>> Good afternoon.
I'm Commander Ibad Khan and I'm representing the Clinician
Outreach and Communication Activity, COCA,
with the emergency risk communication branch
at the Centers for Disease Control and Prevention.
I'd like to welcome you to today's COCA call,
update on Ebola diagnostics at the state
and federal levels in the United States.
You may participate in today's presentation via webinar
or you may download the slides if you are unable
to access the webinar.
The PowerPoint slides and the webinar link can be found
on our COCA webpage at emergency.cdc.gov/coca.
Again that web address is emergency.cdc.gov/coca.
Once you reach the webinar page,
the PowerPoint slides can be found
under the call materials tab.
Free continuing education is offered for this webinar.
Instructions on how to earn continuing education will be
provided at the end of the call.
In compliance with continuing education requirements, CDC,
our planners, our presenters, and their spouses'/ partners wish
to disclose they have no financial interests
or other relationships with the manufacturers
of commercial products,
suppliers of commercial services,
or commercial supporters.
Planners have reviewed content to ensure there is no bias.
The presentation will not include any discussion
of the unlabeled use of product or a product
under investigational use.
CDC did not accept commercial support
for this continuing education activity.
After the presentation, there will be a Q&A session.
You may submit questions at any time during the presentation
through the Zoom webinar system by clicking the Q&A button
at the bottom of your screen.
And then type in your question.
Please do not ask a question using the chat button.
Questions regarding the webinar should be entered using only the
Q&A button.
For those who have media questions,
please contact CDC media relations at 404-639-3286,
or send an email to media@CDC.gov.
If you're a patient please refer your questions
to your healthcare provider.
At the conclusion of today's webinar,
participants will be able to accomplish the following.
Discuss procedures for assessing ill travelers returning
from the outbreak area, including consultation
with the relevant public health authorities.
Describe CDC's role in providing technical support
and testing approval for persons under investigation
for Ebolavirus infection.
Review the procedure for reporting and consulting
on a suspected case of Ebola in the United States.
Discuss considerations and limitations for domestic use
of novel rapid diagnostic tests for Ebola.
And discuss how to coordinate between clinicians,
state health departments, and CDC as it pertains
to domestic Ebola preparedness and diagnostics.
I would now like to introduce our presenters
for today's webinar.
Our first presenter is Captain Joel Montgomery.
Capt. Montgomery is the chief
of the Viral Special pathogens Branch at CDC.
He oversees a diverse portfolio
of public health research response
and partner country capacity enhancement
to high consequence pathogens such as Ebola.
Capt. Montgomery brings many years
of in-depth global experience as a laboratorian, microbiologist,
and epidemiologist to his role.
Where he is responsible for coordinating scientific efforts
in 10 global disease detection country offices.
And implementing technical aspects
of the global health security agenda.
Our second presenter is Dr. Julie Villanueva.
Dr. Villanueva is the chief of the Laboratory Preparedness
and Response Branch at CDC.
In this role, she oversees the biological component
of the laboratory response network,
which is an integrated domestic and international network
of laboratories designed to respond quickly to biological,
chemical, and radiological threats
and other high priority public health emergencies.
I'll now turn it over to Capt.
Montgomery.
Capt. Montgomery, you may begin.
>> Thanks Commander Khan.
Thank you for the opportunity to speak with you all today.
As Commander Khan mentioned, I'm Dr. Joel Montgomery Chief
of the Viral Special Pathogens branch.
In today's presentation Dr. Julie Villanueva
and I will cover the following topics.
First, we'll provide a historical overview of Ebola
and give an update on the current outbreak in the DRC,
or Democratic Republic of the Congo.
We'll also provide guidance and a step-by-step process on how
to acquire a laboratory diagnosis of Ebola in a person
or persons under investigation.
We'll provide an overview and functions
of the US Laboratory Response Network or LRN.
And finally, we'll provide a description
of the current FDA approved Ebola Rapid Diagnostic Test
developed by OraSure and its intended use, limitations,
and considerations for testing of persons under investigation
or suspect Ebola cases patients.
