Telebriefing Transcript: 2018 STD Prevention Conference

Telephone Press Briefing: New CDC analysis shows steep and sustained increases in STDs

Audio Telebriefing

Edward (Ned) Hook III, MD, Scientific Committee Chair

University of Alabama School of Medicine

Thank you very much. Good afternoon. My name is Ed Hook. I’m a physician. I take care of patients regularly with regard to problems related to sexually transmitted infection. I’m also a clinical investigator and I’m also the director of the CDC funded STD Prevention Training Center for Alabama and North Carolina, where we carry out training for clinicians on how to manage and care for persons with sexually transmitted infection.

For those of you on the phone, we’re speaking to you from the 2018 STD Prevention Conference being held here in Washington, D.C. where hundreds of sexual health experts have come together to help define and discuss the problems related to STD prevention and control. At this year’s conference, and in today’s press briefing, we will be focusing on collaborative efforts to address the continuing and increasing problem of sexually transmitted diseases in America.

From on the ground healthcare workers, to clinical researchers, to state and local policy makers and their implementers, it’s critical that we all work together to address the growing problem and threat to public health of sexually transmitted infections, threat to individuals and to entire communities.

For today’s briefing, I’m joined by three colleagues and partners in this effort: Dr. Gail Bolan, the CDC’s Division of Sexually Transmitted Disease Prevention; Michael Fraser from the Association of State and Territorial Health Officials; and David Harvey from the National Coalition of STD Directors. Together, the whole is greater than the sum of its parts ((inaudible)).

Together, we’ll be addressing some of the most pressing and newest issues related to STDs. Specifically, we’ll be talking about the sustained upward trend of STD rates currently across the United States. We’ll be talking about the growing threat of antibiotic resistance that at some point leads to untreatable gonorrhea infections. And we’ll talk about the vulnerability of the country’s STD prevention infrastructure and its ability in terms of STD prevention funding.

So with that introduction, I’ll go on and turn things over to Dr. Bolan to discuss preliminary data from the CDC Annual STD Surveillance Report.

Gail Bolan, MD, Director

Centers for Disease Control and Prevention (CDC), Division of STD Prevention

Thank you, Dr. Hook. It is a critical time for STD prevention. We face challenges on many fronts, from skyrocketing STDS to the threat of antibiotic resistance. We need bold ideas and as the theme of the conference underscores, integrated solutions that address STDs along with HIV prevention, substance use disorders, and other critical public health efforts.

Let me start by sharing the latest findings of the severity of the nation’s STD crisis. CDC is seeing steep and sustained increases in STDs. Today, CDC is releasing new preliminary data from 2017, the most recent year of surveillance data available. They show that total chlamydia, gonorrhea, and syphilis cases hit an all-time high in 2017 with nearly 2.3 million cases reported to CDC, surpassing the total reported to CDC for 2016 by more than 200,000 cases.

This is the continuation of a persistent and troubling trend. STDs continued to increase for four straight years between 2013 and 2017. Now, let me break this down further. CDC data showed that from 2013 to 2017, gonorrhea diagnosis increased by 67%. They nearly doubled among men and increased by nearly one-fifth among women, which we haven’t seen in a long time. Syphilis diagnosis nearly doubled with most cases continuing to be among gay, bisexual, and other men who have sex with men. And chlamydia remained extremely common; 1.7 million diagnosed cases were reported to CDC in 2017. In fact, chlamydia was the most common condition reported to CDC that year.

After decades of declining STDs, in recent years, we’ve been sliding backwards. In addition to these sharp increases, we’re also facing new challenges that we must address like the potential link between STD risk and drug use and the ongoing threat that gonorrhea will eventually wear down our last highly effective antibiotic. Over the years, gonorrhea has become resistant to nearly every class of antibiotic we’ve used to treat it except for ceftriaxone, the only remaining highly effective antibiotic to treat gonorrhea in the United States now.

Since 2015, CDC has recommended healthcare providers prescribe a combination of two drugs to people diagnosed with gonorrhea: a single shot of ceftriaxone and an oral dose of azithromycin. Azithromycin was added to the recommended therapy to shield ceftriaxone from resistance and that approach seems to be working. Emerging resistance to ceftriaxone has not been seen since the dual therapy approach was implemented and there has not been a confirmed treatment failure in the United States when using the recommended therapy. Therefore, CDC continues to recommend this two-drug combination to preserve the effectiveness of ceftriaxone as long as possible.

