Streams

Flu Outbreak 101

Friday, January 11, 2013

Emergency Room at Maimonides Medical Center (Jennifer Hsu/WNYC)

Dr. Kent Sepkowitz, infectious disease specialist at Memorial Sloan-Kettering Cancer Center and a columnist for The Daily Beast, explains the science behind the flulike epidemic sweeping the country.

Google Flu Trends

This shows the intensity of searches for information about the flu this year compared to years' past. Google has been a reliable indicator of the severity of the outbreak.

 

Basic Flu Information from CDC

Signs and Symptoms

People who have the flu often feel some or all of these signs and symptoms:

  • Fever* or feeling feverish/chills (*It’s important to note that not everyone with flu will have a fever.)
  • Cough 
  • Sore throat 
  • Runny or stuffy nose 
  • Muscle or body aches 
  • Headaches Fatigue (very tired) 
  • Some people may have vomiting and diarrhea, though this is more common in children than adults.

Vaccine (More Information Here)

Who should be vaccinated?

Everyone who is at least 6 months of age should get a flu vaccine this season. It’s especially important for some people to get vaccinated. Those people include the following:

  • People who are at high risk of developing serious complications like pneumonia if they get sick with the flu. This includes: People who have certain medical conditions including asthma, diabetes, and chronic lung disease. 
  • Pregnant women. 
  • People 65 years and older 
  • People who live with or care for others who are high risk of developing serious complications. This includes: household contacts and caregivers of people with certain medical conditions including asthma, diabetes, and chronic lung disease.

Who should not be vaccinated against seasonal flu?

Some people should not be vaccinated without first consulting a physician. They include:

  • People who have a severe allergy to chicken eggs. 
  • People who have had a severe reaction to an influenza vaccination in the past. 
  • Children younger than 6 months of age (influenza vaccine is not approved for use in this age group). People who have a moderate or severe illness with a fever should wait to get vaccinated until their symptoms lessen. 
  • People with a history of Guillain-Barré Syndrome (a severe paralytic illness, also called GBS) that occurred after receiving influenza vaccine and who are not at risk for severe illness from influenza should generally not receive vaccine. Tell your doctor if you ever had Guillain-Barré Syndrome. Your doctor will help you decide whether the vaccine is recommended for you.

 

Guests:

Dr. Kent Sepkowitz

Comments [63]

Sandy from Somerset, NJ

I am sooo unconvinced by the segment on the flu. I have never had a flu shot, and I'd like to keep it that way. I did get the flu this year, but so did other people know who had the shot. Even if you believe the science, there still seems to be little justification for EVERYONE having a flu shot every year. According to the CDC, the shot is not even that effective. Less than 2% of Americans who get the flu die from it (up to 49,000 per year out of more than 300 million, which is a conservative number). (http://www.cdc.gov/flu/about/qa/disease.htm#deaths) Less than 7% are hospitalized. Moreover, the vaccine is minimally effective. To make matters worse, it's least effective on those who need it the most (frail and elderly). (http://www.cdc.gov/flu/about/qa/vaccineeffect.htm) Does that really justify all the hype around pushing the masses to get flu vaccinations? I don't think so.

So what if you get sick for a few days. Suck it up. What doesn't kill you makes you stronger. When I get the flu, I rest for a day, and I'm fine after that. Done. So, unless you are really old and frail, or have a compromised immune system, I see no need for people to have a flu shot every year.

Seems like a money-making scheme for pharmaceutical companies. There are plenty more illnesses that they could be putting their efforts into that are far more serious and debilitating, but providing annual vaccines to almost the entire U.S. population has got to be immensely profitable. I would love to see a comparison of the states that heavily promote flu vaccination, compared with the campaign contributions to the governors of those states. Should be an interesting analysis.

Jan. 12 2013 07:34 PM
steven from New York City

How disingenuous for Dr. Sepkowitz to suggest that anyone who distrusts Big Pharma is a denier of science, equated with those who don't accept global warming or evolution. Rather, we believe in real science that is not funded by, paid for or influenced by Big Pharma (and thus with pre-ordained results, lest the funding suddenly dry up). We don't trust the corporate influence that turns science into corporate product-placement, feeding upon legitimate fears and our very health... I wonder who funds Dr. Sepkowitz's research???

