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Your guide to Philly's diverse creative scene, nightlife, music, food & more
June is always jam-packed with festivals, concerts and other vibrant happenings that make Philly shine. Since the pioneers of Black Music Month are deeply rooted in Philly music, it’s no surprise that Philly does it bigger and better each year.
With favorites like Chaka Khan, The Roots, Chrisette Michele, Earth, Wind & Fire and Sade hitting various stages all over the city, black music will be shaking up the streets of Philly.
Check out our top picks for the ultimate Black Music Month celebration.
Friday, June 3-Saturday, June 4
Highlights: Performances by Doc Gibbs, Johnny DeFrancesco, Tyrone Brown, Webb Thomas and more.
Saturday, June 4
Highlights: Performances by The Roots, Esperanza Spalding, Nas, Wiz Khalifa and more.
Saturday, June 11
Sunday, June 12
South Street (b/w 21st and 23rd Streets)
Friday, June 17-Saturday, June 19
Highlights: Performances by Chaka Khan, Chrisette Michele, Men of Soul (Jeffrey Osborne, Freddie Jackson, Peabo Bryson and Howard Hewett) and more.
Sunday, June 19
Sunday, June 19
Highlights: Performances by Chris Brown, Keri Hilson, Diddy Dirty Money and more.
Friday, June 24
Highlights: Honoring TSOP artists Jerry Butler, Chubby Checker and Dee Dee Sharp.
Friday, June 24-Saturday, June 25
Friday, June 24-Monday, July 4
Highlights: Performances by The Roots, Nancy Wilson, DJ Jazzy Jeff, Estelle, Earth, Wind & Fire and more.
Saturday, June 25
Wednesday, June 29
8 p.m. to midnight
Inside the Studio (featuring very special guests)
Sunday, June 26
Philadanco When: Friday, December 6 - Sunday, December 8, 2:30 p.m. & 7:30 p.m. shows Where: Kimmel Center for the Performing Arts,300 S. Broad Street Cost: $29 - $46 More Info: Buy tickets online here. Prepare to be dazzled as the Philadelphia Dance Company (PHILADANCO) returns with their annual…
A$AP Ferg When: Saturday, December 7, 9 p.m. Where: The Theatre of Living Arts (TLA), 334 South Street Cost: $29 More Info: Buy tickets online here. After the triumphant release of his debut album Trap Lord, A$AP Ferg is on the move and wreckin’ mics across the country with…
Sittin' In With Jeff Bradshaw When: Wednesday, December 11, 8 p.m. Where: Kimmel Center - SEI Innovation Studio, 300 S. Broad Street Cost: Free More Info: Click here for additional details Trombonist Jeff Bradshaw has lent his smokin’ hot horns to some of the top names in the industry,…


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Copyright 2016. Lake Norman High School Wildcat Band. All Rights Reserved.
Tradition Band Registration
Mr. Chris Brown has been the Director of Bands at Lake Norman High School since the school was founded in 2002.
Thank you for visiting the LNHS Band Booster Association Website. Our mission is to give every child the opportunity to participate and grow in the musical arts.

domain: artistic


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Can you imagine a world without zombie shooters? Neither can we. The zombie apocalypse is proving to be nothing more than a sci-fi nerd’s fantasy at this point, but that doesn’t mean that games based on it are not awesome. Especially the ones that fall under the category of side-scrollers, like the new game from Triniti Interactive called Call of Mini: Brawlers. In it, players seem to inhabit a zombie-infested world full of characters that appear to be made out of Lego. This applies to both the playable characters and the zombies.
Call of Mini: Brawlers features 3D graphics, 5 playable characters, and a load of kick-ass weapons that can be used to blast through hordes of zombies in an infinite number of stages. The game also lets users complete challenges and go through certain obstacles apart from simply killing tons of zombies. In short, if you’re a hard core fan of zombie shooters, you’re going to have countless hours of fun playing this one.
To give this game a whirl, just make your way to Google Play where it can currently be downloaded for free. In fact, why don’t you save yourself some time and simply click on the link to Google Play highlighted as a source down below.

domain: entertainment


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According to Lisa Frost, a meteorologist for Sweden’s state forecaster SMHI, the existing record of 38C could be beaten anywhere in the stretch of central Sweden which was issued with an orange weather warning on Wednesday, which includes the cities of Norrköping and Linköping, and borders on Örebro to the north.
“If nothing changes, then the record can be beaten tomorrow,” Frost told Sweden’s TT newswire. saying that Thursday would see “the heat reach a peak in our country.”
Sweden’s highest ever recorded temperature was a temperature of 38C recorded in 1947 at Mälilla in Småland, which sits slightly to the south of the area for which SMHI has issued its orange warning. A temperature of 38C was also recorded at Ultuna, outside Uppsala, in 1933.
Unlike countries further to the south which have been sweltering for weeks, the wave of extreme heat in Europe is only expected to rise up towards Sweden temporarily, with the heat seen on Wednesday increasing into Thursday, and then the mass of warm air shifting south again on Friday and over the weekend.
“It’s only temporary, for two days, after which the mass of air will move south once again and we will get cooler air and slightly more variable weather,” Frost said.
She said that the agency had issued an orange warning because temperatures of 35C and above, “constitute a much increased strain on the body and can create problems, especially for risk groups such as the elderly, the sick or children”.
The yellow warning, which covers a much larger swathe of central Sweden from Gävle down to Växjö, has been issued because temperatures are expected to sit between 30C and 35C, which also could affect risk groups.
Denmark on Wednesday reported the highest-ever recorded temperature for July, the country’s meteorological institute said, warning that the country was nearing an all-time temperature record.
According to the Danish Meteorological Institute (DMI), the previous temperature record for July was measured in 1941, when the quicksilver hit 35.3C
“Today that was beaten with 35.6C, recorded in Borris in West Jutland,” the DMI said in a post to Twitter.
A few hours later, DMI announced that an even higher temperature, 35.9C, had been recorded on the island of Lolland.
Denmark’s all-time temperature high, 36.4C, was recorded in August 1975.

domain: geography


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Last year, DappRadar DAO was able to ensure stable price action on RADAR by accumulating $1M worth of liquidity on Ethereum, with SushiSwap as our main decentralized exchange. With the most recent extension of liquidity provision rewards coming to an end, it is necessary to reevaluate our current incentivisation program on the SushiSwap DEX.
In this Proposal, we propose to continue the Sushiswap rewards at a reduced rate.
SushiSwap and Crypto.com Exchange are leading in terms of volume for RADAR trading and it is important to have centralized and decentralized markets with liquidity. In decentralized markets, rewarding Liquidity Providers (LPs) through farms is important. Although it has a significant cost to DappRadar DAO, it ensures lower slippage and deep depth of our market liquidity, which attracts more RADAR holders. We want to maintain the traction on SushiSwap in regards to liquidity providers and liquidity depth moving forward to ensure a stable value of RADAR.
Last year, we had three SushiSwap campaigns decided upon by the DAO. We allocated 190M tokens as rewards for liquidity providers to ensure that RADAR had a stable price and depth. We were able to grow to 213 liquidity providers.
By working with ApeSwap, we were able to reduce the number of RADAR rewards used by 213.5M, increasing the efficiency of our cross-staking program and making the liquidity allocation more efficient with ApeSwap. This means that we are able to sustain the rewards over a longer period of time, giving more opportunities for new liquidity and users to hold RADAR and become part of our DAO.
As mentioned in the previous DCP-4, when deciding the number of rewards for liquidity providers, it is important to consider how that will affect the liquidity in the pool, the token price, and the benefits for the DAO too. This is even more vital on Ethereum where the gas fees are generally higher compared to other chains. Additionally, we are in the process of updating our Tokenomics in regard to gamification, staking and operational costs. Therefore, we are continuing to monitor these revenues and costs while evaluating other sustainable liquidity programs such as our ongoing Treasury Bills campaign with Apeswap.
We have been running our Liquidity Mining Programs on Sushiswap for ~12 months and at the time of writing, the RADAR-ETH pool on Sushiswap has ~$1M liquidity. The ending date of our most recent SushiSwap’s Liquidity Mining Program will be finishing in January.
For the next extension of LP rewards, we would like to once again use the remaining unclaimed Airdrop tokens and reduce the previously allocated rewards for Sushiswap by 20% to extend farming on SushiSwap 2x Farm for 90 days (3 months) with a reduced total of ~25,600,000 RADAR at a rate of ~284,445 RADAR per day.
- Extending the rewards for loyal RADAR holders and LPs on the Ethereum chain
- Maintaining our cross-chain narrative by ensuring exposure to Ethereum users to gain access to providing liquidity to DappRadar
- Maintaining and potentially increasing liquidity in the RADAR-ETH pool while optimizing the costs and enabling low slippage for DEX trades
- The potential drop in liquidity if rewards are reduced
- Distributing a large proportion of RADAR tokens that could be used for other initiatives
- FOR - Extend farming on Sushiswap 2x Farm for 90 days (3 months) with a reduced total of 25,600,000 RADAR at a rate of 284,445 RADAR per day
- AGAINST - Do not extend farming on Sushiswap 2x Farm

domain: finance


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“It is our duty to ensure a safe environment for all our students,” the West Bengal Chief Minister said on Twitter.
West Bengal Chief Minister Mamata Banerjee on Monday urged the Centre to postpone the National Eligibility cum Entrance Test (NEET) and the Joint Entrance Examinations (JEE).
She took to social media saying that it was “our duty to ensure a safe environment for all our students”.
“Now with the directive of the Ministry of Education to conduct NEET, JEE 2020 in September, I would again appeal to the Centre to assess the risk and postpone these examinations until the situation is conducive again. It is our duty to ensure a safe environment for all our students,” the Chief Minister said on Twitter.
Ms. Banerjee also pointed out that during her last video conference with Prime Minister Narendra Modi she had been vocal “against the UGC guidelines mandating completion of terminal examinations in Universities/Colleges by the end of September 2020, which had a huge potential to put student lives at risk”.
Officials of the West Bengal Education Department as well as the Chief Minister had written letters to the Centre saying that it was not possible to conduct terminal examinations for Universities in the State because of the outbreak of COVID-19 pandemic.

