H1N1 Pandemic H1N1 Pandemic Influenza Planning Influenza Planning VideoconferenceVideoconference

August 24, 2009August 24, 2009

Purpose of the Purpose of the MeetingMeeting

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Pandemic FluPandemic FluH1N1H1N1

Terry L Dwelle MD MPHTM Terry L Dwelle MD MPHTM CPH FAAPCPH FAAP

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Pandemic Influenza – General Pandemic Influenza – General InformationInformation

Pandemic is a worldwide epidemicPandemic is a worldwide epidemicWe can expect several pandemics in We can expect several pandemics in

the 21the 21stst century century

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H1N1 (Swine Origin H1N1 (Swine Origin Influenza Virus)Influenza Virus)

33,902 cases in the US (estimate is that there have been 1 million 33,902 cases in the US (estimate is that there have been 1 million cases in the US) cases in the US)

3663 hospitalizations 3663 hospitalizations 170 deaths 170 deaths Genetically this H1N1 is linked to the 1918-19 strainGenetically this H1N1 is linked to the 1918-19 strain Currently we are seeing almost totally H1N1 circulatingCurrently we are seeing almost totally H1N1 circulating Majority of the cases are in children and young adultsMajority of the cases are in children and young adults Majority of hospitalized patients have underlying conditions (asthma Majority of hospitalized patients have underlying conditions (asthma

being the most common, others include chronic lung disease, DM, being the most common, others include chronic lung disease, DM, morbid obesity, neurocognitive problems in children and morbid obesity, neurocognitive problems in children and pregnancy).pregnancy).

There have been over 50 outbreaks in campsThere have been over 50 outbreaks in camps Southern hemisphere – currently seeing substantial disease from Southern hemisphere – currently seeing substantial disease from

H1N1 that is cocirculating with seasonal influenza. There has been H1N1 that is cocirculating with seasonal influenza. There has been some strain on the health systems in some situations.some strain on the health systems in some situations.

About 30% of infected individuals are asymptomatic (study from About 30% of infected individuals are asymptomatic (study from Peru)Peru)

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Pandemic Influenza - Pandemic Influenza - EpidemiologyEpidemiology

Pandemics occur in waves Pandemics occur in waves The order in which communities will be affected The order in which communities will be affected

will likely be erraticwill likely be erratic Some individuals will be asymptomatically Some individuals will be asymptomatically

infectedinfected A person is most infectious just prior to A person is most infectious just prior to

symptom onsetsymptom onset Influenza is likely spread most efficiently by Influenza is likely spread most efficiently by

cough or sneeze droplets from an infected cough or sneeze droplets from an infected person to others within a 3 foot circumferenceperson to others within a 3 foot circumference

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Pandemic Influenza - Pandemic Influenza - ResponseResponse

We don’t look at pandemic flu as a separate We don’t look at pandemic flu as a separate disease to be dealt with in a different way disease to be dealt with in a different way from regular seasonal influenzafrom regular seasonal influenza

Influenza response toolboxInfluenza response toolboxSocial distancing and infection control measureSocial distancing and infection control measureVaccineVaccineAntiviral medicationsAntiviral medications

The most effective way to prevent mortality The most effective way to prevent mortality is by social distancingis by social distancing

Proxemics of Influenza Proxemics of Influenza TransmissionTransmission

Elementary Schools

Hospitals

Offices

Residences

3.9 ft

7.8 ft11.7 ft

16.2 ft

Goals of Influenza PlanningGoals of Influenza Planning

Cases

Day

Goals•Delay outbreak peak•Decompress peak burden on hospitals and infrastructure•Diminish overall cases and health impacts

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IsolationIsolation From From

www.cdc.gov/h1n1flu/guidance_homecare.htm Data from 2009Data from 2009

Most fevers lasted 2-4 daysMost fevers lasted 2-4 days90% of household transmissions occurred within 5 90% of household transmissions occurred within 5

days of onset of symptoms in the 1days of onset of symptoms in the 1stst case caseRequires 3-5 days of isolation (different from the 7 Requires 3-5 days of isolation (different from the 7

days previously used for influenza). The rule here is days previously used for influenza). The rule here is isolation for 24 hours after resolution of the fever isolation for 24 hours after resolution of the fever without the use of fever-reducing medications.without the use of fever-reducing medications.