Jan. 11 2013 06:13 PM
Bill from Bronx

I would get the flu vaccine if it could be proven to be free of toxins.
Years back when the son of my friends became autistic soon after being vaccinated it was too much of a coincidence for me. When my wife and I had our own kids they were not vaccinated. We are holistic, healthy and vaccine-free.

Jan. 11 2013 12:21 PM

I want to know exactly what I'm doing right because I NEVER get the flu.. and I've never gotten a flu shot.

Jan. 11 2013 11:51 AM

I'd like to know exactly what I'm doing right because I NEVER get the flu.

Jan. 11 2013 11:50 AM

Chinese Medicine has been developing strategies for treating conditions like the flu for over 2,000 years. The understanding of the progression of pathogens is slightly different than in conventional Western Bio Medicine. One difference, which is why people with this understanding might be hesitant to get a vaccination, is that the route of entry is through the nose and mouth or the pores, gradually entering into the blood as a later stage of the disease. There are tactics for dealing with the disease at every stage of the disease, and here you are directly introducing it into the blood, which is not otherwise how you would contract it. Preventative Medicine in our medicine means taking it easy in the winter, going to bed early, eating a healthy diet, and getting acupuncture and/or herbal medicine to regulate and support your immune system. The therapies we have for addressing things like the flu do not necessarily directly "kill" the virus, although some may- they do shorten the duration of the illness and lessen the severity. Of course those who are elderly, immune compromised or otherwise susceptible should get a vaccine if they choose, but for the bulk of the population, there are other, equally effective options, which will have less side effects as well as allow your immune system to become more educated naturally.

Jan. 11 2013 11:30 AM
Julie from Brooklyn

To Mark from Chelsea: The flu shot is NOT free if you're on Medicaid (there are so many misconceptions about Medicaid). I'm ON Medicaid and I can ONLY get the flu shot covered by Medicaid if I get it from my doctor (who is out of the vaccine). A pharmacy will NOT let me get the shot unless I pay for it, even though I'm on Medicaid. A free clinic is a good idea, but Chelsea is a LONG way from where I live. It's a good suggestion, though, and I'll try to find something closer. However, since Medicaid patients can only get their shots paid for through their doctor, I think it would be nice if they held some aside for those of us on Medicaid! I suppose it's too much to ask for them to act compassionately and efficiently like that, though. Anyway, thank you for your help, Mark, and I'll try a free clinic!

Jan. 11 2013 11:25 AM

"The world today has 6.8 billion people... that's headed up to about 9 billion. Now if we do a really great job on new vaccines, health care, reproductive health services, we could lower that by perhaps 10 or 15 percent." Bill Gates
Vaccines & health care will reduce the population?!?!?!?
Is that why Federal law eliminated manufacturers' liability for their own vaccines?

Jan. 11 2013 11:03 AM

Flu and viral treatments:
Huge quantities of Vitamins D & C.
Slices of Ginger; Cinnamon; Zinc; drink fluids; colloidal silver.
Multivitamins. B-vitamins. Honey.
Epazote - various sources including: TheTeaOfLife.com

Don't take iron. Anemia helps kill viruses. The body defends itself against viruses by becoming anemic.

AIRBORN tm - fizzzy tabs of C, Zinc, & herbs. Despite the FDA's disapproval, I've felt AIRBORN cure my colds! I don't sell them, so I can say anything I want about AIRBORN. See Amendment 1, Bill of Rights. Store brands are similar, but not as tasty. AIRBORN is worth the extra $1 to me.

Keep warm. High fevers kill viruses. Don't take fever-suppressants, unless your fever is life-threatening >104 F, at which point you may want a Doctor.
Steam room, or Sauna, or hot bath.
I've bundled-up and exercised to overheat, followed by a nap in a sun-heated car. The cold was gone when I awoke.
But avoid not-awakening, and thereby dying of hyperthermia (getting too hot).
If you plan to overheat and sleep, have a conscious person monitor you. Hyperthermia may cause unconsciousness that you won't wake up from, before a further temperature increase causes death, as on a sunny roof, in a hot tub, or in an untimed sauna.
Don't heat a stationary car with the engine, and thereby die of CO.

Proteins should be more Lysine than Arginine. See chart:
http://www.herpes.com/Nutrition.shtml

A recent beer company study suggests vast quantities of beer, but that study may have been self-serving. Beer has echinacea.