domain: news


Dry practice – practicing shooting techniques without using live ammunition – is an excellent way to strengthen the basic skills of good marksmanship. You will notice that I am using the term “Dry Practice,” instead of “Dry-Fire Practice,” in order to remind us that there is no firing, no loud noise and no bullet holes in stuff that you don't want bullet holes in, when dry practice is done correctly and safely.
All dry practice should begin by unloading the firearm. Check your gun several times to make sure that there is no ammunition in it. In fact, you should put all of the ammunition for that gun in another room. During a dry practice session, you simply can't check your gun often enough to make sure it is unloaded. Practice sessions don't have to run very long – 10 to 15 minutes is plenty of time to focus on your shooting skills.
While dry practice is most often associated with the personal-defense gun, it is really a good form of practice for any of the shooting disciplines. The rifle hunter can practice his field positions and basic marksmanship skills just like the defensive shooter may practice his pistol presentation. In fact, I even use dry practice to improve my ability to smoothly mount my shotgun for the bird-hunting season.
One thing to keep in mind is that some guns should not have their triggers snapped on an empty chamber because doing so could damage the firing pin. Rimfire guns are particularly susceptible to this because the firing pin must hit the rim of the cartridge in order to detonate it; lacking a cartridge, the pin will strike the steel chamber and damage to the pin could result. Older styles of single-action revolvers, such as the ones cowboy action shooters use, may also be damaged by snapping the gun on an empty chamber.
This is one reason that I like to have dummy ammunition for all of my guns. I use them during my dry practice sessions. Not only will dummy ammunition help protect your gun, but it can also give you practice in developing ways to reload that gun more quickly and smoothly. Again, reloading is often thought of as a part of defensive shooting, but it is just as critical for the rifle hunter and shotgunner.
Dummy ammunition is made for virtually every common caliber and gauge, including the rimfire .22s and .17s. Check for dummy ammunition at your local gun store, or go online to Brownells for a complete selection. Dummy ammo is not expensive and it will go a long way towards preventing damage to a valuable firearm.
It is a good idea to establish a regular dry practice session. Three to four times a week is probably plenty to time to devote. Work on your basics of sight picture, trigger squeeze and breath control. Work on your hunting field positions. In fact, you can work on just about anything that you think will improve your shooting skills. The key is to do it safely. We keep our guns safe by using dummy ammo. We keep our home and family safe by making sure that the gun we are practicing with is completely empty of live ammunition and that the live ammunition is safely put up, some distance away.
Just remember ... your shooting skills should be almost as strong as your gun safety skills.


SVM CWP18 Billet Clutch System
SVM strive to want the best for its customers, not only with the service they provide but also with the products that they sell, that is why it is so important to make sure that we test various options available on the market and either recommend them or see if we can better the available products. After testing Clutch options from many other manufacturers, we are now in the process of manufacturing a mark 2 version of the 18 plate Clutch system, We will announce on our website when this will be available.
Capable of Handling 1000BHP + (Suited to very High BHP Cars)
What you get:
- The Mark 1 version of this Clutch System is no longer on sale.
£TBA (Please call for Installation charge)
Some of the OEM Clutch System Parts will need to be retained, please call for further details.
Trade Enquiries welcome, Please email: firstname.lastname@example.org