Consider closing a school or business for a minimum Consider closing a school or business for a minimum of 5 days which should move the infected into the of 5 days which should move the infected into the area of much lower nasal shedding and contagion. area of much lower nasal shedding and contagion.

Unstressed Hospital and Clinic SurgeUnstressed Hospital and Clinic SurgeNorth DakotaNorth Dakota

Hosp / ILI

Regional ILI Rate

Clinic Caution 16.5

Clinic Crisis 21 X

Expected Response Expected Response RolesRoles

Brenda Vossler, DirectorBrenda Vossler, DirectorHospital Preparedness Hospital Preparedness

DivisionDivision

Response RolesResponse RolesStaff VaccinationStaff VaccinationTriage Triage

Decrease stress on Emergency RoomsDecrease stress on Emergency RoomsSeparation of infectious from non-Separation of infectious from non-

infectiousinfectious Infection ControlInfection Control

Healthcare worker protectionHealthcare worker protectionPrevent nosocomial transmissionPrevent nosocomial transmission

Response RolesResponse Roles

Implement surge strategies as Implement surge strategies as neededneededPatient capacityPatient capacitySuppliesSuppliesStaffStaff

Participate in surveillance activities Participate in surveillance activities

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Pan Flu AntiviralsPan Flu AntiviralsTerry L Dwelle MD MPTHM Terry L Dwelle MD MPTHM

CPH FAAPCPH FAAP

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Intervention - AntiviralsIntervention - Antivirals Antivirals (Tamiflu and Relenza) will be used Antivirals (Tamiflu and Relenza) will be used

primarily for treatment not prophylaxisprimarily for treatment not prophylaxisND will have approximately 160,000 treatment ND will have approximately 160,000 treatment

courses available for a pandemic (25% of the courses available for a pandemic (25% of the population)population)

Distribution flowDistribution flowNormalNormalNormal + Supplementation (from the state cache, Normal + Supplementation (from the state cache,

some prepositioned with LPHU’s) some prepositioned with LPHU’s) Points of DistributionPoints of Distribution

Resistance is a major concernResistance is a major concern

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Antiviral Treatment – H1N1Antiviral Treatment – H1N1 Sensitive to zanamivir (Relenza) and oseltamivir Sensitive to zanamivir (Relenza) and oseltamivir

Tamilflu but resistant to amantadine and rimantadineTamilflu but resistant to amantadine and rimantadine Some circulating seasonal Influ A viruses may be Some circulating seasonal Influ A viruses may be

resistant to oseltamivir – consider combination resistant to oseltamivir – consider combination treatment with oseltamivir and amantidine or treatment with oseltamivir and amantidine or rimantidinerimantidine

Uncomplicated febrile illness due to H1N1 does not Uncomplicated febrile illness due to H1N1 does not require treatmentrequire treatment

Treatment is recommended forTreatment is recommended for All hospitalized patients with confirmed, probable or All hospitalized patients with confirmed, probable or

suspected H1N1suspected H1N1 High risk patients for complicationsHigh risk patients for complications

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High risk groups for High risk groups for complicationscomplications

< 5yo (highest risk is < 2yo)< 5yo (highest risk is < 2yo) Adults Adults >> 65yo 65yo Persons with the following conditionsPersons with the following conditions

AsthmaAsthmaOther chronic pulmonary diseasesOther chronic pulmonary diseasesCardiovascular disease (except hypertension)Cardiovascular disease (except hypertension)Renal, hepatic, hematological (including sickle cell disease), Renal, hepatic, hematological (including sickle cell disease),

neurologic, neuromuscular, metabolic (including diabetes neurologic, neuromuscular, metabolic (including diabetes mellitus)mellitus)

Immunosuppression including that caused by medication or by Immunosuppression including that caused by medication or by HIVHIV

Pregnant womenPregnant women< 19yo receiving long-term aspirin therapy< 19yo receiving long-term aspirin therapyResidents of nursing homes and other chronic care facilitiesResidents of nursing homes and other chronic care facilities

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Treatment guidanceTreatment guidanceStart treatment as soon as possible Start treatment as soon as possible

after onset of symptoms after onset of symptoms Best if started before 48 hours from Sx Best if started before 48 hours from Sx

onsetonsetStill may be some benefit in Rx after 48 Still may be some benefit in Rx after 48

hourshoursDuration – 5 daysDuration – 5 daysDoses – H1N1 same as for seasonal fluDoses – H1N1 same as for seasonal flu