Hot rum toddy, followed by a hot bath. But don't fall asleep and drown.

Jan. 11 2013 10:53 AM
Mark from Chelsea

For those that are encountering an issue (Julie from Brooklyn ) with the $30.00 fee for the shot at either CVS or Rite Aid etc. or alternatively have a particular insurance that won't pay for it..... the shot is FREE at any city public health center (go early in the morning Chelsea at 28th and 9th ave.) and if you have medicaid the shot is also FREE.
I'm 59, get the shot every year, have not had a Flu since 1986.

Jan. 11 2013 10:47 AM
Anna M. from Brooklyn

Thanks very much to Dr. Sepkowitz and Brian for this great segment, the doc was clear, understandable in an accessible way for medical and lay people alike and very helpful.

My specific question is: what are the policies and recommendations on flu vaccine in countries where pharmaceutical companies don't have as much profit at stake? I'm thinking about places like Cuba and Scandanavia, and my hunch is that doctors and public health officers in those places follow the science and recommend the vaccine as well. I understand the ire that caller Steve has against the pharma industry, but flu is dangerous and we stand to benefit far greater than lose by following evidence-based recommendations.

I'm making a point here, but also this is a real question, so if anyone has info on how countries with a more socialized medicine system handle this issue I'd really like to know!

Anna MacEwan, BSN
ER nurse, Lutheran Medical Center
Public Health Nurse, DOHMH

Jan. 11 2013 10:46 AM
stuart rudin from manhattan

Having just had three days (Monday to Wednesday) of what I assume was the noravirus - projectile vomiting, diaria - and being now a day past the effects, and just now getting back to eating. Should I get a flu shot right away, or is it even advisable to get a flu shot after this particular noravirus version?

Jan. 11 2013 10:45 AM

Fever helps kill viruses.
Mortality of the 1918 pandemic was increased by the recent availability of aspirin, which suppressed fevers.

Jan. 11 2013 10:45 AM
Patrick from Brooklyn

I was the caller with the 4 month old and I was not suggesting that we get him a flu shot, but was looking for a resource that my wife and I can peruse together on vaccinations in general. Is it possible to have one posted? I will be looking at the Harper's article.

Jan. 11 2013 10:44 AM
Margaret from Gillette, NJ

The NY Times article "Reassessing Flu Shots as the Season Draws Near" (11/6/12)was referenced by a caller and does report on a study finding "little if any protection for those 65 and older."

Jan. 11 2013 10:39 AM
Nikki Jo from NYC

I wish I could've called into your show just now but being at work prohibited me. Dr. Sepkowitz is spreading false information. The flu shots do still contain thimerosal!! It's right on the CDC's webpage! It is the spread of this type of false information that scares me into not believing medical professionals as far as it goes to providing correct information on an informed consent basis.

Do the 2012-2013 seasonal flu vaccines contain thimerosal?

The Food and Drug Administration (FDA) has approved several formulations of the seasonal flu vaccine, including multi-dose vials and single-dose units. (See Table of Approved Influenza Vaccines for the U.S. 2012–2013 Season.) Since seasonal influenza vaccine is produced in large quantities for annual immunization campaigns, some of the vaccine is produced in multi-dose vials, and contains thimerosal to safeguard against possible contamination of the vial once it is opened.

Jan. 11 2013 10:36 AM

Why is there more flu in winter?
We don't get out in the sun. So our Vitamin D levels are lower.
Take several thousand units of Vitamin D3 per day, and you will likely not be as sick as you usually are in winter.

Jan. 11 2013 10:32 AM
Duchess of NYC from NYC

Why don't you do a segment on alternative treatments and preventative measures for the flu--i.e. what people who don't take the flu shot do to boost their immune systems to prevent getting the flu; and what they use to treat the flu.

There are homeopathic remedy called Influenzinum that you can take to prevent getting flu for instance, and many other remedies one can take if you do contract flu.

Also many many herbal remedies, honey and lemon, etc.

I have experimented with many of these for myself and my 4 year old son. It's all about finding out what works for YOU. I know the naysayers say there is no science behind these natural, non-pharma remedies... but that has much to do with the FDA's bias and how studies are funded. More and more studies are in fact confirming the efficacy of "natural" remedies, and since so much of your audience doubts the efficacy of flu vaccines, why don't you ask your listeners what they take?? There's a lot of collective wisdom on this if you want to tap it.