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View full article on HHS.gov website
Statement by Howard K Koh, M.D., M.P.H.,
Assistant Secretary for Health
U.S. Department of Health and Human Services (HHS)
Viral Hepatitis: The Secret Epidemic
Committee on Oversight and Governmental Reform
United States House of Representatives
Thursday, June 17, 2010
Good morning, Chairman Towns, Ranking Member Issa, and other distinguished Members of the Committee. I am Dr. Howard Koh, the Assistant Secretary for Health in the Department of Health and Human Services (HHS or the Department). I am honored to be here today to discuss the silent epidemic of viral hepatitis in this country, and the coordinated steps the Department is taking to effectively address this significant public health problem through better prevention, care and monitoring efforts.
Viral hepatitis is a collective term describing liver inflammation or hepatitis caused by a group of several different viruses. Three viruses, Hepatitis A virus (HAV), Hepatitis B virus (HBV) and Hepatitis C virus (HCV) cause most viral hepatitis in the United States. Spread in unsanitary conditions, hepatitis A cases have declined significantly in the U.S. in recent years as a result of vaccination programs and food safety efforts. Today, I will focus my remarks on the prevention of HBV and HCV transmission and associated morbidity and mortality. Unlike HAV, HBV and HCV infections are blood-borne and often persist for years, resulting in ongoing (chronic) but usually asymptomatic liver inflammation, and in some cases scarring (cirrhosis) that leads to liver failure and/or and liver cancer. Chronic hepatitis is a major cause of liver cancer and chronic liver disease globally and in the United States.
HBV and HCV Disease Burden
Worldwide, 480 million to 540 million persons are living with chronic viral hepatitis, with 350 million 1, 2 to 370 3 million infected with HBV and 130 million to 170 million infected with HCV.4
All told, chronic viral hepatitis afflicts about 1 in every 12 persons worldwide. About 54,000 persons with chronic hepatitis B infections immigrate to the U.S. annually. Chronic hepatitis causes considerable morbidity. Globally, an estimated 78% of primary liver cancer and 57% of liver cirrhosis are caused by chronic viral hepatitis and about one million deaths from viral hepatitis occur each year.4 Liver cancer is the fourth -leading cause of death from cancer worldwide, the third -leading cause among men.5 The most recent liver cancer surveillance data indicate that long-term liver cancer incidence is increasing in the U.S., with an average annual percentage change in incidence between 2001 and 2006 of 3.5% per year.6
In the United States, viral hepatitis remains no less of a problem; 3.5 million to 5.3 million Americans have chronic viral hepatitis. 7, 8, 9 The vast majority, an estimated 65 % and 75% are not aware they are infected with HBV and HCV, respectively. 7 In the absence of appropriate treatment, 15-40% of infected persons will develop liver cirrhosis. 10, 11, 12 Viral hepatitis is the leading cause of liver transplantation in the United States. 13 Co-factors, including HIV, excessive alcohol use, and fatty liver disease associated with obesity and diabetes, amplify the effects of viral hepatitis, hastening development of liver disease. Fifteen to thirty percent of all persons infected with HIV have chronic viral hepatitis, 14 and liver disease is now the main non-AIDS cause of death in HIV-infected persons. 15 In contrast to almost all other types of cancer, liver cancer rates have tripled over the last several decades, 16 fueled in large part by the progression of viral hepatitis to end-stage disease among persons infected years ago. In the United States, viral hepatitis causes 12,000 to 15,000 deaths annually, 17, 18 and viral hepatitis-related illness, deaths, and costs are all expected to rise substantially in the coming years.
Viral hepatitis poses a major health threat for certain populations. Among persons aged 46 to 64 years (i.e., baby boomers), about 1 in 33 have chronic viral hepatitis. 9 One out of every 7 African American men in their 40s is living with chronic hepatitis C, 9 and approximately 1 in 12 Asian Americans is living with chronic hepatitis B. 19 Similarly, the profiles of persons with liver cancer mirror the demographic characteristics of persons with chronic viral hepatitis; liver cancer incidence is highest among Asians/Pacific Islanders, and is increasing among Hispanics, African Americans, baby boomers, and males. 20
New HBV and HCV infections add to the burden of chronic viral hepatitis and liver disease. In 2007, there were an estimated 43,000 new cases of HBV infection. 10 HBV is spread from mother to child at the time of birth, among household contacts through incidental blood exposures in the home, through injection drug use, and through sexual contact. Viral hepatitis transmission should never occur as a result of health care delivery, but transmission has been documented in a variety of health care settings when providers have failed to follow basic infection control practices. Rates of HBV infection are highest among adults, reflecting low hepatitis B vaccination coverage among persons with risks such as injection drug use and multiple sexual partners. Prevention of mother-to-child transmission is critical, as 90% of HBV -infected newborns remain infected 21, 22, 23 and about 1 in 4 die from complications of chronic viral hepatitis in later life. 11 Outbreaks of hepatitis B occur in persons not currently recommended to receive the vaccine, such as persons with diabetes, patients in outpatient settings, and residents of long term care facilities; they also occur in health care settings when providers fail to follow basic infection control.
Surveillance data suggest nearly 20,000 10 persons are newly infected with HCV annually in the United States. HCV is primarily a blood-borne virus spread through injection drug use. Transmission also occurs in health care settings as a result of unacceptable lapses in infection control, primarily related to the misuse of syringes and medication vials. Non-injecting drug users who snort cocaine and other drugs also have elevated risks for HCV, possibly from blood exposure associated with intranasal use. Perhaps typically thought of as an urban disease, HCV transmission has been detected among young drug users in suburban and rural communities. In addition, after reports from Europe for several years, sexual transmission of HCV has been detected among U.S. cohorts of HIV-infected men who have sex with men (MSM). In certain circumstances, HCV can be transmitted sexually and at the time of birth.
Public Health Prevention Measures to Address Viral Hepatitis
Public health measures can prevent transmission. These measures have helped our nation achieve remarkable declines in the number of new infections with both viruses. Safe and effective vaccines are available to provide long term protection from hepatitis B. In 1991, the Centers for Disease Control and Prevention (CDC) and the national Advisory Committee on Immunization Practices (ACIP) set forth an ambitious vaccine-based strategy to eliminate HBV transmission in the United States. 24 This strategy involves vaccinating newborns and older children, as well as vaccinating at-risk adults.
Routine vaccination of infants and catch-up vaccination of older children under federally -supported vaccination programs has successfully driven down rates of HBV transmission and acute cases of disease, with rates falling 82% from 8.5 cases per 100,000 population in 1990 to 1.5 cases per 100,000 population in 2007, the most recent year for which data are available. 10 Rates have declined most dramatically—98%—among children aged 15 years and younger. Vaccine coverage among children aged 19 months to 35 months is 93%. 25, 26
In the United States, approximately 24,000 HBV-infected women give birth each year 27 , most of whom are identified by prenatal screening. Their infants are recommended to receive protective hepatitis B vaccination and other prevention services. State and local prevention programs currently do not have the capacity to manage all of the estimated newborns who are exposed. To assure newborns exposed to HBV are protected, CDC recommends that all infants receive a birth dose of hepatitis B vaccine. In 2008, 55% of newborns received a birth dose in the first three days of life. 30 As not all newborns receive protective interventions, each year hundreds of infants are infected with HBV in the United States. 28
Hepatitis B vaccine is also recommended for adults with sexual and blood exposure risks. As the result of improvements in infection control and ongoing hepatitis B vaccination, relatively few cases now occur in certain populations such as dialysis patients and healthcare workers that previously were considered to be at high risk. However, while the number of new cases has declined among adults, 95 % of all new cases are among adults. A high proportion of those cases occur among persons with risk behaviors such as injecting drug users, MSM, and persons with multiple sex partners. Rates are particularly high among males aged 25 to 44 years old. 10
Unlike HBV, there is no vaccine yet developed for HCV. However, since HCV was discovered in the 1980s, the development of prevention interventions has caused a significant decline in new cases. Screening of donated blood and other tissues and organs now protects recipients of these donations. Screening, together with behavioral education, and access to clean syringes and drug treatment have had a role in reducing the number of new cases of HCV related to injection drug use 8 In addition, the adoption of standard precautions in health care settings has reduced transmission risks for all blood -borne viruses, including HBV and HCV.
The onset of liver cancer and other liver disease can be prevented through screening and care for persons chronically infected with HBV or HCV. Current treatments can halt or even reverse the liver damage caused by viral hepatitis. New treatments on the immediate horizon hold even greater promise for a definitive cure. CDC recommends screening to identify persons with viral hepatitis and prevention and care services to reduce transmission and morbidity.
Prevention and care for viral hepatitis makes economic sense. Published studies estimate that medical costs for viral hepatitis run in the billions of dollars per year. 29, 30 Numerous studies reveal the cost-effective benefits of screening and care for populations at risk for viral hepatitis. 31, 32, 33, 34 Hepatitis screening linked to vaccination and care is a cost -effective prevention approach to eliminating health disparities for Asian and Pacific Island Americans. 35 Preliminary data from a CDC model show that by identifying and referring for appropriate care all HCV-infected persons in primary care, approximately 87,000 cases of end stage liver disease and 11,000 liver transplants can be prevented, and 840,000 undiscounted life years would be gained, with an estimated cost per discounted quality adjusted life year, or QALY, of $43,000. Similarly, preliminary estimates reveal that expanded HBV screening and care could avert approximately 140,000 cases of end stage liver disease and gain 3.3 million QALYs.
The Institute of Medicine Report
In January 2010, The Institute of Medicine (IOM) issued a report titled, Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C. The report identified multiple barriers that have combined to create a situation in which inadequate public resources are available to support the prevention, care and monitoring needed to fully and effectively address this important public health problem.
The IOM report described deficiencies that have created adverse consequences for the health of our nation:
* Inadequate disease surveillance systems underreport acute and chronic infections, so the full extent of the problem is unknown;
* At-risk people do not know that they are at risk or how to prevent becoming infected;
* At-risk people may not have access to prevention services;