Ebolavirus disease is a rare and deadly disease caused
by infection with one of the species in the genus Ebolavirus.
Four of these species can cause disease in humans,
and other can cause disease in nonhuman primates and pigs.
And one species is not known
to cause disease in humans or animals.
I'll describe these in more detail in subsequent slides.
Ebolavirus was first discovered in 1976, near the Ebola River
in what is now known
as the Democratic Republic of the Congo.
Since then outbreaks have appeared sporadically in East,
Central, and West Africa.
There have been 28 independent outbreaks recorded in humans
in Africa since that time,
including this most recent outbreak in DRC.
This is 10th Ebola outbreak in DRC on record.
Based on evidence and nature of other similar viruses,
we believe that Ebola is an animal-borne or zoonotic disease
with bats being the most likely animal reservoir
or primary source for the initial introduction
or spillover into human populations.
The spillover event from the natural reservoir,
presumably a bat, is thought to occur through direct contact
with a bat, such as through hunting or through contact
with bat excretions and/or bodily/fluids such as urine,
feces, saliva, or blood.
Once the initial introduction into a human,
known as the index case has taken place,
subsequent transmission from person-to-person may occur
in healthcare settings
and resource constrained settings often due
to a breakdown in proper infection prevention
and control procedures.
Additional transmission within the general community may
and often does occur, as in the current situation
in DRC frequently as a result of poor access to healthcare.
The current outbreak in eastern DRC is the second largest
Ebola outbreak ever recorded.
And the largest outbreak DRC has experienced to date.
Currently, there are 6 known
and recognized species of Ebolavirus.
Zaire ebolavirus, Sudan ebolavirus,
Bundibugyo ebolavirus, Tai Forest ebolavirus,
Reston and Bombali ebolaviruses.
Local transmission, outbreaks, and/or imported cases
of Zaire ebolavirus on the continent
of Africa have occurred in the DRC Republic of Congo, Gabon,
Guinea, Sierra Leone, Liberia, Mali, Senegal,
Nigeria, and South Africa.
For Sudan ebolavirus, outbreaks have been restricted
to South Sudan and Uganda.
Bundibugyo ebolavirus has occurred in DRC and Uganda.
And finally, Tai Forest ebolavirus outbreaks
or cases have occurred only in Cote d'Ivoire or Ivory Coast.
All species, other than Reston and Bombali are known
to cause human disease.
The latter two species have only been associated
with either nonhuman primate and/or pig outbreaks,
that is Reston ebolavirus in Reston Virginia and Texas.
With some evidence of transmission to humans
with no overt disease.
While Bombali ebolavirus has only been identified
in the Angolan free-tailed bat and little free-tailed bat.
First in Sierra Leone, and later, in Guinea and Kenya.
Ebola spreads through direct contact.
Through broken skin or unprotect mucous membranes
with any or all the following.
Blood or bodily fluids such as urine, saliva, sweat, feces,
vomits, semen, breast milk, and vaginal fluids from someone
who is sick with, or has died from Ebola.
Through fomite contact contaminated
with infected bodily fluids.
For example, needles, syringes, bedding.
Contact with infected animals, as I mentioned previously,
such as fruit bats, and/or nonhuman primates.
And from semen from an individual
who has recovered from Ebola.
The signs and symptoms often grouped
as either dry or wet symptoms.
May include the following.
Fever, severe headache, fatigue,
muscle pain, rash, abdominal pain.
The so-called dry symptoms.
These are often followed by the wet symptoms.
Including vomiting, diarrhea, unexplained bleeding,
and in females, miscarriage.
It's important to note and reemphasize
that a person infected with Ebolavirus is not contagious
until symptoms appear.
The progression of Ebolavirus disease begins
with the incubation period.
The time from exposure to when signs and symptoms first appear.
Incubation for EBD is 2-21 days with an average
of 8-10 days for most cases.
Again, a person infected
with Ebola cannot spread the virus prior to symptom onset.
Wet symptoms generally develop approximately four days
into the course of illness.