However, new CDC data indicate the small but growing fraction of gonorrhea lab specimens are now showing emerging resistance to azithromycin. This finding adds concerns that azithromycin resistant genes in some gonorrhea could cross over into strains of gonorrhea with reduced susceptibility to ceftriaxone and that a strain of gonorrhea may some day surface that does not respond to ceftriaxone.

Though not surprising, the finding adds to the complexities of gonorrhea treatment because preserving the effectiveness of ceftriaxone may become more difficult. Our nation must plan for the future. Our nation urgently needs additional treatment options for gonorrhea. It’s also important to note that one of the most important ways to combat drug resistance is to prevent disease transmission in the first place.

So through STD surveillance, CDC is in a unique position to see the nation’s public health landscape. Enhancing STD surveillance allows programs to better assess STD trends, population burdens, and outcomes, and to improve program efficiencies. And through action, CDC can deploy resources where they are needed most. However, CDC alone cannot turn the tide on rising STDs. It is important for partners to come together to combat STD increases and the threat of antibiotic resistant gonorrhea.

Countering the current STD crisis requires new commitment from the healthcare sector, from scientists, from industry, from state and local health departments, and federal officials alike. So on that note, I’d like to welcome Michael Fraser, the Executive Director of the Association of State and Territorial Health Officers to outline what’s needed to address vulnerabilities in the county’s STD prevention efforts.

Michael Fraser, PhD, CAE, FCPP, Executive Director

Association of State and Territorial Health Officials (ASTHO)

Great. Thanks, Gail. Appreciate that. It’s nice to be with you all. ASTHO, the Association of State and Territorial Health Officials, as mentioned, and our members are the secretaries and commissioners of public health in all the states and territories, and we work in partnership obviously with CDC and local health officials, local health departments, healthcare partners, and many others.

So certainly, the data that CDC is releasing on the rising rates have us all very concerned. If you look at where state and territorial health agencies spend a lot of their time, it’s on STD prevention. There’s a lot of work going on in the states and territories on this issue. And so folks may be wondering why are we seeing these increases now and why have they been pretty steady increases over time.

And I think what’s important for us all to understand is in addition to the amazing work that happens clinically and some of the science that Dr. Bolan shared, state and public health departments also have a role in community prevention and addressing the primary prevention of STDS in every state and territory. And so your mention of primary prevention is really important and that’s the work of state health departments.

And what we’ve seen not just with STDs but lots of other infectious disease and chronic disease threats is a tremendous increase in many, primarily due to an eroding public health infrastructure. We all understand that you’ve got to maintain your bridges and your roads, and we see them on TV when they crumble. You don’t always see a crumbling public health infrastructure and a lot of folks don’t even know what public health does.

But part of the rise, we believe, in STDs and particularly some other concerning news around gonorrhea is the lack of funding for capacity at the state level to really invest in prevention work. And that prevention work is done by people, not just about the medicines. And in every state and in local health jurisdictions, there are disease investigators who meet individuals, talk to them about their behavior, do contact tracing, and try to prevent future infection while treating the individual. And that’s just core public health work that takes people. And we’ve actually seen a decrease in the federal dollars to support that kind of work in the States.

So I think we all have to ask ourselves these questions. Certainly, there’s an individual component to this but really what these rates show to me is someone who works with state health departments is our lack of investment in public health and prevention and actually, we shouldn’t be all that surprised in many ways by these increases when we look at the decreases in public health funding and the purchasing power of state health departments over time.

We know what works with STD prevention. We just don’t necessarily want to pay for all of it. And so we have to really ask ourselves if we are to take this seriously and we want to get on top of this, are we willing to make that investment. According to figures by David’s group, and he’s going to talk in a minute, that’s a nominal investment. That’s another $50 million to fully build the capacity of CDC’s work and their work with states to fund adequately the STD prevention workforce that we need.

So while we all should be very concerned, I think we all need to be incredibly interested in how we’re going to solve this problem and we’re going to solve this problem with great science and surveillance data from CDC and states. We’re really going to solve it with those boots on the ground, DIS officers, and others working in public health to do both the treatment and prevention work with individuals but the broader prevention work with communities.