* Chronically infected people do not know they are infected;
* Many healthcare providers do not screen people for risk factors or do not know how to manage infected people; and
* Infected people often have inadequate access to testing, social support, and medical management services.
The IOM called for an intensified, coordinated national effort to improve the prevention of viral hepatitis and better protect the health of Americans.
The HHS Response to the IOM Report
HHS and its agencies are fully committed to accelerating progress towards the prevention of viral hepatitis and associated disease in the U.S., and advancing this strategy. In January, HHS established an interagency work group on viral hepatitis, which I chair, that has diverse representation from HHS operating divisions. A work group subcommittee is currently drafting a comprehensive strategic action plan for HHS to improve the coordination of viral hepatitis prevention, care and monitoring activities within the Department. The action plan is grouped by focus areas: Increasing community awareness and provider education; strengthening surveillance for viral hepatitis; preventing viral hepatitis transmission through vaccination; preventing blood-borne transmission; and improving clinical preventive care and treatment services. The current timeline is to complete this action plan by October 1, fall 2010.
There are millions of persons who are unaware they have a potentially life -threatening disease. Major goals of viral hepatitis prevention programs are to screen high-risk persons and to increase the number of infected persons who know their status and are linked to preventive and care services. For communities experiencing health disparities, culturally appropriate education programs can increase awareness of this silent epidemic, and of the health benefits and vaccination and screening, while addressing issues of stigma. Provider education can increase understanding of screening and vaccination policies, interpretation of laboratory tests, and management of viral hepatitis care and treatment. Viral hepatitis services can be integrated with other appropriate prevention services for HIV, STD, and cancer. Public health surveillance and case management can link communities with viral hepatitis prevention and care services.
HHS also recognizes the important health benefits of eliminating HBV transmission. State and local perinatal prevention have a proven track record of success and can provide the necessary services to eliminate HBV among newborns in this country. Studies have shown that cost is a major barrier to successful implementation of adult immunization strategies. Health reform provides new opportunities to increase uptake of immunizations recommended by the HHS Advisory Committee on Immunization Practices (ACIP).
More interventions are needed to prevent hepatitis C. Efforts to find an effective vaccine for HCV should be a continued priority. In the meantime, other new hepatitis C prevention tools must be developed, tested and translated into action. One avenue to explore is to refine and adapt HIV prevention strategies for hepatitis C prevention. Hepatitis C testing and counseling to increase awareness of infection status will promote safe behavioral practices. Together, these approaches can substantially reduce transmission among injection drug users. HHS is working to ensure adherence to proper infection control practices are needed to reduce transmission risks in health care settings, including improved oversight and regulatory approaches, development of new technologies, and training for health care professionals. Rapid tests can improve access to screening, and new assays may improve detection of recent hepatitis C infection. Studies of HCV transmission will help form the evidence base for new interventions. Also, studies suggest that, if detected early, many hepatitis C infections can be cleared (i.e., cured) 36.As new and improved therapies are introduced, research should be conducted to guide how best to use them to preserve the health of those infected and prevent transmission.
The HHS interagency working group will also examine ways to improve viral hepatitis surveillance. Effective prevention requires state and local systems that provide consistent and reliable reporting of new infections, rapid detection of disease outbreaks, and identification and referral of persons with chronic infection for appropriate care and treatment. Currently, CDC estimates that about only 10 percent of new cases of viral hepatitis are reported each year. Two-thirds of states report cases of HCV infection, but those that do have large backlogs of uninvestigated cases. 8 As a result, a clear picture of the nature and scope of chronic HCV infections across every State is not available at this time. HHS is working to improve monitoring of viral hepatitis.
Viral Hepatitis Prevention Activities within HHS
Multiple agencies within HHS are working hard to maximize the impact of available resources in responding to the viral hepatitis epidemic and respond to the recommendations of the IOM report.
Centers for Disease Control and Prevention (CDC)
At CDC, the primary responsibility for prevention and control activities rests with the Division of Viral Hepatitis. Those activities are broadly grouped under four programmatic priorities:
1) Reduce illness and death by identifying persons with viral hepatitis early and referring them to care;
2) Eliminate hepatitis B transmission;
3) Develop, test and translate into action tools to decrease the incidence of HCV; and
4) Guide and evaluate prevention efforts by improving the monitoring of viral hepatitis.
To address those priorities, CDC currently supports viral hepatitis coordinators in 49 states and
the District of Columbia. These coordinators are tasked with integrating viral hepatitis services with other public health efforts to reach populations at risk. While funding does not support direct service provision, the coordinators seek whenever possible to leverage available resources and integrate viral hepatitis education, vaccination, and screening with services provided by federally-supported STD and HIV testing and treatment sites, federally qualified health centers supported by the Health Resources and Services Administration, and other programs.
In addition to supporting coordinators, CDC assists states in responding to disease outbreaks by deploying field investigators and by conducting rapid laboratory serologic and genetic testing to identify sources of infection and direct control strategies. CDC also provides technical support to all states for monitoring acute and chronic infections, including assisting states in adopting surveillance for chronic HBV and HCV infections and investigating cases suggestive of the emergence of rare or new causes of viral hepatitis. Funding for enhanced surveillance activities is provided to 9 state and local health departments.
CDC’s surveillance activities also include monitoring liver cancer incidence and prevalence through the National Program of Cancer Registries, in collaboration with the National Cancer Institute’s Surveillance, Epidemiology, and End Results Program. Data indicate that liver cancer incidence rates vary widely across states, and persistent racial and ethnic disparities exist. 21 These surveillance efforts articulate the burden of liver cancer and can assist states in targeting prevention and control efforts, including primary prevention efforts targeted to the populations most at risk of contracting HBV and HCV.
To identify and address health disparities, CDC surveys populations at increased risk for viral hepatitis, including racial and ethnic minority communities, MSM, and injection drug users. CDC follows approximately 12,000 patients in care for viral hepatitis to study the implementation of recommended preventive and care services.
CDC also supports state and local perinatal prevention coordinators to prevent mother-to-child transmission of hepatitis B. This effort includes ensuring the screening of pregnant women, vaccination of infants at birth, follow-up with infants to ensure completion of the vaccine series, and testing of infants to ensure the development of antibodies. Similarly, through immunization funding for its Adult Hepatitis B Vaccination Initiative, CDC has begun to close the gap in vaccination of at risk adults. Since the beginning of the Initiative in FY 2007, CDC has made approximately $42 million in Section 317 funds available for the purchase of hepatitis B vaccine for use in over 2,600 venues.
Healthcare-associated transmission of viral hepatitis is entirely preventable through adherence to basic infection control. In the area of healthcare-associated transmission of hepatitis, CDC monitors the size and scope of the problem and assists state and local health departments with healthcare-associated outbreak investigations. Perhaps most importantly, CDC identifies best practices regarding infection control and educates providers, patients and industry about these practices through evidence-based infection control guidelines, peer-reviewed publications, and educational campaigns.
In addition to CDC’s work with the states, CDC conducts prevention research to guide policy and program development. CDC fosters development of new approaches to health education, investigation of new screening tests and strategies, studies of licensed and experimental vaccines, and the emergence and implications of viral mutations for diagnosis, prevention, and therapy.
Finally, CDC works with the World Health Organization and other partners to prevent viral hepatitis globally. As of 2008, a total of 177 countries had incorporated hepatitis B vaccine in their national infant immunization programs, and an estimated 69% of the 2008 birth cohort received hepatitis B vaccine. Worldwide, only about 27% of newborns received the birth dose of hepatitis B vaccine.37The FY 2011 Budget includes an increase of 10 percent over the FY 2010 Omnibus to support these activities.
National Institutes of Health (NIH)
At NIH, the primary responsibility for hepatitis research and prevention activities rests with the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and the National Institute of Allergy and Infectious Diseases (NIAID). NIDDK and NIAID support many activities in hepatitis B and C research and education including the following:
Hepatitis B Research: NIAID supports basic and translational research on hepatitis B. Efforts include drug discovery and development and vaccine improvements, as well as many efforts related to HBV pathogenesis and the varying human responses to infection. In addition, the Institute supports many resources for outside investigators to screen and develop new HBV-specific therapeutic candidates at no cost. NIAID resources include tissue culture and animal model screens and preclinical drug development services. In addition, NIAID is currently soliciting applications for research on new classes of HBV therapies.
Hepatitis B Research Network: This multi-center research Network, established in 2008, aims to advance understanding of disease processes and natural history, as well as to develop effective approaches to treating and controlling hepatitis B. The Network currently includes 21 clinical sites across the United States, including Hawaii, and a central data coordinating center. The Network’s centers are in the final stages of planning multiple clinical trials in both adults and children that are responsive to the recommendations of the IOM report regarding pregnant women and at-risk populations.
Clinical Research on Hepatitis C: NIH conducts many clinical trials of available antiviral therapies against hepatitis C, such as the drug interferon. Research to develop a vaccine against hepatitis C is also a major priority for the NIH. Basic and applied studies on hepatitis C virus vaccine development are being funded by NIAID, NIDDK, the National Cancer Institute, and the National Institute on Drug Abuse, including those being conducted by the NIDDK intramural NIDDK Liver Diseases Branch and NIAID’s Laboratory of Infectious Diseases.