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Antiviral dosesAntiviral dosesMedication / GroupMedication / Group Rx for 5 daysRx for 5 days ChemoprophylaxisChemoprophylaxis

Oseltamivir (Tamiflu)Oseltamivir (Tamiflu)AdultsAdults 75 mg bid75 mg bid 75 mg od75 mg odChildrenChildren << 15 kg 15 kg 30 mg bid 30 mg bid 30 mg od30 mg od

16-23 kg16-23 kg 45 mg bid45 mg bid 45 mg od45 mg od24-40 kg24-40 kg 60 mg bid60 mg bid 60 mg od60 mg od> 40 kg> 40 kg 75 mg bid75 mg bid 75 mg od75 mg od

Zanamivir (Relenza)Zanamivir (Relenza)AdultsAdults Two 5 mg Two 5 mg

inhalations bidinhalations bidTwo 5 mg Two 5 mg inhalations odinhalations od

ChildrenChildren Two 5 mg Two 5 mg inhalations bid (inhalations bid (>> 7 yo)7 yo)

Two 5 mg Two 5 mg inhalations od (inhalations od (>> 5 5 yo)yo)

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H1N1 Oseltamivir doses for < H1N1 Oseltamivir doses for < 1yo1yo

AgeAge Rx for 5 daysRx for 5 days ChemoprophylaxChemoprophylaxis for 10 daysis for 10 days

< 3 mo< 3 mo 12 mg bid12 mg bid Not Not recommended recommended unless criticalunless critical

3-5 mo3-5 mo 20 mg bid20 mg bid 20 mg od20 mg od

6-11 mo6-11 mo 25 mg bid25 mg bid 25 mg od25 mg od

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ProphylaxisProphylaxisClose contact of cases (confirmed, Close contact of cases (confirmed,

probable or suspected) who are at probable or suspected) who are at high-risk for complicationshigh-risk for complications

Health care personnel, public health Health care personnel, public health workers, or first responders who have workers, or first responders who have unprotected close contact to a case unprotected close contact to a case (confirmed, probable or suspect) during (confirmed, probable or suspect) during the infectious period (24 hours before the infectious period (24 hours before to 24 hours after becoming afebrile)to 24 hours after becoming afebrile)

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Close contactClose contactCare for or live with a person who is a Care for or live with a person who is a

confirmed, probable or suspect caseconfirmed, probable or suspect caseHaving been in a setting where there is a Having been in a setting where there is a

high likelihood of contact with respiratory high likelihood of contact with respiratory droplets and or other bodily fluidsdroplets and or other bodily fluids

Activities like kissing, embracing, sharing Activities like kissing, embracing, sharing of eating/drinking utensils, physical of eating/drinking utensils, physical examination examination

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Pregnant womenPregnant womenTreatment – oseltamivir preferredTreatment – oseltamivir preferredProphylaxis – zanamivir Prophylaxis – zanamivir

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Prepositioning of Antivirals in the Prepositioning of Antivirals in the HomeHome

Relationship well established between the clinician Relationship well established between the clinician and patient or familyand patient or family

Medical history of all family members well known Medical history of all family members well known including medication allergies and underlying including medication allergies and underlying conditionsconditions

Compliance with physician instructions assuredCompliance with physician instructions assured Physician office capable of handling phone calls to Physician office capable of handling phone calls to

triage families / patients having antivirals in the triage families / patients having antivirals in the homehome

System to monitor expiration dates in placeSystem to monitor expiration dates in place Physician willing to accept liability for this practicePhysician willing to accept liability for this practice Patient willingness to pay for this medicationPatient willingness to pay for this medication

Vaccination StrategyVaccination StrategyMolly Sander, MPHMolly Sander, MPH

Immunization Program Immunization Program ManagerManager

VaccineVaccine Separate novel H1N1 influenza vaccine Separate novel H1N1 influenza vaccine

from seasonal trivalent vaccine.from seasonal trivalent vaccine. Five manufacturers: same age Five manufacturers: same age

indication as seasonal vaccine.indication as seasonal vaccine.Novartis (45.7%): multi-dose vialsNovartis (45.7%): multi-dose vialsSanofi (26.4%): multi-dose vials and Sanofi (26.4%): multi-dose vials and

pediatric preservative free syringespediatric preservative free syringesGSK (3.4%): multi-dose vialsGSK (3.4%): multi-dose vialsCSL (18.7%): multi-dose vials and CSL (18.7%): multi-dose vials and

preservative free syringespreservative free syringesMedimmune (5.8%): nasal sprayersMedimmune (5.8%): nasal sprayers

