’s the case, but if it is, it leads to some very clear prevention steps that we can implement to prevent those infections. On the other hand, if we see that a lot of these infections are caused by, for example, pneumococcus, there’s a vaccine for that. Maybe we need to be doing a better job of making sure everyone’s immunized against vaccine preventable infections. So, this is an opportunity for us to look very clearly in places that we're not routinely measuring and say which of these things needs to have that level of attention directed towards it next. Another big chunk of this was the deadly diarrhea, Clostridium Difficile. When we see that many infections caused by that one pathogen, it’s yet another piece of the scaffolding that supports our drive for better antibiotic prescribing. The need for good antibiotic stewardships in every hospital is further emphasized by the number of infections we’re seeing by those organisms. So that's how we're using this particular study to find out where else we need to look and also to get a better estimate of how much of a problem this is. We have a couple in the room. Please. Whoever was first. Don't fight.
DIANA DAVIS: Hi, I’m Diana Davis from WSB in Atlanta. What you just alluded to, it mentions some things you're looking at. Are you also looking at if staffing shortages, problems, overloaded staff, if that may be contributing to some of this?
MICHAEL BELL: The staffing question is a huge challenge. I wish there were good data that proved a certain amount of staffing led to a better outcome. We don't have data to say that. I know many facilities are struggling with the staffing question. We see this not only in hospitals, but if you compare healthcare ten years ago to when the 2007 numbers were released, things are different. A lot of care that used to only take place in intensive care units is now being provided on wards. The staffing is not the same. The level of training may not be the same. Similarly, patient care that took place on wards is now happening in skilled nursing facilities, nursing homes, and in home care. Again, it’s not just a matter of do we have enough nursing staff or doctors, it's where are we providing this care? And part of the work that CDC is engaged in right now is making it possible for us to reach into nursing homes and ambulatory surgery facilities to get the same sorts of data that inform our quality improvement question just as we’re doing in hospitals. As soon as we have information that says staffing should be exactly this, I will be happy to trumpet that. But right now, we don’t have a lot of clarity.
DIANA DAVIS: One follow up. Patients being aggressive or family members if the patients are not able to speak for themselves, how do you get people over the intimidation of being in a hospital, saying -- challenging a doctor. What's your message to people watching this right now about their “Gee, I don't want to be rude” or “Gee, that's impolite.”
MICHAEL BELL: It’s really hard. When my own mother was in the intensive care unit, I found it hard to pipe up. If I find it hard, I can't imagine what it's like for everybody else. But what I can tell you is, when a friend of mine was recently in the intensive care unit, two of us, another friend and myself, we took turns being the bad cop. We supported each other. It's easier to do when you decide up front I’m going to be the bad cop today. It's hard to do. But it's very important that people try. Do we have a call from the -- yes, please.
MICHAEL BELL: Hi Carrie.
CARRIE TEEGARDIN: I just had a question, when we're using the state figures. So, for example, in Georgia, the Class B number is down 33 percent. That's compared to the national benchmark. Would it be accurate to say that we had a drop in Georgia of 33 percent? Or is that compared to the national benchmark? I'm wondering whether that's accurate given that depending on where Georgia started.
MICHAEL BELL: Right. Depending on where you started is the key to the question. The baseline for many of these numbers is 2006 to 2008. We have been reporting progress year by year. So, continuing to show that same arrow is not as helpful at this point since it's 2014. That's why we compared it to the national progress level. So, when you say that, you know, there's a 30 percent improvement in Georgia compared to the national, it is really only compared to the national.
CARRIE TEEGARDIN: Is it accurate to say that's a lower number than we've seen nationally for Class B? I'm assuming that means Georgia’s kind of lagging behind the nation in progress.
MICHAEL BELL: So, I’m going to let our specialists in that arena address this next, but again, I think the reason for producing this report at all is to push, just as I’m being pushy when it comes to asking questions at the bedside, we're also being pushy when it comes to our state colleagues and our healthcare colleagues saying, look, there's more to be done. Paul, Jonathan, do you want to say a word?
PAUL MALPIEDI: Just to jump in on the state question. MICHAEL is correct. We're comparing back to the national baseline. We do do a comparison in the progress report that compares the state progress to the rest of the nation without--with the state excluded. And there is a conclusion we’ve been able to see. Whether the state's progress is significantly different from the rest of the nation, again, like MICHAEL also alluded to, that differs between the different infection types. We're not looking at a composite measure as a whole.
MICHAEL BELL: I'll follow up also by saying that these things tend to taper off. And we don't want to penalize places that are doing a great job because they're down so low there's not a lot of progress left to make. You'll see us continuing to work with the issue of baselines in different ways of presenting the data so we can give a clear puck chore of how we're progressing, where we need work, but also without taking away the success of a place that's gotten so low that there's no place else to go. Do we have a call from the phone, please?
OPERATOR: We do have a question from Daniel White from McClatchy Newspaper, your line is open.