Basic Research on Hepatitis C Virus Infection: NIAID and the NIDDK Liver Diseases Branch conduct basic research and fund research on how the hepatitis C virus infects human cells. New animal models and cell culture systems developed by NIAID and NIDDK-funded investigators are instrumental to advancing hepatitis C prevention and therapy. For example, high-impact research projects are developing a mouse model of hepatitis C virus infection and pioneering advanced tissue culture systems that mimic human liver biology for studying the viral life cycle testing new antiviral agents, and identifying viral and human host factors that may serve as targets for future therapies.
The NIAID-supported Hepatitis C Cooperative Research Centers seek to improve basic understanding of HCV pathology. This program, renewed in Fiscal Year (FY) 2010, sponsors five centers which will advance understanding of the host immune response to infection and the factors that determine whether HCV infections are cleared or persist chronically. The underlying mission of the Centers is to help define successful immune response to HCV and identify new targets for drugs, vaccines, and other therapeutic strategies for the prevention or treatment of HCV infection.
NIAID intramural scientists and grantees pursue basic and translational studies on the pathogenesis and molecular biology of HCV, investigate the basic immunology of HCV infection, and partner with industry to further the development of HCV vaccines. NIAID scientists also are collaborating with international researchers to understand why cirrhosis is a fairly stable disease for decades in some patients, while in others it may lead to liver-related death or liver cancer. Investigators are performing genetic analyses and searching for biomarkers for the early detection of liver cancer.
NIAID currently is developing and evaluating new agents to treat HCV/HIV co-infected individuals and is supporting clinical research to define the most effective, long-term treatment strategies for HIV/HCV co-infecton. Currently, NIAID researchers are conducting several clinical studies of patients with chronic viral hepatitis at the NIH Clinical Center. These studies are focused on developing better therapeutics for the management of HCV infection in HIV co-infected individuals.
Trans-NIH and Trans-Agency Viral Hepatitis Research Planning: Strategic research plans, such as the trans-NIH Action Plan for Liver Disease Research, and the National Commission on Digestive Diseases’ research plan, both developed with trans-NIH and trans-HHS input, highlight important research goals relevant to controlling hepatitis B and C. These plans (available at http://liverplan.niddk.nih.gov and http://NCDD.niddk.nih.gov) are currently being implemented by the NIH and partners in the larger research community.
NIH Consensus Development Conferences and Meetings: The NIDDK has provided leadership, along with other NIH Institutes, Centers, and Offices, and other professional organizations, for convening several consensus development conferences on hepatitis B and C, including Management of Hepatitis C (2002), and Management of Hepatitis B (2008). The NIDDK also helped to organize a meeting on Management of Chronic Hepatitis B in 2006, as well as the International Symposium on Viral Hepatitis and Liver Disease in 2009. Recommendations from these conferences and meetings helped to inform the IOM’s report.
Health Resources and Services Administration (HRSA)
Within HRSA, many of the activities related to Hepatitis B and C are overseen by the HIV/AIDS Bureau (HAB) and the Bureau of Primary Health Care (BPHC). HAB and BPHC are collaborating on ways to increase screening and referral to treatment for Federally Qualified Health Center (FQHC) patients who are mono-infected with hepatitis C and those who are dually infected with HIV and hepatitis. Examples of HAB and BPHC hepatitis B and C activities include the following”:
* HRSA/BPHC is working with the Association of Asian Pacific Community Health Organizations (AAPCHO) and the White House Initiative on Asian American and Pacific Islanders to develop strategies for improving prevention and treatment of viral hepatitis among Asian and Pacific Islander Americans.
* Hepatitis C Treatment Expansion Initiative - Evaluation and Technical Assistance Center (CFDA: 93.928): Under the Special Projects of National Significance Program of the
* Ryan White HIV/AIDS program, administered by HRSA’s HIV/AIDS Bureau, this initiative will provide funds for up to 2 years to build capacity among Ryan White-funded
* organizations through the implementation of demonstration models for enhancing HCV treatment protocols in integrated HIV medical treatment settings in the context of providing HIV primary medical care and treatment to individuals co-infected with HCV. In addition to treatment implementation, awarded organizations will also assist the Evaluation and Technical Assistance Center in assessing the effectiveness, feasibility and costs of these service delivery models.
* HRSA supports FQHC services for viral hepatitis treatment and prevention in the following ways:
o Requiring that, as a condition of health center funding and the FQHC "Look-Alike" designation, all federally-funded health centers and FQHC Look-Alikes provide diagnostic lab services, screenings for communicable diseases, and immunizations against vaccine-preventable diseases, including HBV.
o Requiring that federally-funded health centers and FQHC Look-Alikes provide health education to patients and the general community. This includes patient education on diseases that may be prevalent in the community or for which the population may be vulnerable, such as viral hepatitis.
o HRSA promotes screening and treatment of viral hepatitis through a national cooperative agreement. Activities resulting from this agreement include raising awareness of viral hepatitis among health center providers and patients, and providing technical assistance on strategies to treat and prevent viral hepatitis. For example, HRSA recently met with the National Alliance of State and Territorial AIDS Directors and the Northeast Hepatitis Coordinators’ Alliance to strategize on hepatitis prevention and treatment in FQHCs.
* In order to better monitor hepatitis incidence in health center patients, HRSA revised its health center grantee reporting mechanism to track patient hepatitis rates.
* The only successful treatment available for endstage liver disease due to HCV is liver transplantation. HRSA provides oversight for the Organ Procurement and Transplantation Network (OPTN) operated under contract by United Network for Organ Sharing (UNOS). Currently there are 16,072 patients on the nationwide liver transplant waiting list, and 6.320 liver transplants were performed in 2009. Because of the critical shortage of donor organs, 1,461 patients died in 2009 waiting for a liver transplant. About 40% of liver transplants performed in the U.S. have HCV, and experts expect this number to rise significantly during the next decade. Although liver transplantation can successfully treat chronic liver failure due to HCV, a major challenge facing these recipients is recurrence of HCV in the new liver that eventually leads to reduced graft survival. 38
Food and Drug Administration (FDA)
The FDA has multiple centers working on hepatitis B and C prevention activities:
CDER Activities Relating to Hepatitis B and C: FDA’s Center for Drug Evaluation and Research (CDER) has the responsibility of reviewing drug products and certain biological products including therapeutic proteins and monoclonal antibodies for the treatment and/or prevention of viral hepatitis including hepatitis B and C.
Currently, there is a great deal of interest within industry in developing treatments for both hepatitis B and C. FDA has approved five drugs and two interferon products to treat hepatitis B. FDA has approved three distinct types of interferon products from three different sponsors for the treatment of hepatitis C. FDA has also approved multiple versions of ribavirin, a drug approved to increase the effectiveness of intereferons in the treatment of hepatits C.
CDER also regularly meets with numerous issue groups and pharmaceutical companies to discuss drug development plans, protocols and proposals. CDER is currently collaborating with the Forum for HIV Research to plan a workshop on hepatitis C drug development. FDA also held a public meeting in April 2010 to discuss expanded access to direct-acting antiviral agents for the treatment of chronic hepatitis C infection in patients with unmet medical need. CDER is in the process of drafting a guidance to industry on the development of direct-acting antivirals for the treatment of hepatitis C. And lastly, FDA issued a Citizen Petition response which recognized the crisis of hepatitis C among people with bleeding disorders and the need to take definite steps to allow people with bleeding disorders and hepatitis C and other patients with hepatitis C with no treatment options to have access to promising investigational drugs beyond current clinical trials.
CBER Activities Relating to Hepatitis B and C: The FDA’s Center for Biologics Evaluation and Research (CBER) regulates biological products for human use under applicable federal laws, including the Public Health Service Act and the Federal Food, Drug, and Cosmetic Act. CBER protects and promotes the public health by ensuring that biological products are safe and effective and available to those who need them. CBER also provides the public with information to promote the safe and appropriate use of biological products. CBER regulates an array of diverse and complex biological products, both investigational and licensed, including vaccines, blood and blood products, and human tissues and cellular products. In carrying out its mission to ensure the safety, purity, and potency (effectiveness) of biological products, CBER engages in a number of activities pertinent to HBV and HCV.
Scientists in CBER laboratories are currently working on several research projects pertaining to HCV. One research program, Hepatitis C Vaccines: Development of in vitro and in vivo Systems for HCV Replication and Evaluation of Vaccine Efficacy, seeks to evaluate new methods and models for evaluating the immune responses to HCV in systems that may be predictive of outcomes in people. Evaluating immune correlates of protection will be invaluable in the assessment of candidate HCV vaccines and to support development of new HCV vaccines.
Another research program – Studies of Efficacy, Safety and Potency Assay Development for Prophylactic and Therapeutic Vaccines against Hepatitis Viruses – is focused on developing scientific tools to understand the immunobiology and pathogenesis of HCV. Studies include the development of a small animal model for HCV infection, identification of efficacy biomarkers (i.e., immunologic correlates of protection), development of neutralization tests for the virus, use of nanotechnology for induction of protective immune responses, and studies on the safety of therapeutic vaccines for this virus. These studies will provide the ability to evaluate new technologies being applied to vaccine development, and will be pivotal in guiding and assessing the safety, efficacy and manufacturing issues associated with HCV vaccines.
CBER also engages in research activities pertaining to the safety and efficacy of plasma-derived products in the context of HBV and HCV. CBER research studies have impacted: (1) the safety of blood and blood products with respect to viral pathogens in transfusion recipients; (2) the establishment of national, international, or global standards that would ensure the safety of blood and potency of plasma-derived products; and (3) the development of cell culture based-assays to test for pathogen inactivation.