And I think David is going to share a little bit of that from his perspective.

David Harvey, MSW, Executive Director

National Coalition of STD Directors (NCSD)

Thank you. I go by David C. Harvey, Executive Director of the National Coalition of STD Directors. The acronym is NCSD. We represent state, and city, and territorial STD public health programs. I want to summarize for members of the media three reasons why STDs are rising in America. The first is an extreme lack of awareness and education about STDs and sexual health.

The second reason is that doctors are not screening and testing for STDs and patients don’t know that they need to ask for that screening and treatment. The third reason is that we’ve had a tremendous cut back in federal and state funding over 20 years.

Continuing on, I want to make four points. The United States continues to have the highest STD rates in the industrialized world. We are in the midst of an absolute STD public health crisis in this country. It’s a crisis that has been in the making for years. It’s under recognized and it preys on the most vulnerable among us. This is a crisis that costs the United States more than $16 billion in preventable health care costs a year.

The American public and members of Congress need to know that the explosion in STD’s comes on the heels of years of cutbacks in federal funding. Federal STD funding has seen a 40% decrease in purchasing power since 2003. That means that state and local health departments most of which depend primarily on federal funding to support their STD programs are working with budgets that are effectively of what they were 15 years ago.

We at the National Coalition of STD Directors estimate that at the very least, an additional $70 million is needed immediately to sufficiently arm state and local STD programs to confront this crisis. That means that Congress needs to allocate $227 million total dollars in FY19. Congress also needs to add funding for more research at the National Institutes’ of Health to support STD research activities.

Congress has the opportunity right now to do something about this. As they debate the FY19 appropriations bill and decide how to allocate new funding to address these very serious life-threatening diseases.

Here’s a quote from members of the media. Ready? “It is time that President Trump and Secretary (Azar) declare STDs in America a public health crisis. What goes along with that is emergency access to public health funding to make a dent in these STD rates and to bring these rates down and to ensure that all Americans get access to the health care that they need. Thank you.

Edward Hook: With that we would questions from the people in the room or people who are on the phone lines. Question?

Q1: How does sexually transmitted infections affect the birth rate?

Q1: The question is how do sexually transmitted infections affect the birth rate? Dr. Bolen would you like to comment on the issues of infertility and sexually transmitted infections?

Gail Bolan: So first of all we know that chlamydia and gonorrhea are most common in young people between the ages of 15 and 24 and half of those young people are women and these infections cause serious reproductive health consequences.
If left untreated where the infection goes up into the upper reproductive health tract resulting in PID which then results in entopic pregnancy which is a mortal condition in this country, as well as chronic pelvic pain and infertility when they choose to have children.
So we know that there’s significant contribution at a young age for these infections into infertility and we’re trying to better quantify the birth that have been not happening because of infertility. We also know that STDs if they infect pregnant women, can be transmitted to either the fetus or the newborn child.
And we’re most concerned about syphilis infecting the fetus where it can be a significant cause of stillbirths. So we know that it can affect the mortality of infants in this country as well.
David Harvey: This is David Harvey from the National Coalition of the STDs Directors. Shockingly, in America today, we have 1,000 and it’s an undercount, 1,000 babies born with congenital syphilis. We know around 40% of them will be stillbirth. Compare that to what we face with babies born with HIV in the United States.

We have virtually eradicated mother to child HIV transmission. It is shocking that today in America, 1,000 babies have been born with congenital syphilis. We are failing these mothers and their newborns and something needs to be done about it.

Edward Hook: Thank you. We’d welcome other questions.

Q2: Yes. Thank you for taking my call. Nobody specifically mentioned the opioid crisis as being a factor in this explosion of STDs and I know CDC put out some information recently on the explosion of use of opioids in pregnant women. I’m just wondering if any of you could comment on what role this drug use is having on STD rates.

Edward Hook: There’s certainly a lot of overlaps in the opioid epidemic and the ongoing epidemic of sexually transmitted infection. (Mr. Harvey) has a comment.

David Harvey: David Harvey from NCSD. There are infectious disease consequences of the opioid epidemic in America including sexual transmitted infections. We know today that some of what is driving congenital syphilis are women who are trading sex for drugs and that that explains some of the infections we are seeing in babies of syphilis.

So there is a direct link and causality and as the Trump Administration continues to do good work, to battle opioid misuse in America, we cannot forget the infectious disease consequences which include STDs.