VaccineVaccine45 million doses in mid-October

20 million doses each week afterStorage and handling: same as seasonal

vaccine35 – 46 degrees Fahrenheit2 – 8 degrees Celsius

FDA approval: strain change, same as seasonal influenza vaccineUnlikely to use adjuvanted vaccine

Assume 2 doses required, separated by 3 to 4 weeks

ACIP RecommendationsACIP Recommendations Pregnant womenPregnant women because they are at higher because they are at higher

risk of complications and can potentially provide risk of complications and can potentially provide protection to infants who cannot be vaccinated; protection to infants who cannot be vaccinated;

Household contacts and caregivers for Household contacts and caregivers for children younger than 6 months of agechildren younger than 6 months of age because younger infants are at higher risk of because younger infants are at higher risk of influenza-related complications and cannot be influenza-related complications and cannot be vaccinated. Vaccination of those in close vaccinated. Vaccination of those in close contact with infants less than 6 months old contact with infants less than 6 months old might help protect infants by “cocooning” them might help protect infants by “cocooning” them from the virus; from the virus;

ACIP RecommendationsACIP RecommendationsHealthcare and emergency

medical services personnel because infections among healthcare workers have been reported and this can be a potential source of infection for vulnerable patients. Also, increased absenteeism in this population could reduce healthcare system capacity; Include public health personnel

ACIP RecommendationsACIP RecommendationsAll people from 6 months through 24

years of age Children from 6 months through 18 years

of age because many cases of novel H1N1 influenza are in children and they are in close contact with each other in school and day care settings, which increases the likelihood of disease spread, and

Young adults 19 through 24 years of age because many cases of novel H1N1 influenza are in these healthy young adults and they often live, work, and study in close proximity, and they are a frequently mobile population; and,

ACIP RecommendationsACIP RecommendationsPersons aged 25 through 64 years who

have health conditions associated with higher risk of medical complications from influenza. Chronic pulmonary disease, including asthmaCardiovascular diseaseRenal, hepatic, neurological/neuromuscular, or

hematologic disordersImmunosuppresionMetabolic disorders, including diabetes mellitus

ACIP RecommendationsACIP Recommendations Once the demand for vaccine for the prioritized Once the demand for vaccine for the prioritized

groups has been met at the local level, groups has been met at the local level, programs and providers should also begin programs and providers should also begin vaccinating everyone from the ages of 25 vaccinating everyone from the ages of 25 through 64 years.through 64 years.

Current studies indicate that the risk for Current studies indicate that the risk for infection among persons age 65 or older is less infection among persons age 65 or older is less than the risk for younger age groups. However, than the risk for younger age groups. However, once vaccine demand among younger age once vaccine demand among younger age groups has been met, programs and providers groups has been met, programs and providers should offer vaccination to people 65 or oldershould offer vaccination to people 65 or older. . 

ACIP RecommendationsACIP Recommendations If demand exceeds supply (not expected):

pregnant women, people who live with or care for children

younger than 6 months of age, health care and emergency medical

services personnel with direct patient contact,

children 6 months through 4 years of age, and

children 5 through 18 years of age who have chronic medical conditions.

DistributionDistributionH1N1 vaccine purchased from

manufacturers by the federal government.Vaccine is allocated to states based on

population.ND should receive 0.208% of vaccine supply.

H1N1 vaccine will be distributed through a third party distributor (McKesson).Same distributor as Vaccines For Children (VFC)

vaccine.Will also ship ancillary supplies (needles,

syringes, etc.)Increments of 100 doses per vaccine type.

DistributionDistributionMcKesson will report doses shipped

to the NDDoH.Electronically transferred to inventories

in NDIIS.Unknown number of sites for vaccine

to be shipped to in North Dakota.Providers should check cold storage

capabilities.What is the maximum amount of

storage available during seasonal influenza vaccination?