CDRH Activities Relating to Hepatitis B and C: FDA's Center for Devices and Radiological Health (CDRH), which is responsible for regulating firms who manufacture, repackage, relabel, and/or import medical devices sold in the United States, has a dedicated Office of In Vitro Diagnostic Device Evaluation and Safety (OIVD) charged with regulating all aspects of in-home and laboratory diagnostic tests (in vitro diagnostic devices, or IVDs). OIVD's multidisciplinary group of scientists, medical technologists, policy analysts, engineers, pathologists, and clinicians has a dual charge to foster the rapid transfer of new IVDs into the marketplace while preventing marketing of unsafe or ineffective devices, and is engaged in a number of activities related to hepatitis B and hepatitis C.
In addition, OIVD scientific reviewers and managers participate in several interagency groups associated with viral liver disease. The Hepatitis "Think C" Personalized Medicine Group works to improve the dosage of anti-viral medication at the individual patient level through a combination of appropriate diagnostic test and drug regimes. The Liver Fibrosis Interagency Group meets to discuss the ongoing search for new diagnostic biomarkers for liver fibrosis, which could replace the current practice of diagnosis by liver biopsy.
Indian Health Service (IHS)
IHS works to prevent viral hepatitis in its beneficiary population. IHS has a vaccination program to prevent hepatitis B in the Indian communities it serves. Routine vaccination of all newborns occurs at IHS birthing hospitals, with the first dose of hepatitis B vaccine administered as soon as possible after birth. The hepatitis B vaccine series started at birth is completed as part of normal pediatric vaccine schedule. Catch-up hepatitis B vaccination is offered to children and adolescents who need it. Vaccination of at-risk adults varies by site. Screening for the hepatitis B surface antigen in pregnant IHS patients is generally done as part of the regular health care treatment protocol. Treatment of chronic hepatitis B is provided, most notably in Alaska.
Treatment of hepatitis C occurs at some service units, with four IHS areas providing hepatitis C treatment in at least one service unit. Again, the Alaska Area offers the most developed program. The Seattle Indian Health Board Viral Hepatitis Education and Training (VHET) Project offers education and training of providers in screening of at-risk adults for hepatitis B and hepatitis C, and in hepatitis A and B vaccination. The IHS is also developing electronic health record-based surveillance methods to describe the epidemiology of hepatitis C in the HIS beneficiary population.
HHS Office of Minority Health (OMH)
OMH helped sponsor the IOM report, and is ingworking to elevate viral hepatitis as a priority public health issue. AActivities led by OMH include the following:
Hepatitis B Video, titled “B”/PSA: The OMH was asked by the Association of Asian Pacific Community Health Organizations and the Hepatitis B Foundation to collaborate on the national release of the Hepatitis “B” video/PSA. The PSA was awarded the Grand Prize of the B Real Short Film Competition at the Los Angeles Asian Pacific Film Festival in 2009 and, prior to the partnership with OMH, was played in every major feature at the Asian American International Film Festival in New York. As part of the partnership, the PSA was recently aired on ABC during the Oprah Winfrey Show, CNN’s Anderson Cooper, Good Morning America, Today Show, the evening news and various Asian media networks. The PSA will be translated into six different Asian languages.
World Hepatitis Day: The OMH, Association of Asian Pacific Community Health Organizations, National Alliance of State and Territorial AIDS Directors, and National Viral Hepatitis Roundtable recently hosted a World Hepatitis Day event to highlight the importance of global action to eliminate viral hepatitis in Asian American, Native Hawaiian, Pacific Islander, African American, American Indian, Alaska Native, and Hispanic/Latino communities.
Compendium Distribution: Compendium on Local Hepatitis B Activities: The Association of Asian Pacific Community Health Organizations (AAPCHO) received an OMH National Umbrella Cooperative Agreement to enhance hepatitis B activities in communities across the nation. As part of this award, AAPCHO will work with the Hepatitis B Foundation and Asian Pacific Islander American Health Forum to develop and implement a comprehensive strategy to promote and distribute a hepatitis B compendium to catalyze partnerships for local and national action.
The compendium includes case studies on the successes and lessons learned from local coalitions that are part of AAPCHO's hepatitis "B Activated" network. The case studies provide examples and recommendations for enhancing coalition efforts for increasing local awareness, and enhancing screening and vaccination activities. The compendium is intended for communities who are interested in developing or strengthening local hepatitis B awareness and prevention efforts.
Bilingual Bicultural Demonstration Program: Funded by OMH under the Bilingual Bicultural Demonstration Program, the Asian Liver Center at Stanford University’s “Building the Community Partnership for San Francisco: Hep B Free Campaign” works to screen, vaccinate and treat all San Francisco Asian and Pacific Islander residents against hepatitis B by providing convenient, free or low-cost testing opportunities at partnering health facilities.
Community Partnership: The Immigrant and Refugee Community Organization (IRCO), an OMH Community Partnership grantee, seeks to decrease the prevalence of hepatitis B and HIV in the Asian and Pacific Islander, African Refugee, and Immigrant communities in Portland, Oregon. Since September 2009, IRCO has reached 210 members of the Asian and African refugee and immigrant community and trained 43 healthcare interpreters on hepatitis B transmission, symptoms, and the importance of early detection.
Given the substantial and increasing disease and economic burden from viral hepatitis, HHS is taking immediate and coordinated steps to reverse these trends, which represent a health priority for our nation. HHS greatly appreciates the committee’s interest in these important issues.
Thank you for the opportunity to share this information with you. I recognize that the problems I have identified are significant ones, but I am confident that working together we can succeed in protecting this nation against the needless disease, pain, suffering, and death caused by viral hepatitis. Thank you. I will be happy to answer any questions.
1 Goldstein ST, Zhou F, Hadler SC, Bell BP, Mast EE, Margolis HS. A mathematical model to estimate global hepatitis B disease burden and vaccination impact. Int J Epidemiol 2005;34:1329--39
2 World Health Organization. Hepatitis B. Geneva, Switzerland: World Health Organization; 2000. Available at http://www.who.int/mediacentre/factsheets/fs204/en/print.html
3 W.M. Lee, Hepatitis B virus infection, N Engl J Med 337 (1997) (24), pp. 1733–1745.
4 Perz, J.F., The contribution of hepatitis B virus and hepatitis C virus infections to cirrhosis and primary liver cancer worldwide. Journal of Hepatology 2006; 45 (4):529-538.
5 WHO Cancer Fact Sheet No 297 Feb 2009. http://www.who.int/mediacentre/factsheets/fs297/en/print.html
6 CDC. Hepatocellular carcinoma – United States, 2001-2006. MMWR 2010;59 (17:517-20).
7 IOM (Institute of Medicine). Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C. Washington, DC: The National Academies Press. At 21 (2010)
8 Armstrong GL, Wasley A, Simard EP, McQuillan GM, Kuhnert WL, Alter MJ. The prevalence of hepatitis C virus infection in the United States, 1999 through 2002. Ann Intern Med 2006;144:705--14
9 CDC. Surveillance for Acute Viral Hepatitis – United States, 2007. 2009;58 (No. SS-3)
10 CDC. Recommendations for Identification and Public Health Management of Persons with Chronic Hepatitis B Virus Infection. 2008;57 (No. RR-8)
11 Lok AS, McMahon BJ. Chronic Hepatitis B. Hepatology2007; 45:507-539
12 Seeff LB. Natural History of Chronic Hepatitis C. Hepatology 2002; 36:S35-S46.
13 Brown RS Jr. Hepatitis C and liver transplantation. Nature 2005;436:973-978.
14 Sherman KE, Rouster SD, Chung RT, Rajicic N. Hepatitis C virus prevalence among patients coinfected with human immunodeficiency virus: a cross-sectional analysis of the U.S. Adult AIDS Clinical Trials Group. Clin Infect Dis 2002;34:831-7.
15 D:A:D Study Group. Factors associated with specific causes of death amongst HIV-positive individuals in the D:A:D study. AIDS 2010 [epublication May 6, 2010 ahead of print]
16 Altekruse SF, McGlynn KA, Reichman ME. Hepatocellular carcinoma incidence, mortality, and survival trends in the United States from 1975 to 2005. J Clin Oncol 2009;27:1485--91.
17Vogt T, Wise ME, Shih H, Williams IT. Hepatitis B Mortality in the United States, 1990-2004 [Abstract]. 45th Annual Meeting of Infectious Diseases Society of America, San Diego, CA; October 4-7, 2007
18 Wise M et al. Changing trends in hepatitis C-related mortality in the United States, 1995–2004. Hepatology 2008;47:1–8.
19 CDC. Screening for Chronic Hepatitis B Among Asian/Pacific Islander Populations – New York City, 2005. MMWR 2006; 55(18):505-509.
20 CDC. Hepatocellular carcinoma – United States, 2001-2006. MMWR 2010;59(17;517-20.
21 Edmunds WJ, Medley GF, Nokes DJ, Hall AJ, Whittle HC. The influence of age on the development of the hepatitis B carrier state. Proc R Soc Lond B Biol Sci 1993;253:197--201
22 McMahon BJ, Alward WL, Hall DB, et al. Acute hepatitis B virus infection: relation of age to the clinical expression of disease and subsequent development of the carrier state. J Infect Dis 1985;151:599--603.
23 Hyams KC. Risks of chronicity following acute hepatitis B virus infection: a review. Clin Infect Dis 1995;20:992--1000
24 CDC. Hepatitis B Virus: A Comprehensive Strategy for Eliminating Transmission in the United States Through Universal Childhood Vaccination: Recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1991;40 (RR-13): 1-19. http://www.cdc.gov/mmwr/preview/mmwrhtml/00033405.htm
25 Estimated Vaccination Coverage* with Individual Vaccines and Selected Vaccination Series Among Children 19-35 Months of Age by State and Local Area US, National Immunization Survey, Q1/2008-Q4/2008† http://www2a.cdc.gov/nip/coverage/nis/nis_iap2.asp?fmt=v&rpt=tab02_antigen_iap&qtr=Q1/2008-Q4/2008
26 CDC. National, State, and Local Area Vaccination Coverage Among Children Aged 19--35 Months --- United States, 2008. MMWR 2009;58: 921-926.
27 CDC. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP) part 1: immunization of infants, children, and adolescents. MMWR 2005;54 (RR-16):1–31.
28 CDC Unpublished Data
29 JB Wong, GM McQuillan, JG McHutchison and T Poynard. Estimating future hepatitis C morbidity, mortality, and costs in the United States, American Journal of Public Health, Vol 90, Issue 10 1562-1569.
30 Milliman Study for Vertex Pharmaceuticals. Consequences of Hepatitis C Virus – Costs of a Baby Boomer Epidemic of Liver Disease. 2009
31 A Rajendra, JB Wong Economics of chronic hepatitis B and hepatitis C Journal of Hepatology, 2007 Oct: 47 (4):608-17. Epub 2007 Jul 30
32 Kanwal F, et al., Treatment alternatives for hepatitis B cirrhosis: a cost-effectiveness analysis. The American Journal of Gastroenterology, 2006;101(9):2067-2089.
33 Spackman DE, Veenstra D. A cost-effectiveness analysis of currently approved treatments for HBeAg-positive chronic hepatitis B. PharmacoEconomics, 2008;26(11):937-949.
34 Wong JB, et al., Cost-effectiveness of interferon-alpha 2b treatment for hepatitis B e antigen-positive chronic hepatitis B. Ann Intern Med, 1995;122(9):664-675
35 Hutton DW, Tan D, So SK, et al. Cost-effectiveness of screening and vaccinating Asian and Pacific Islander adults for hepatitis B. Ann Intern Med, 2007;147(7):460-469.
36 Licata A, DiBona D, Schepis F, Shahied L, Craxi A, Camma C. When and How to Treat Acute Hepatitis C? J Hepatol 2003;39:1056-1062
37 CDC. Implementation of Newborn Hepatitis B Vaccination – Worldwide, 2006. MMWR 2008;57(46):1249-1252.
38 TD Schiano and P Martin, Review: Management of HCV infection and liver transplantation, International Journal of Medical Sciences (2006) 3(2):79-83.
Last revised: September 09,2010