Jan. 11 2013 10:32 AM
Alison from Westchester

I just called this morning to get a flu shot for my 9 year old son and was told it is the same shot for kids and adults. Really? How is that possible? Can anyone confirm if this is true? Thanks!

Jan. 11 2013 10:29 AM
Tim from Nyack

"Crud", "fastball"... I like this doctor! I'm stunned by the fluers (kinda like birthers).

Jan. 11 2013 10:28 AM
David from Fredericksburg, VA

@Mark from NYC

You're either lying that your're a doctor or the worst informed physician I've ever heard of. Thiomersal is no longer used in vaccines.

Jan. 11 2013 10:28 AM
Westchester Rob from westchester

ASk him about people with HIV getting 3 vaccines shots. Like elderly should?

Jan. 11 2013 10:27 AM

thank you!

Jan. 11 2013 10:27 AM
carol from n. jersey

i am one of those people who had the flu and almost died. it happend in 201o, when i did not have a vaccine, and had an undiagnosed flu that then became pneumonia. by the time i was seen in the er, and admitted to hospital for over a week, i had almost no liver, kidney function. heart and lung complications and was almost in diabetic shock...i learned i was diabetic!!

get a flu shot. it is so much cheaper!

Jan. 11 2013 10:26 AM
Mark Sugarman from Park Slope, Brooklyn

As an asthmatic most of my life, I have been getting the flu shot most of my life. I find I usually dont get that sick during the flu season & when I do its not nearly as bad as it could be. When I was a young adult, a few times i resisted the shot & I remember getting so sick with the flu, it lasts longer than it would if I had gotten the flu shot & the after-effects from the flu; various ear, nose & throat infections persist way past when the flu has gone. I am a big proponent of the shot even though I do believe that Big Pharma is generally not in the publics best interest

Jan. 11 2013 10:25 AM
Nancy R. from Brooklyn

I question the efficacy of flu shots, and my doubts are related to how big Pharma pushes treatments that make a lot of money from them, and don't necessarily help the recipients.
However, I strongly object to your guest, Dr. Sepkowitz, linking flu-vaccine questioners with creationists who doubt evolution and climate-change doubters. I am a scientist and I firmly believe in evolution and climate change.
I do question the motives of big corporations like pharmaceutical companies, and how they promote unnecessary, expensive, and sometimes harmful treatments. It makes me doubt treatments, even if they might work.

Jan. 11 2013 10:25 AM
Ellen M. from CT

3 comments:

1.My husband is a pharmaceutical chemist and has worked for "Big Pharma" and "little pharma," and I must refute some peoples' opinions that these companies are somehow on par with Nazi doctors in their insidiousness. Yes, the companies are in it for a profit-- but it can take decades to develop a successful drug and hundred of people --the costs are unimaginable--how are they supposed to finance this? (these companies DO give away millions of dollars of drugs to 3rd world countries, etc.) While he wants and needs to make a living, he chose this path because he honestly wants to help people as do 100% of his colleagues. Too suggest otherwise, is unfair.

2. I had an uncle who died in the 1918 Flu Epidemic--he died on the trolley before he could even get home. Why anyone would want to risk serious illness and risk passing it on to children and the elderly is strange and selfish.

3. The science is there, if people would stop getting their information on Facebook and Twitter--the stats are all available at legitimate sources--the CDC, NIH, etc. Jeez.

Jan. 11 2013 10:25 AM
David from Fredericksburg, VA

@Jeanne from New Jersey
"Why not let your own immune system protect you?"

Umm - that's exactly what a vaccine does.

Jan. 11 2013 10:24 AM
Bob from Westchester, NY

@ Jim from NYC/NJ: You need to check your facts. Tamiflu is a treatment for the flu after you come down with it, not a vaccine. Therefore NOT getting a flu shot is potentially enriching Mr. Rumsfeld, as more people will come down with the flu and will buy the Tamiflu treatment. SO GET YOUR SHOT and stick it to Rumsfeld (and protect the rest of us in the meantime).

Jan. 11 2013 10:23 AM

Is it too late in the season to get a flu shot?

Jan. 11 2013 10:23 AM
David from Fredericksburg

@ JoeCorrao
Re: Creationists
You're right - there's actually something to point to support their belief (the bible). You, on the other hand, don't even have that.