EnrollmentEnrollmentProviders are required to sign an

enrollment form in order to receive H1N1 vaccine.CDC is creating a standardized form. It is

currently unavailable.Enrollment needed regardless if already

enrolled in VFC program.Unknown if each site needs to enroll or if a

health system can enroll.Enrollment requirements unknown, but

most likely include:Proper storage and handlingFollowing of ACIP recommendationsReporting of doses administered?

Administration FeeAdministration FeeThe federal government will set a

maximum administration fee.Most likely at the Medicare rate: $18.45/dose in

North Dakota. (Different than Medicaid fee cap for VFC: $13.90)

Administration fee may be billed to patient, Medicaid, Medicare, private insurance, etc.

Local public health units cannot refuse to vaccinate based on inability to pay.Private providers will probably be able to refuse

vaccination if patient is unable to pay.

NDIISNDIISThe North Dakota Immunization

Information System (NDIIS) will be used to track doses administered.Similar data entry to other vaccines, but

includes high-risk groups for vaccination.Exploring the possibility of scanning.

Doses administered must be reported to CDC by the state on a weekly basis.Report each Tuesday for the previous

week.

NDIISNDIISAbility to run reports to determine

who needs second dose vaccination.Reminder/Recall conducted by NDDoH.

Must have username and password to access the NDIIS.

Contact the NDDoH at 701.328.3386 or toll-free at 800.472.2180 if interested in obtaining access.

Trainings are being scheduled for the NDIIS.

VAERSVAERSVaccine adverse events should be

reported to the NDDoH.Forms available at:

http://vaers.hhs.gov/ or through the NDDoH Immunization Program.

VAERS module will be available in NDIIS.Same fields as VAERS form.Pre-populated with demographic and

vaccine information from NDIIS.

Strategies for VaccinationStrategies for VaccinationCheck with local public health unit

about local strategies.Mass Immunization ClinicsSchool Clinics:Vaccination similar to seasonal

influenza vaccination. (mixture of private and public)

Seasonal Influenza Seasonal Influenza VaccinationVaccination

May be started when vaccine is available.May be administered at the same time as

H1N1.ACIP recommendations published and

available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5808a1.htm?s_cid=rr5808a1_e. No changes from last season.

Some private vaccine has already shipped.

Pneumococcal VaccinationPneumococcal Vaccination The ACIP recommends that persons The ACIP recommends that persons

recommended for pneumococcal vaccine recommended for pneumococcal vaccine receive it in light of the potential for receive it in light of the potential for increased risk of pneumococcal disease increased risk of pneumococcal disease associated with influenza. associated with influenza.

There are at present no recommendations There are at present no recommendations to give pneumococcal vaccine to groups for to give pneumococcal vaccine to groups for whom it is not currently recommended. whom it is not currently recommended.

ACIP will revisit this question over the ACIP will revisit this question over the summer as epidemiologic data from the summer as epidemiologic data from the Southern hemisphere influenza season and Southern hemisphere influenza season and from the U.S. become available. from the U.S. become available.

Community Community Mitigation and Mitigation and

Infection ControlInfection ControlKirby Kruger, DirectorKirby Kruger, Director

Division of Disease ControlDivision of Disease Control

Community MitigationCommunity MitigationSchoolsSchoolsChildcare settingsChildcare settingsHealthcare settingsHealthcare settingsBusinessesBusinessesGeneral PublicGeneral PublicHome careHome care

Community MitigationCommunity MitigationIsolation or exclusion

Voluntary and passive24 hours after fever subsides and not using fever

reducing medication

Hand hygieneRespiratory etiquette

Exclusion Period - time ill people Exclusion Period - time ill people should be away from othersshould be away from others

Applies to settings in which the Applies to settings in which the majority of the people are not at majority of the people are not at increased risk for complicationsincreased risk for complications

In general - for the general publicIn general - for the general publicDoes Does NOTNOT apply to health care settings apply to health care settings

StaffStaffVisitorsVisitors

Antivirals not considered with exclusionAntivirals not considered with exclusion

Infection ControlInfection ControlHealthcare FacilitiesHealthcare Facilities

CDC still recommending airborne CDC still recommending airborne precautionsprecautions (N95) with all (N95) with all encounters with patients with ILIencounters with patients with ILI