domain: medical


text:
Advancing Arts and Culture in the Monadnock Region
Arts Alive! is a nonprofit organization working to sustain, promote and expand access to arts and cultural resources in the Monadnock Region. Arts and culture are community assets that enhance financial strength, health and wellness, and social capital in the communities where they are supported.
Arts Alive! enhances quality of life by advancing arts and culture in the Monadnock Region.
The Monadnock Region will have a flourishing cultural community that values arts and culture and provides community support to facilitate success.
Already a Member?
You can log into the site here to access the planning calendar that was previously located on monadnockevents.org.

domain: sociology


text:
by Rimsha Tanaaz
Without loved ones, life lacks meaning. It’s in our nature to get attached to those around us, and this attachment begins with our family. Then, extending the list, the next immediate choice will be our friends. In other words, friends are the bunch of maniacs we choose to give our time. When talking about our friends, all those beautiful memories, those silent giggles, and wild laughter, crying together or teasing each other, come to our minds. However, on the other hand, there are those who may recall bitter experiences, when it comes to friends. Whatever it may be, this crazy group of people, whom we call our friends has an immense impact on our lives, a fact that is not new to us at all.
Another well-known truth is, how important it is to choose good friends, as they play a crucial role in shaping our lives. Studies and research, prove that good friendships bring only benefits for the overall development of an individual. While bad friendships negatively impact the growth of a person.
More specifically, our chosen companions affect our spirituality. As Muslims, we don’t have the luxury of thinking about just this tiny little world, our vision and aim are far greater. It’s for the endless life we shall have to face after death. With this scenario in mind, then everything that we choose to have in our lives should help us to fulfill the ultimate goal of a peaceful hereafter. Even the friends we choose should become a means of motivation, and support to strive for the ultimate goal.
At all points of life, when making any decision, we have to keep the akhirah in mind. And now without any further ado, let’s discuss the qualities we should look for while choosing friends:
LOVING THOSE WHO LOVE ALLAH
Messenger of Allah(ﷺ) said: “A man is upon the religion of his friend, so let one of you look at whom he befriends.” [Jami` at-Tirmidhi 2378]
“A man is upon the religion of his friend” SubhanAllah! How profound this is. When you stay in the company of someone, you develop a strong bond with them. It’s our human nature, we get along with them, and we start sharing our problems and joys with them. One shouldn’t miss out on the blessing of a good friend. Their presence makes a difference in our lives, especially, if the people we choose to be with, are those who fear Allah, those who have their day revolving around Salah. Then, gradually but ultimately we too end up being like them. Having a good friend is a bounty from Allah.
THOSE WHO UPLIFT YOUR IMAAN
A true friend is the one whose presence reminds you of Allah, and in whose presence you feel comfortable practicing deen. Simply, a normal conversation with them can uplift your spirits. You might be struggling with your faith, or carrying the burden of guilt on your shoulders, a cool talk with a good friend can lighten you, as well as, uplift your imaan.
But why does this happen? It happens because the bond you share with your friend is built on the foundation of taqwa, both of you knowing that Allah is above everything.
Allah (SWT) says:
“Close friends, that Day, will be enemies to each other, except for those who have taqwa(fear of Allah)”
Allah is telling us that except for that friendship which is based on Taqwa, every other friendship in this world is going to become a means of enmity on the Day of Qiyamah. It will be on that day, that one will realize how he has been led astray and pushed away from the right path because of his friends that lacked a proper understanding of life. So, if your friend is your imaan booster, then Alhamdulillah the bond between you is for the sake of Allah. But if the case is the opposite, then you must find a way to rectify it.
BELIEVER IS THE MIRROR OF ANOTHER BELIEVER :
Allah(SWT ) says:
“The believing men and believing women are allies of one another. They enjoin what is right and forbid what is wrong and establish prayer and give zakah and obey Allah and His Messenger. Those – Allah will have mercy on them. Indeed, Allah is Exalted in Might and Wise.”
This ayah highlights the qualities of a good companion. True friends will stay by your side come what may. They will be your guide when you go wrong and your support to enjoin right. In other words, ‘a believer is the mirror of another believer’ which is the foundation of this site ‘Ayeina’. It is all about helping each other, lending helping hands to fall hopes, and becoming a beam of light in heights of darkness. Friendship is this caressing bond that when nourished and brought up for the sake of Allah, will yield beautiful flowers of peace, fun, and encouragement.
If you are surrounded by such people and share a strong bond with them, then that’s Allah’s mercy upon you.
Let us now look into the qualities of a bad friend. A bad friend:
DRAWS YOU INTO HIS BAD FOLDS:
Allah’s Messenger (ﷺ) said, “The example of a good companion (who sits with you) in comparison with a bad one, is like that of the musk seller and the blacksmith’s bellows (or furnace); from the first you would either buy musk or enjoy its good smell while the bellows would either burn your clothes or your house, or you get a bad nasty smell thereof.” [Sahih al-Bukhari 2101]
Talking about toxic friendship, in particular, Nabi Sallallahu Alayhi Wasallam mentioned an example of going to a blacksmith in the above hadith.
If a person has a blacksmith as his friend and goes and spends time with him, what will happen? Either his clothes will get burnt due to the sparks, or at the minimum, he will be stinking of smoke when he comes out. Perhaps today we do not have such incidents where a person goes and sits with a blacksmith; more commonly, if a person goes and sits with a smoker, then the same thing happens. Either he may burn you by not taking care where he puts his cigarette, or at the minimum, you will be smelling of smoke.
In a nutshell, staying in a bad company can only take you away from Allah and put you in harm. But the question now.. how do you know if you are in a toxic friendship? Let me jot down a few signs for Y’all:
- Your friends always force you to fit in with them, they do not accept you as you are.
- When you’re depressed, they suggest unhealthy ways to get better.
- When it comes to your faith and your salah, you get the least motivation from your friends.
- You feel uncomfortable to even speak up about your faith issues or talk about religion in general.
- You never feel a back push from them to go forward in any good activity.
Now if this is so very much happening with you; then yes… you need a change. You are in a toxic friendship and you need to get out of it.
The fact is that good company may take time to affect our nature, but bad company is like a fire kindled to dry grass, it influences us very quickly and takes us into its bad folds.
It will become very easy for the shaitan(satan) to take us over and pull us away from Allah when we are surrounded by people who do not possess proper Islamic values.
If you are in a friendship that brings no good in you but lets you drive away from your Creator, then dear, it’s high time that you intoxicate. Get these people out of your life and start fresh. Do not get into an emotional drive and let your so-called “friends” take you over. Hadhrat Maulana Hakeem Akhtar Saheb Rahmatullahi Alayhi would say:
“Don’t lose your suitcase in trying to take care of the slippers of your friend.”
So at the end of it all, choose your friends wisely and always remember that the final destination is to Allah, so let everyone and everything you keep in your life be a support in your journey.
Author’s Bio: Rimsha Tanaaz is a Muslimah Blogger, freelancer, and a science student by qualification. She blogs on www.beflawlessmuslim.wordpress.com

domain: literature


text:
I first titled this article “Learners vs. Keepers” and expected to write about how doing artwork is always about learning, even if you don’t like what you end up with. But when I started writing, I wandered over into a rabbit trail. Sometimes that’s a good thing, as this is an important issue to discuss.
Every adult I’ve ever taught has a story from their youth, about how an art teacher told them to stop doing art because they weren’t good enough. Every single one.
One of the most amazing myths of art that almost everyone believes, is that doing bad work means you’re a bad artist. Some artists, especially young ones, believe doing bad art means you are not worthy of doing art and they will quit.
What makes this myth even worse, is when an art teacher believes it, and then tells a student they’re not good enough.
There is no circumstance where you should ever say that to anyone.
Ok, I’m sure that someone is now thinking they want to add a comment to the effect of, “hey Dennas, what about the dismal work consistently produced by my young student who thinks he is somehow going to make a fabulous career out of art?”
Vincent is cool
Who wouldn’t want to see this in their living room every day? (if it wasn’t so valuable).
He got better.
I respond with, “what would you have told Vincent Van Gogh?” He consistently created horribly dismal work for quite some time, before trying new things, and developing a style that is arguably one of the best known and well-loved styles of any artist who ever lived. He created bad work (like the baby above), later in life too, but we would still gladly pay millions to have one. Not because it’s good to look at, but because Vincent painted it. The value is created by supply and demand. This painting is Vincent’s learner. He made better babies afterwards.
I feel a need to defend my use of the word “bad” when referring to a Van Gogh painting. “Look at all that expressive vigor in the baby’s face! The potato eaters are so expressive and amazing. Look at the genius!”
Come on admit it. You think that baby is a mess. You would worry about this young man’s ability to make it as an artist. And he didn’t. Vincent was an utter failure at the business of art. No one saw value in his efforts at the time.
But should he have quit?
The fact is, that it’s not an art teacher’s responsibility to decide who can make it as an artist. You can talk to students who are clueless about their work, and suggest that they try new things. You can treat people with respect, and still gently help them think about their work and what they are good at.
Steer, do not apply brakes. You cannot know what someone is capable of when they go after it with time and determination.
You could tell young Vincent, “have you thought about adding more color to these potato eaters?”
You can tell a student who wants to be an animator, yet can’t draw figures at all, “you’ll need to study and work on anatomy to do what you want to do.”
But don’t tell her she is not “cut out to be an animator”.
Ok. I’m done with my rant. Go back to changing lives, and remember… encouragement matters.
The World Needs Happy Artists.