Gail Bolan: So if I could add, we’d like to point out that you know injection drug use itself does not seem to be causing sexually transmitted infections. We certainly know there are other infectious diseases that are more blood borne infections like HIV and Hepatitis C that are associated with injecting drug use.

But we’re very concerned about the connection between drug use including opioid but we’re also concerned about methamphetamines and other drugs that place people at risk for sexually transmitted diseases. This has been known for a long time.

We do have some new data from CDC where we’ve found that 15 to 24 year olds who reported injection drug use within the past year were more likely to be diagnosed with chlamydia, syphilis, and gonorrhea and injecting drugs was also associated with the higher rates for force sex, sex in exchange for money and sex with other people who inject drugs. So all of these factors can lead to increases in STDs.

Q3: Hi. Thank you for taking my question. How much of a role do you think sex education programs in schools and the lack thereof also contributes to this and what more needs to be done in schools to help attack this crisis?

Edward Hook: Certainly young people are the individuals in our nation who are at greatest risk for sexually transmitted infections. Perhaps Mr. (Frazier) would like to make a comment.

Michael Fraser: Sure. Thanks. This is Mike Fraser from ASTHO. It’s a great question and I think it points to a couple of different things. One is the solution to this issue is going to require both a public health perspective, but also a real cross agency approach that includes education, healthcare financing, insurers, families – all across the country.

You know I certainly would urge our members and I know they do this to look at evidenced based approaches to sexual health education. There’s a really good science out there. There’s ways to do effective programs based on evidence and data, but certainly there’s a lot more that we could do and in a lot of states this is a difficult conversation due to the politics of the state.

And you know it really is our hope that when you take a science-based data informed approach that we do see good outcomes. So we urge all of our states and partners to really get to know what those programs are and a lot of them have benefit not just for STD infection, but substance use and addiction issues, physical activity and chronic disease prevention. They’re really about promoting positive youth development and that leads to better health overall in not just preventing STDs.

David Harvey: David Harvey from NCSD. The United States today, unfortunately continues to debate the need for comprehensive sex education across the United States. There is no question that young people need accurate information about sexual health. Young people today face the highest risk of STD infections as any other age group. So we are failing young people today by not supporting comprehensive sex education.

This also speaks to the importance of some federal programs that help support this and on the health side of the equation which intersects with this issue is the importance of the adolescent school based health programs also supported through CDC.

Edward Hook: This is Ned Hook. I would just add as a clinician that the problem of sexually transmitted disease education is not a matter of (emancipating) the nuances of how these diseases are transmitted, but explaining and correcting the misperceptions that are widely held.

For instance, most people with sexually transmitted diseases are asymptomatic, not symptomatic and so there’s a real need for screening and testing as part of sexual health. And that misperception that if people have STIs, they know is, is simply incorrect.

Similarly, we now know that most people who transmit sexually transmitted infections don’t know they have sexually transmitted infections. So the intervene that academic education is really misstating point. Thanks for the opportunity to comment.

Q4: Hi everyone. I wanted to ask if there was any sort of geographic breakdown of the increase of STDs in 2017 – if it was located in a particular geographic area or more urban or rural settings or a mix.

Edward Hook: Dr. Bolen would you please…

Gail Bolan: I have to say that STDs are widespread in the United States. They really cross urban and rural boundaries. They cross socioeconomic boundaries and so we really encourage both at the community level and at the provider level. People need to look at their local data and talk to their health departments and talk to their providers and really have a good understanding of the level of infections that they are seeing in their community.

We certainly know if you live in community with high prevalence of infection, you’re more likely to get infected. If you live in a community with low prevalence of infection, then your chances are less.

So with our rising rates, they’re going up everywhere, we’re seeing STDs in places that we haven’t seen before. We’re really on a bad trajectory and I think right now we’ve got to get the message out to everyone. You really need to go in and get checked if you’re young and sexually active.

We do have very clear recommendations about screening. We recommend that all sexually active women less than the age of 25 go in and get checked for chlamydia and gonorrhea on an annual basis. We recommend that men who are having sex with men, go in and get checked at least annually for sexually transmitted diseases and we have to recognize you need to be checking at sites of infection. So it’s not just looking for urethra infections, we need to make sure that we’re looking for infections in the rectum and in the throat.