And patients with Ebolavirus disease become increasingly
contagious or infectious, as the illness advances.
Without treatment, supportive care,
or therapeutic intervention, generally, death occurs within 7
to 10 days after illness onset.
Finally, the concentration of the virus
in the body is the greatest at the time of death.
And the point when an individual is most infectious to others.
The current outbreak in the DRC was confirmed in August 2018.
And on September 26, 2018, the US Agency
for International Development
or USAID activated a disaster assistance response team,
co-led by CDC.
On 13 June 2019, due to the unabated progression
of the outbreak, increasing complexity of CDC engagement,
and a confirmed case in neighboring Uganda,
CDC activated its emergency operation center.
It's the first urban outbreak in DRC occurring
in a highly insecure, densely populated area near
international borders
with extensive cross-border movement and trade.
From 20 November to 10 December,
there have been 42 confirmed cases in 4 health zones of DRC.
The outbreak does show signs of slowing, however,
upticks of violence, insecurity,
and stability have hampered the response activities.
I'll discuss this in more detail in subsequent slides.
But as you can see from the maps, the current outbreak
in DRC is affecting very remote areas of the country,
including North Kivu and the three provinces shown in detail
on a map on the left-hand side.
The map on the right shows just how distant the current Ebola
transmission zone is from Kinshasa, the capital of DRC.
The outbreak zone is approximately 1600 km,
or 1000 miles by air, or 3000 km or 1900 miles by ground.
Therefore, the ease of population movement or movement
of an individual outside of these areas
to other locations including the United States,
via Kinshasa is very difficult but not impossible.
It is also very distant from other large cities in the region
such as Kampala, Uganda.
And we have and are seeing movement
of individuals across the borders.
The current outbreak
and in eastern DRC is the second largest
of all outbreak ever recorded.
And the largest outbreak DRC has experienced to date.
As of 18 December, there have been more than 3300 cases
and 2200 deaths in 29 health zones.
The provinces affected by this outbreak border Uganda, Rwanda,
South Sudan, and Burgundy with significant population movement
across poorest country borders.
Case movement poses increased risk of new infections
and a resurgent of cases in health zones that have gone
without reporting cases for some time.
This is further complicated by the possibility
of infected people moving into areas where insecurity
and violence make it impossible for cases to be isolated,
contacts to be traced, and vaccination to occur.
This past fall, cases fell significantly.
And the geography of the outbreak was reduced.
However, violence and unrest
since late November have significantly impeded the Ebola
response efforts in the remaining outbreak areas.
An attack specifically targeting the Ebola response
for non-USG US government Ebola responders were killed
and 27 November.
And as a result, the response has been partially
or completely interrupted in key communities.
The affected DRC population have low levels of trust
in the government and the international community.
And violence has hampered the public health response efforts.
As previously mentioned, the risk of Ebola importation
to the US is low at this time.
But we must remain vigilant.
This assessment is based on the travel volume
and travel patterns from outbreak areas to the US.
As well as the implementation of border screening measures
at key airports and ports in DRC and neighboring countries
such as Sudan, Rwanda, and Uganda.
There are no direct flights to the US from DRC.
The total number of travelers from all DRC,
including nonaffected areas
to the US was less than 16,000 in 2018.
On average, of approximately 325,000 air travelers arriving
in the United States daily from abroad,
only 43 travelers have been from DRC.
Largely from unaffected regions.
The persons at risk are travelers to the eastern DRC
where the outbreak is occurring.
And those who have had contact with someone infected with Ebola.
I'll now hand over the presentation
to Dr. Villanueva.
>> Thank you, Capt.
Montgomery.
And thank you all for your time today.
I'm Dr. Julie Villanueva of the Laboratory Preparedness
and Response branch Chief at CDC.
And I'm here to talk about the role
of the Laboratory Response Network,
or the LRN in testing specimens from patients
with suspected Ebolavirus disease, as well as the role
and limitations of Ebola rapid diagnostic tests.
I'll begin by explaining the role of the LRN
in Ebolavirus disease testing.