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In some cases laser treatment is used to seal the lattice degeneration and associated retinal holes. Laser treatment is a simple procedure that can be completed in the office. Laser is not effective in preventing retinal detachment in patients who have no symptoms. Therefore prophylactic treatment for all lattice degeneration is not useful. Lattice degeneration is the most common type of peripheral retinal degeneration. It is seen in about 1 out of every 10 people in the general population. It is common for the condition to be found in both eyes. Lattice degeneration also commonly leads to the development of retinal holes. Lattice degeneration is a condition that causes your retina to degenerate break down. The retina is the part of the eye that captures light and delivers messages to the brain. Lattice degeneration may increase your risk for a retinal tear, hole, or detachment. Retinal detachment means the retina is pulled out of position. This can lead to permanent loss of vision. treatments for lattice dystrophy include: prescription eyedrops ointments eye patches corneal transplant symptoms may go away with treatment, but over time you may need a corneal transplan. Lattice degeneration is thinning and weakening of the retina, the light-sensitive layer of cells lining the back of the eye that can lead to a retinal tear.
29.11.2019 · For example, if someone with lattice eye detachment has a detached retina in one eye, his or her other eye may be treated to prevent detachment. The detached retina may also be treated to prevent further damage. Laser photocoagulation of retinal tears is the most common prophylactic treatment used for lattice eye degeneration. This therapy is. Lattice degeneration is most often found on routine ophthalmic exam and delineated from other peripheral lesions with scleral depression. Laboratory test. No laboratory tests are indicated. Lattice degeneration treatment. There is no mandatory treatment for lattice degeneration alone. While lattice degeneration is associated with retinal holes. Interventions for asymptomatic retinal breaks and lattice degeneration for preventing retinal detachment Review question We reviewed the evidence about whether treatment of retinal breaks holes or tears in the retina and retinal lattice degeneration thinning and atrophy of retinal tissue can prevent retinal detachment, a serious vision-threatening problem. In lattice degeneration alone, prophylactic treatment is not practical in that the risk of detachment is only 0.1 to 0.7 percent in the phakic eye. Atrophic holes in phakic eyes with lattice degeneration also do not require prophylactic treatment, as the risk of progression to detachment is two percent or less. In one study, about half of the transplant patients with lattice dystrophy had a recurrence of the disease between two and 26 years after the operation. Of these, 15 percent required a second corneal transplant. Early lattice and recurrent lattice arising in the donor cornea responds well to treatment.
Treatment and Prognosis: Lattice is thought to be minimally progressive and fortunately, the vast majority of patients with this condition never develop a retinal tear or detachment. Therefore, in general, no treatment is needed for lattice degeneration aside. Answer: Lattice degeneration is a developmental thinning of the retina that occurs in about 6 percent of the population. It is a risk factor for retinal tears and retinal detachment, but the vast majority of people with lattice degeneration never have a problem.
Lattice is more likely to be associated with retinal detachment in near sighted eyes and eyes that have had previous surgery. Commonly, the presence of lattice degeneration runs in families. No one knows for sure whether lattice increases the risk for retinal detachment following laser vision correction treatment for near sighted eyes. Lattice degeneration is an eye condition. It is the disease affecting the retina. In this condition the retina becomes thin and atrophied. Lattice degeneration is comparatively common nowadays and many people have been detected with this disorder.
01.07.2016 · Lattice degeneration of the retina is not infrequently encountered on a dilated retinal examination and many of them do not need any intervention. We report a case of atypical lattice degeneration variant with peripheral retinal detachment. An asymptomatic 35. The disease is most often diagnosed during routine eye examinations when tears and holes in the peripheral retina are noticed by your optometrist. If your eye doctor believes there is cause for alarm, he or she may refer you to our San Diego lattice degeneration treatment team for further examination.
Retinal Break Lattice Degeneration Drops Eye Treatment Eyes Dry at Cancer Treatment Centers of America we believe that nutritional therapy However an emerging variant termed HAdV-14p1 recently has been described in the United States Cod Liver Oil also great for I have had a lessening of the liver spots on my hands and some large flat rough. I had my laser barrage done 15 days ago. here is my observation. The procedure lives up to its name, it's a barrage of laser right into your eye. there is a subtle pain but it is from inside of your eye and thus it really becomes uncomfortable.
BACKGROUND/AIMS Fellow eye prophylaxis for retinal detachment RD is still a controversial issue since opinions are not unanimous regarding the kind of lesions to be treated or the method of treatment. This prospective clinical study aimed to follow the course of vitreoretinal conditions in 150 high risk fellow eyes. METHODS 150 consecutive. Lattice degeneration is a disease of the human eye wherein the peripheral retina becomes atrophic in a lattice pattern and may develop tears, breaks, or holes, which may further progress to retinal detachment.
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We are able to install steel framed roll-up and walk in doors, windows and sky lights. We use 2″x3″ steel tubing framed pre-hung doors. The walk in doors can be single or double (french door) style.
Doors can be placed on the ends or any where on the sides allowing you to have customization that fits your exact needs. This picture is of a roll-up door placed in a 20′ container on the opposite end of the cargo doors. All doors and windows can be ordered in custom sizes as well.

domain: design


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Why this book?
In Angie Debo’s classic book And Still the Water Runs, the tragic history of the forced removal of the Five Civilized Tribes which consist of the Choctaw, Chickasaw, Cherokee, Creek, and Seminole nations is well visualized in words by Debo. Due to the murderous overthrow of the tribal ways of life, Europeans forced the Five Civilized Tribes off their land in the Southeast region to settle in Indian Territory (what is now known as the state of Oklahoma). The depiction of the tribes' fight for their land, the deadly trek of the Trail of Tears, to the foreseen dispossession of the tribe’s land in Oklahoma by the U.S. government is a heart-breaking synopsis which Debo captures passionately in a visually impactful manner.
Why should I read it?
What is this book about?
Debo's classic work tells the tragic story of the spoliation of the Choctaw, Chickasaw, Cherokee, Creek, and Seminole nations at the turn of the last century in what is now the state of Oklahoma. After their earlier forced removal from traditional lands in the southeastern states--culminating in the devastating 'trail of tears' march of the Cherokees--these five so-called Civilized Tribes held federal land grants in perpetuity, or "as long as the waters run, as long as the grass grows." Yet after passage of the Dawes Act in 1887, the land was purchased back from the tribes, whose members were then…

domain: library


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The Goélia "Les Chalets des Ecourts" tourist complex with heated outdoor pool is located in Saint Jean d'Arves.
LES CHALETS DES ECOURTS COMPLEX
This complex, that is both authentic and modern, is made up of delightful small timber chalets divided into apartments (some with lifts) and all south-facing, and is located in the place known as "Les Chambons" where the traditional Savoie village is, with 2 restaurants. It is 1.5km away from the "La Chal" neighbourhood where the ski lifts, the majority of the shops and the Goélia Les Marmottes complex are.
A free municipal shuttle service to get to La Chal (ski lifts and shops) is in place every day including Saturdays (reduced service) from the start of the season until 01/04/22 (subject to change by the municipality). Stop in front of Les chalets des Ecourts complex, the first pick-up is at 08:30 and service continues without interruption to 18:30 with a rotation every half and hour at the maximum. Then, from 01/04/22 until the end of the season, the shuttle will operate a reduced service, from Sunday to Friday only. More shuttles on Saturdays from 01/04/22. The timetables are available at the reception of the complex.
For your comfort, you will find a reception, ski lockers, but also an outdoor heated pool (depending on weather conditions) and a fitness area with free access (sauna, Turkish bath and fitness room), as well as an outdoor car park.
OUR APARTMENTS FOR YOUR HOLIDAYS
All the apartments have a furnished kitchen area (refrigerator, hobs, microwave oven grill, dishwasher, coffee maker, toaster and kettle), a bathroom, WC and a balcony or terrace. You will also find enough crockery as well as blankets and pillows. TV included.
- 2 room 4 people accommodation, approx. 32m² on the ground floor: living room with 1 sofa bed (sleeps 2) and a bedroom with a double bed
- 3 room, 6 people accommodation, approx. 43m² with 1st or 2nd floor balcony: living room with 1 double sofa bed (sleeps 2), 1 bedroom with 1 double bed, another bedroom with, most often, 2 single beds, or very occasionally 1 double bed.
- 6 room apartments for 12 people, (2 x 3 room 6 people apartments twinned via the balcony)
- Discover our promotional and last minute offers under the "Prices-Promos-Availability" tab. Discounts and promotions are not backdated nor can they be combined and can only be booked when they are online.
YOUR Goélia STAYS:
- Do you want to go for a weekend, a short stay or a stay arriving on a day other than Saturday? Then view our "Weekend" tab or contact the booking centre: 01.60.76.59.00 (press 3).
- All the useful information for your stay (schedules, contact details, services...) is in the "Practical information" tab". Reserve your skis and ski lift packages at preferential rates.
- Under our "Great Goélia Plans" heading, discover all the trips and leisure activities at preferential rates.

domain: travel