Jan. 11 2013 10:22 AM
Chris B from Morrristown NJ

An egg allergy may be a reason not to get some flu shots, but, there is a non-egg based flu shot available - it is called Flucelvax.

Jan. 11 2013 10:22 AM
LK from east village nyc

There's a great article about the political/social/historical/scientific issues surrounding vaccination in the January 2013 issue of Harper's. Definitely worth a read for anyone who's interested:

http://harpers.org/blog/2013/01/the-class-politics-of-vaccination/

Jan. 11 2013 10:21 AM

Vaccine suspicion comes from a place of great privilege. It will take one serious outbreak, a "9/11" of infectious disease in the US to remind all of us just how important the discovery and use of vaccines is. Until then, our 1st world comfort will allow misinformation and superstition to continue informing attitudes toward medical science and disease prevention.

Dash

Jan. 11 2013 10:21 AM
Mark from NYC

I'm a physician who got the flu shot. Can you speak to the nature of the mercury in the thimerasol preservative? People are concerned about mercury as a neurotoxin.

Jan. 11 2013 10:21 AM

seems selfish to spread the flu around.

anyone know how many times a day the subways are disinfected?

Jan. 11 2013 10:20 AM
Mary from Long Island City

I've been told not to get a flu shot if you have an autoimmune disease, since the shot can cause a flare-up.

Jan. 11 2013 10:20 AM
JJ from NJ

Q: What is the advantage of the 1918 Flu Pandemic that killed 20 million people worldwide? A: Fewer of those people reproduced! This makes the population stronger. If our reaction to the flu is to always vaccinate everyone, then we get weaker and weaker as a society.

Jan. 11 2013 10:20 AM
Paul

I and family are not against vaccination. A friend will not vaccinate due to an allergy to corn. Is that a valid concern?

Jan. 11 2013 10:19 AM
juljo from BKLYN

My 25 year old sister died from the flu in 2002. She was a type-1 diabetic. She took impeccable care of herself, diet, exercise, vitamins, excellent HA1C.

I am also a type-1 diabetic with a child and will never miss a flu vaccination.

Whatever the wide variety reasons that I have hear people give, the pale in comparison of the experience of losing someone you love needlessly.

Jan. 11 2013 10:19 AM
Valerie from NYC

My sister, mother and I are all very susceptible to flu. I could always count on getting it once a year, and being down for the count for a week - often longer - before I started getting flu shots. Once I was down three weeks, and continued to be very weak for another month after I was up and around. The shots don't always work - at least once I got sick despite my shot - but it's been a life changer for me. I congratulate people with hardier genes, but my genetic makeup welcomes all flu viruses, so I get my shot every year now, and am very grateful they're available.

Jan. 11 2013 10:19 AM
SuzyS

What is the problem with getting the flu?
When does a cold become FLU?
I can't remember getting the Flu and I 62!
I have C-Diff from anto-biotic i HAD to take for a staff infection and I have a very small cold?
I don't know anybody who had the FLU.
etc..

Jan. 11 2013 10:18 AM
Richard Unice from Tinton Falls, NJ

For an informative analysis about the history and reasoning behind vaccinations, read the piece by Eula Biss in the Jan issue of Harper's, "Sentimental Medicine".

Jan. 11 2013 10:18 AM
Florence

People I know who are/have been sick have not have fever. Are we sure that this surge of illness is really the flu and not a cold?

Jan. 11 2013 10:17 AM
Jeanne from New Jersey

Why not let your own immune system protect you? Does your body not build up a natural immunity - if you are healthy - to these viruses?

Jan. 11 2013 10:17 AM
Heather from Hoboken

For those folks not gettting vaccinated & simply "suffering through" the flu: at least think of the other people that you are infecting as you make your political point.

Jan. 11 2013 10:17 AM
Daniel Ortega from West New York, NJ

I have allergies, particularly to eggs and that is wait I do not take the flu shot. What can your guess say about this? Any alternative?
Also take a look:

http://www.huffingtonpost.com/2013/01/08/jeremy-pereira-new-jersey_n_2432932.html?ir=Education

Jan. 11 2013 10:16 AM
Jim from NYC/NJ

Donald Rumsfeld.
I remember he made a ton of money from tamiflu vaccine - and there you go - it's not medical, it's political/corporate (which I think is the definition of fascism.) I'm still mad about Irag/Afghanistan. Similar reason I try to get checks instead of credit cards - It's my little way of punishing the culprits who our "leadership" won't punish. The Hawks and the Banks.