DANIEL WHITE: Thank you guys for taking my call. The CDC projects that with the $30 million in funding requested by the president's fiscal year '15 budget that its antibiotic resistance initiative could achieve a reduction in health care infection. You guys project this would save a number of lives, prevent hospitalizations and cut more than 2 million in costs. How would the AR. Initiative accomplish this?
MICHAEL BELL: The AR Initiative is in the FY-15 president's budget. It is an investment propose to improve our ability to track the infections. Improve the ability to get the data to tell us where the hot spots are. Improve the nation's capacity to do the laboratory testing that's needed to figure out which of these germs is causing the problem. And then also bolster our ability to put, as they say, boots on the ground in places that are having a problem and actually deliver assistance to improve practices. Is there another question on the phone?
OPERATOR: We do have a question from Mary Ann Roser from Austin American Statesman, your line is open.
MARY ANN ROSER: Thanks. I'm wondering if we have data on individual facilities and state rankings. I had a second part to that.
MICHAEL BELL: We do provide hospital level data from the Centers for Medicare and Medicaid services hospital compare website. Our national health care safety CDC gate ta gets handed off to CMS, they can public those infection rates by hospital with the address for every hospital they support with CMS money.
MARY ANN ROSER: So we have those for this year?
MICHAEL BELL: yes.
MARY ANN ROSER: And state rankings for the report today, do you have that?
MICHAEL BELL: When you say state rankings --
MARY ANN ROSER: I'm in Texas. Are we near the bottom or near the top--
MICHAEL BELL: No. We don't have that. The problem here is you might be at the bottom for one infection type, but you might be leading the pack for another. So it doesn't really help anybody to say one state is good or bad.
MARY ANN ROSER: And just the other question I had, Do you have advice for the public about using anti-bacterial soap? Is there a brand you recommend? Because I find it very difficult to find antibacterial soaps.
MICHAEL BELL: I understand. There's a huge amount of commercial product out there. Really plain soap and water works really well for almost everything. Using it constantly is a good thing. Alcohol hand rubs are a great thing. When I’m transiting in airport, I’m constantly using them. For some things, anti-microbial soap solutions are important. If you're about to have surgery, your doctor may say take a shower with this soap twice in the next couple of days so your infection risk is lower. There's a role for all of these things. For routine day in and day out use, at my house I use a nice soap that smells like flowers. That's fine. You don't need anything special. We have time for two more questions.
MARY ANN ROSER: Thank you.
[ inaudible ].
MICHAEL BELL: No , we don't come out and say don't use anti-bacterial soap. We are specific about where we say it should be used. What we want people to do, though, is focus on keeping their hands clean at all times. Especially in health care settings. Another question on the phone?
OPERATOR: Dan Childs, ABC News, your line is open.
DAN CHILDS: Thank you very much for taking my question. With regard to the problem of antibiotic resistance that you were talking about, where are we in terms of new approaches to these untreatable infections that you mentioned and will we get a second chance to get it right with antibiotics? and if so, when?
MICHAEL BELL: Great question. So, as a nation in addition to preventing antibiotic resistance in organisms by better antibiotic use, and in addition to not letting the organisms spread from patient to patient with good hand hygiene and infection control, we're also supporting the generation of new antibiotics. The challenge that we have is that it takes a long time to go from some rare chemical in a jungle to something that we know is safe and effective for human beings. During that span of time, what we have right now is pretty much it. So a lot of the very intense work we're doing with regard to antibiotic stewardship and prevention of resistance is about how we keep these handful of antibiotics that still work for us effective and available for the next, who can say, seven, eight years maybe before we have a new truly useful antibiotic that has come through the pipeline. There's that piece of it. You also talked about other approaches. And there is an interesting area of work, not completely mature yet; of other ways to take care of infections. Some of you may have heard about medical honey. There are ways to treat wounds that seem to be successful, if there's overwhelmingly supportive data, we may be recommending to do that routinely. We're not quite there yet. I think the desperation with which some of these infections are being approached is leading to interesting new approaches. Lastly, the question of will we get a second chance is an important one. There are two pieces to this. One is, once we do have new antibiotics, if we treat them the way we've been treating them up until now, we'll lose those quickly as well. I guarantee it. It's like ordering a new credit card when you're bankrupt. It doesn't work. The flip side is when you don't use an antibiotic for a long time, bacteria stop fighting it. So one of the medications that we use for the nightmare bacteria is a thing called, colistin. It's a terrible drug to use, because the side effects are horrible. So it still works. In desperation, we're using that. There's a possibility that with very good antibiotic stewardship, using less broad spectrum antibiotics and using them as widely as possible, we may be able to move the needle back a little bit for some of these bacteria.
DAN CHILDS: Thank you.BARBARA REYNOLDS: Thank you. This concludes today's media briefing on health care-associated infections. Thank you, Dr. Bell. Thank you, Victoria. For media attending today's briefing in person, we are happy to be joined by the members of the Georgia health care department, the quality improvement association, and they're available for interview also. For those not in the room, media who have follow-up questions or requests for interview, please call CDC's media line at 404-639-3286 or e-mail media@CDC.gov. Thank you.
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