We have for years have been recommending to all pregnant women and most states have law. By law, they need to be tested for syphilis at the first pre-natal visit, and if you’re in a high risk community, again, in the third trimester because many women are acquiring syphilis during their pregnancies. Assumptions are being made that they’re in a monogamous relationship, and they’re not. They’re at risk and if they don’t have that second test, then they have a baby born with congenital syphilis.

So we have really clear recommendations what needs to be done. We just need to get our providers doing sexual histories and doing the appropriate screening and we need to have clients who come in and access care to be asking, do I need to be – everyone needs to ask their doctor, should I be tested for STD’s, I hear they’re going up. So, and have that conversation. That’s the conversation that’s not happening in most medical homes these days and it really needs to be routine care in this – in our country.

Edward Hook: David Harvey has additional comment.

David Harvey: In addition to Dr. Gail Bolan’s excellent response. I just want to also point out that we are seeing disproportionate rates of STD’s in certain areas of the country. Southern states, lower income states. We’ve already cited some of the worst statistics among American youth. We see young people of color, young gay men of color, disproportionately and hugely burdened by STD rates. This requires us to take a hard look at social determinates of health and to address social disparities.

Michael Fraser: Yes, this is Mike Fraser from ASTHO. I think STDs are a problem in every state but there are certainly a disproportionate burden in the Southeast and a lot of that has to do with the financing of public health and what public health services there are in those areas as well as the communities that live in those areas. The data, I believe, will – you have some state specific data later in the year so we’re anticipating that and – you know, but I think it’s important that it is a national issue.

I think the other thing that both David and Gail shared that’s important is we don’t want to take a one-size fits all approach to STD prevention. The techniques you might use in the MSM community is really different from what you might use with pregnant women and so we have to get it a little more refined too in our approach and I think that’s another place where states have a lot of expertise because they know their population and they know some of the stuff that works well in some of those areas.

Q5: Hi, yes thank you for taking another question from me. You’ve mentioned clinicians, providers, several times, and I’m wondering what is it going to take? What do you think it will take to get them to ask questions to do the sexual history, to ask about sexual activity and really start that conversation?

Edward Hook: This is Ned Hook. As a care provider myself, I can tell you that care providers have an awful lot of things that are recommended to them on a routine basis and they have a hard time doing all of those things. I would also suggest that both providers and their patients sometimes are a little bit reticent to start the conversation. Despite that, research has shown that actually patients feel better about the care they’re providing when they have had an in-depth conversation regarding their sexual history. So, I think that it’s both incumbent amongst providers to try to do that but I think it’s equally and even more importantly to emphasize what Dr. Gail Bolan said, which is that for instance, for every women under the age of 26 who is sexually active in our country, it’s recommended that she be tested every year for chlamydia. Our data suggests that that happens about half the time that women interact with healthcare providers. So, what that means is that for women out there, if they’re seen a healthcare provider and they don’t know that they were tested for an STI in the past year, only one of two things has happened; they were tested and not told or they weren’t tested despite the fact that virtually every professional organization recommends testing for Chlamydia in that situation. That really, for me, is a call to action for our patients and for the population to be introducing and starting those conversations with their healthcare providers.

Mr. (Harvey) has an additional comment.

David Harvey: Very quickly, CDC supports an excellent training program, clinical education providers called the STD Prevention Training Centers. They have been cut in their funding over the last 20 years, congress needs to add funding for more provider training.

Michael Fraser: I would just add, this is Mike Fraser from ASTHO. I would just add that this – you know, the solution to this problem is not going to be to treat our way out of it. I mean, like the antimicrobial gonorrhea is probably the best example of that that, in fact, this gets more difficult. We are just going to rely on medicine as the primary prevention strategy here and expecting a physician who is already pretty hurried in her day-to-day practice to do the slew of recommended things is probably just not realistic given the way physicians practice. So, one of the roles public health can play, and has done very successfully is to take some of that pressure off the clinical system and pretty much every state and territory runs an STD prevention program that’s highly effectively it’s just that there’s not enough of it.

And so I think we shouldn’t necessarily just look to medicine for a solution to this. We need to look at the just core public health capacity to work in communities, do the contract tracing and all that’s involved there but also to use evidenced based prevention and train public health folks. You don’t need a medical degree necessarily to prevent an STD. You need to talk to people about using condoms, it’s that simple. So, you know, that for us at the state level it’s a very effective, good science behind primary prevention of STD’s and we need to scale and spread those, continue to scale and spread those.