Jan. 11 2013 10:16 AM
Steve from Chelsea from Chelsea

I hear the dangers for pregnant women can be severe...is there a way beyond getting the shot that pregnant women can protect themselves?

Jan. 11 2013 10:16 AM

Whoa cochise did you equate not getting a flu shot the same as believing in creationism? Cause thats a stretch.

Jan. 11 2013 10:15 AM
Sara B. from nyc

I got my first flu shot in 2001. Bernhard Goetz was running for Mayor and exhorted his fellow citizens to get flu shots and take the pressure off of medical 1st responders. But I was going to get one anyway ;)

Jan. 11 2013 10:15 AM
Julie from Brooklyn

I can't get the flu shot because my doctor is out of the vaccine. His office sent me to the pharmacy to get the shot instead, but they don't take my insurance (the insurance company will only pay for the shot if it's done at my doctor's office). I can't afford the $30 the shot costs at the pharmacy, so...I'm out of luck. Just thought I'd mention this, as there are so many people who CAN get the shot who are refusing to, while, meanwhile, I WANT to get the shot, but can't due to bureaucracy (and poverty).

Jan. 11 2013 10:15 AM
William Finke from Port Chester JNY

I'm with the skeptics. Believe me, I was nothing but enthralled with science as a pre-teen. Unfortunately, the promotion of benefits often suffers from the down the road bad news that has broken out since thalidomide.

Jan. 11 2013 10:14 AM
Stefanie Weiss from West Village

How about if everyone who has the flu would just stay home instead of selfishly going to work, to the gym, etc. I cannot stand it when I'm on the train, working out, in the market, etc. and there are people coughing relentlessly, clearly very ill, yet out and about. It's not fair for sick people to subject everyone to these germs. We'd probably have far fewer cases if they would just take a few days off. I know some folks need to go to work - it's not their fault. But the gym???? That's just pure selfishness. Stay home with tissues.

Jan. 11 2013 10:14 AM
cb from Brooklyn

When were flu shots first on the market? I'd like to see data about flu epidemics before and after that date.

Jan. 11 2013 10:14 AM
M from NYC

People like caller Steve who want to take a personal stand against the pharmaceutical industry should also keep in mind that they are putting the less immune-competent at risk when they insist on riding public transportation and going to work while they are infectious. Let's have a discussion about that responsibility.

Jan. 11 2013 10:14 AM
alisonjas from Bklyn

Flu shot all the way! After living in India for a few months, I am so pro-vaccine. Where are the history buffs? Where are the Downton Abbey Don't they remember the deaths from the flu epidemic of 1918?!

Jan. 11 2013 10:13 AM
Henry from Maryland

I used to take flu shots every year until this year when I heard that one of the components of the shot is H1N1. Well, I took the swine flu shot some years ago and suffered as a result a complete collapse of my left leg. It took months at the chiropractor to restore partial use of the leg.

Jan. 11 2013 10:12 AM
joan m. from beacon, ny

My dentist got transverse myelitis and is disabled from it; he said 60% of mt sufferers got it from a vaccine. He is a medical professional and he would not get a vaccine.

Jan. 11 2013 10:11 AM
Wendy from Paramus

◦Fever* or feeling feverish/chills (*It’s important to note that not everyone with flu will have a fever.)
◦Cough
◦Sore throat
◦Runny or stuffy nose
◦Muscle or body aches
◦Headaches Fatigue (very tired)
◦Some people may have vomiting and diarrhea, though this is more common in children than adults.
The above are reasons enough for me to get the flu vaccine!

Jan. 11 2013 10:11 AM

I don't think its the science i just think in so many cases it doesn't matter...some people it may be really bad when they get the flu, but for the vast majority its a yawner.

Jan. 11 2013 10:11 AM
Jessica from Chelsea

These people who dont want to get flu shots obviously dont have kids who pick up these viruses like velcro.

Jan. 11 2013 10:10 AM
David from Fredericksburg, VA

Why don't more people get flu shots? Pure ignorance.

Jan. 11 2013 10:07 AM

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