The Laboratory Response Network, or the LRN,
was founded to create and sustain a network
of laboratories that can respond to biological
and chemical threats as well as public health emergencies.
In the years since its creation,
the LRN has played an instrumental role
in improving domestic public health infrastructure by helping
to boost state, local, and federal laboratory capability.
The LRN includes not only a network of federal, state,
and local public health laboratories
but is also a vast national network of sentinel
and clinical laboratories.
Our clinicians serve as the entry point to this network.
And we rely on you to alert us to the usual findings.
Currently, there are 69 LRN laboratories primarily in state
and local public health laboratories
that can perform the CDC real-time reverse transcriptase
polymerase chain reaction, or rRT-PCR Ebola tests
which I will explain in the next slide.
Healthcare providers and clinicians that are interested
in testing a patient
for Ebolavirus should first contact their state
or local public health authorities.
After you consult with your state
or local public health authorities,
together you will contact and consult with CDC.
If there is agreement that the patient meets the criteria
for persons under investigation for Ebolavirus disease,
then specimens may be collected and sent for testing at one
of the 69 LRN laboratories that are qualified
to conduct Ebola testing using the CDC assays.
The test used
by LRN laboratories are the CDC Ebolavirus NPrRT-PCR assay
and the CDC Ebolavirus BP 40 rRT-PCR assay.
These assays are intended for the detection of Ebolavirus RNA,
species Zaire ebolavirus in clinical specimens.
These tests have been authorized for use by the FDA
under emergency use authorization.
And both tests are conducted for a specimen from a person
under investigation for Ebolavirus disease.
Each of these assays use a real-time reverse transcriptase
polymerase chain reaction, or RT-PCR technology.
This is a commonly used diagnostic method
because of its ability to detect low levels of Ebolavirus.
PCR methods can also detect the presence
of a few virus particles in a small amount of blood.
But the ability to detect the virus increases as the amount
of virus increases during an active infection.
Acceptable specimens for testing
with these tests are whole blood, serum, and plasma.
Urine specimen are also acceptable only when tested
in conjunction with the patient matched whole blood,
serum, or plasma specimen.
Please consult the website listed on slide 21
for more information on specimen collection and transport.
The results from the CDC test are either negative,
inconclusive, or presumptive positive.
A negative results means Ebolavirus RNA was not detected.
If you receive this result, consult state
and local health authorities and CDC to determine
if additional patient testing is warranted.
Depending on the patient's travel history, signs,
and symptoms, it may be helpful
to perform diagnostic tests for other pathogens.
An inconclusive result means the test is not interpretable.
This result may be associated
with an inadequate specimen being collected
or a problem during specimen transport.
If you received this result consult state
and local health authorities and CDC to determine
if additional specimens need to be collected
from the patient and re-tested.
A presumptive positive result means Ebolavirus RNA
was detected.
Additional testing at the CDC is required
for the definitive identification of Ebolavirus.
Consult with your state and local health authorities and CDC
for confirmatory testing as well as guidance
for patient management.
Confirmatory testing at CDC is required to confirm the presence
of Ebola RNA and other viral hemorrhagic fevers,
as well as to differentiate
between the different species of Ebolavirus.
State and local public health authorities will coordinate
confirmatory testing at CDC for all specimens
that test presumptive positive
with the CDC Ebola, rRT-PCR assays.
Now, I'd like to discuss the intended use, some limitations
and consideration of Ebola Rapid Diagnostic Test.
In October of 2019, the US Food
and Drug Administration allowed marketing
of the OraQuick Ebola Rapid Antigen Test,
which is a Rapid Diagnostic Test or RDT for the detection
of Ebola virus in both symptomatic patients
and deceased individuals.
This is the first Ebola rapid agnostic test
that FDA has cleared by the 510K process
for marketing in the United States.
The test is an antigen capture lateral flow immunoassay capable
of detecting antigens of species including Zaire ebolavirus,
Bundibugyo ebolavirus, and Sudan ebolavirus.
Ebola Rapid Diagnostic Tests were originally developed
as a tool for rapid presumptive diagnosis
of Ebola in outbreak settings.