HICPACHICPACHas endorsed standard precautions plus Has endorsed standard precautions plus

droplet precautionsdroplet precautionsWHO – same as HICPACWHO – same as HICPACNDDoH Similar to HICPAC and WHONDDoH Similar to HICPAC and WHO

HomecareHomecare Infection controlInfection control Drink plenty of clear fluidsDrink plenty of clear fluids OTC medications (no aspirin)OTC medications (no aspirin) Monitor fever and other symptomsMonitor fever and other symptoms When to seek medical careWhen to seek medical care

Difficulty breathing or chest painDifficulty breathing or chest pain Purple or blue color in lipsPurple or blue color in lips Severe vomiting Severe vomiting Signs of dehydration (dizzy, low urine output, no tears, Signs of dehydration (dizzy, low urine output, no tears,

loss of elasticity in skin)loss of elasticity in skin) Less responsive than usual or confusionLess responsive than usual or confusion

Infection Control in the Infection Control in the HomeHome

Place ill person in a private room try to designate one Place ill person in a private room try to designate one bathroom for ill personbathroom for ill person

Have ill person wear a surgical maskHave ill person wear a surgical mask No visitorsNo visitors One non-pregnant person should provide careOne non-pregnant person should provide care Caregiver should consider wearing maskCaregiver should consider wearing mask Caregiver should consider N95 if assisting with Caregiver should consider N95 if assisting with

respiratory treatmentrespiratory treatment Hand hygiene and respiratory etiquette for householdHand hygiene and respiratory etiquette for household Use paper towels to dry handsUse paper towels to dry hands

Surveillance, Testing Surveillance, Testing and Reportingand Reporting

Kirby Kruger, State Kirby Kruger, State Epidemiologist, Division Epidemiologist, Division

DirectorDirectorof Disease Controlof Disease Control

What have we seen in ND?What have we seen in ND?

 

Laboratory SurveillanceLaboratory SurveillanceSentinel PhysiciansSentinel PhysiciansSyndromic SurveillanceSyndromic SurveillanceFollow-up of random sample of Follow-up of random sample of

children under the age of 18children under the age of 18School absenteeism reportsSchool absenteeism reportsOutbreak SupportOutbreak Support

SurveillanceSurveillance

HospitalizationsHospitalizationsWork with Infection Control NursesWork with Infection Control NursesParticipate in the Emerging Infections ProgramParticipate in the Emerging Infections ProgramUse of RedBat to gather Hospitalization dataUse of RedBat to gather Hospitalization dataUse of HC StandardUse of HC Standard

School absenteeism ratesSchool absenteeism ratesIncrease the number of schools that reportIncrease the number of schools that reportMonitor school closuresMonitor school closures

SurveillanceSurveillance

Outbreak SupportOutbreak SupportIncrease the number of facilities that Increase the number of facilities that

can report outbreaks and receive free can report outbreaks and receive free testingtesting

SurveillanceSurveillance

TestingTesting Limited testing in all areas of North Dakota Limited testing in all areas of North Dakota

where novel H1N1 has not been where novel H1N1 has not been demonstrateddemonstratedTesting will be stopped once ongoing transmission is Testing will be stopped once ongoing transmission is

likely (2-5 positive tests)likely (2-5 positive tests)Current restriction on testing Current restriction on testing

• Ward, Cass and Burleigh CountiesWard, Cass and Burleigh Counties All areas can continue to test for novel All areas can continue to test for novel

H1N1 in hospitalized patients in which H1N1 in hospitalized patients in which H1N1 infection has not been ruled outH1N1 infection has not been ruled out

Rapid Testing - 1Rapid Testing - 1FrequencyRow PercentColumn Percent H1N1 Positive H1N1 Negative Total

Rapid A Positive

2153.8580.77

1846.1525.35

58

Rapid A Negative

58.6219.23

5391.3874.65

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Total 26 71 97*

Sensitivity = 80.77% Proportion of actual positives that were correctly identified.

Specificity = 74.65% Proportion of actual negatives that were correctly identified.

Rapid TestingRapid Testing

ResourcesResourcesNDDoH flu web-page (updated every

Wednesday)http://www.ndflu.com/

CDC flu web-pagehttp://www.cdc.gov/flu/http://www.cdc.gov/flu/

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State LaboratoryState LaboratoryMike TrythallMike TrythallLaboratorianLaboratorian

Questions and Questions and AnswersAnswers