David Harvey: In addition to Michael’s comment, this is David Harvey again from NCSD. The question is a good one. There is a range of public health programs that need to be doing more around STD screening treatment prevention and education. The Ryan White Care Act, the Maternal and Child Health Block Grant Program, Community Health Centers, these are all public health systems that must step up to the plate to do more.

Gail Bolan: And so I also think we need to take advantage of some of the newer technologies that we’ve seen in the field, certainly we would like more because we still use a test in syphilis that was created in 1906 and we’ve been using penicillin since 1940 so we’ve had limited biomedical examples, limited biomedical advances. But I will say that we do now have testing for Chlamydia and gonorrhea that patients can do their own collection. So there are opportunities where we don’t need to have the provider actually see the patient and examine the patient. There are systems that can be created in the healthcare clinic setting where someone can come in and there can be standing orders. If you’re a young women, sexually active and 20-years-old, the registration desk can actually provide you a swab to go into the bathroom and collect your own Chlamydia specimen. So I think we’ve got a lot of opportunities, there’s been some new models that we have limited demonstration grants that we’re looking at express visits where the patient comes in and does their own, in a kiosk, sexual history, goes to the bathroom, collects all of the appropriate specimens, there’s a phlebotomist to draw blood and in these express visits, there’s not an involvement of a clinician. So I think we need to look at some new models and then lastly with the advent of electronic health records, in the healthcare system, we have opportunities to actually design the system so there’s a portal. Most young people have apps these days and they can be filling out their sexual history before they ever enter the clinic to talk to the provider and then the provider can spend their limited 15 minutes with that one-on-one personal interaction because they have all of the information in the electronic health record of what’s needed for that visit before the client comes in.

Q6: Sure, if I have time for a follow-up, you’ve talked about – so somebody could come in and fill out a sexual history but also isn’t part of the problem that people are reluctant to talk about maybe they’re sexual orientation or their actual sexual behavior that maybe they might not be so forthcoming about that?

Gail Bolan: Well, certainly I think we need to improve our societal discussions on the importance of healthy relationships and sexual health. But I think that if you create a welcoming environment in your clinics and a patient walks into the clinic and they see that there’s a transgender pamphlet for a client to look at, I think there’s ways that you can foster a welcoming environment because most people become sexually active and really want to talk about their issues with their providers. So I think the reluctance sometimes is more on the provider level at times then I think it is on the client level.

Edward Hook: This is Ned Hook, as a clinician I would add that many clinicians are a bit reticent to introduce the discussion about STDs and sexual risks to their patients and as a result of that, and in our prevention training centers, we’ve shifted the conversation and the starting point of those conversations is not so much you could have a disease but rather aren’t you interested in your health? There are good ways to screen, to stay healthy, to avoid these problems. There are modern vaccines for STI’s like HPV, there are opportunities to screen to assure yourself that you don’t have these problems which might otherwise go undetected. So by a focus on sexual health rather than on disease, we’re trying to make those conversations easier. I think Mr. (Harvey) has another comment.

David Harvey: Very quickly, your question again was good. I just want to add that the beauty of a new model that is getting discussed and implemented in some parts of the country are express clinics, express STD clinics and the beauty of that is that for some people this works well. Self-collected swabs, going through a process where a patient doesn’t necessarily have to disclose much but does the testing and then if a test comes back positive they’ll interact with the provider and then treatment is offered. But I think that’s one thing, that’s one way to get around what is essentially an enormous problem that we have around stigma related to STD’s in America.

Gail Bolan: Okay, well I would just really like to thank everyone for joining us to discuss the STD crisis facing America today. Stayed tuned for additional data and analysis of STD’s in the United States with the release of our full 2017 STD surveillance report in late September. Again, I would like to thank our moderator, Dr. Hook and our valued partners from the Association of State and Territorial Health Officers and the National Coalition of STD directors, Michael Fraser and David Harvey. So more than ever, we need to look to our partners for their on-the-ground expertise in local disease control outbreaks and the burden of infection in their communities and I really would like to thank you for being here.

Edward Hook: Thank you. Thank you members of the media for being with us today.

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