They have utility for low resource areas where access
to more sensitive molecular confirmatory testing is
a challenge.
These tests are not intended to be used
for general Ebola infection screening or testing
of asymptomatic individuals, or those without risk factors
and compatible symptoms of Ebola virus disease.
And as with any diagnostic tests, we encourage you
to please read the manufacturer's instructions
for use for additional important information about the test.
Like all diagnostic tests,
the OraQuick Ebola Rapid Antigen Test has some limitations.
The OraQuick Ebola Rapid Antigen Test cannot differentiate
between the three species of Ebolavirus that it detects.
CDC recommends that all results, both positive or negative
from the OraQuick Ebola Rapid Antigen Test are presumptive
and must be verified through real-time reverse transcriptase
polymerase chain reaction testing performed
in the Laboratory Response Network or at CDC.
Results from an Ebola Rapid Diagnostic alone should not be
used to make certain public health decisions.
Rapid diagnostic test results should not be used to rule
out Ebola infection, or to determine the use or type
of infection prevention and control precautions
when managing a patient with compatible symptoms
and epidemiological risk factors.
And now I'd like to turn the call back to Capt.
Montgomery.
>> Thanks, Dr. Villanueva.
So, in summary.
All of our ET results, both positive
and negative are presumptive and must be verified
through real time RT-PCR testing available at one
of the 69 LRN laboratories in 49 states and at the CDC.
The OraQuick Ebola Rapid Antigen Test should be used only
in circumstances where more sensitive molecular testing
at LRN laboratories or CDC is unavailable.
Which is being used in DRC for example, for testing of cadavers
for safe and dignified burials.
Healthcare providers who may be concerned about a patient
with Ebolavirus infection, should first contact their local
or state public health authorities
for consultation and guidance.
RDT results alone should not be used to rule
out Ebolavirus infection, or to determine the use or type
of infection prevention and control precautions,
when managing a patient with compatible symptoms
and epidemiological risk factors.
Finally, CDC is available to provide consultation,
technical assistance,
and confirmatory testing as necessary.
And with that I'll close and we are open for questions.
>> Thank you so much Capt.
Montgomery and Dr. Villeneuve for providing our audience
with this important update on Ebola diagnostics at the state
and federal levels in the United States.
We appreciate your time and value your insights.
We will now begin our Q&A session.
Please remember, you may submit questions
through the webinar system by clicking the Q&A button
at the bottom of the screen and then typing your question.
Again, please do not ask a question using the chat button.
Our first question is regarding the confirmatory testing results
from RDT.
Can you please elaborate if it's the positive RDT results
or the negative RDT results that need to be verified
through confirmatory testing?
>> Thank you, this is Julie Villeneuve.
All results, both positive and negative need to be confirmed
with a molecular assay.
>> Thank you for that.
And our next question is also similarly related.
And the question asks, can you please differentiate again the
difference between test results being inconclusive
or presumptive positive.
>> Of course, this is Julie Villeneuve again.
An inconclusive result means we can't interpret the test.
And so, that might mean
that there was an inadequate specimen that was collected.
Or, there may have been a problem
that could have damaged the specimen during transport
or elsewhere.
And so, the inconclusive result means you need to talk
to your state and local health authorities as well as CDC
and determine whether additional samples need to be collected
from that patient and retested.
>> Thank you.
Another question is regarding the specificity
and the sensitivity of RDT for Ebola.
Can you speak on that please?
>> So, again, this is Julie Villeneuve.
There is very detailed information
in the package insert from the manufacturer.
And I strongly encourage anyone that's interested in this test
to read that package insert.
And it has all the information about the sensitivity
and specificity of the test.
>> Thank you.
A follow-up question on that is the RDT available commercially?
>> Yeah. This is Dr. Joel Montgomery.
The OraSure RDT is available commercially.
But you would have to contact OraSure.
>> Thank you.
Also can the RDT be used effectively
when the patient is asymptomatic?
>> This is Dr. Joel Montgomery.
No, it cannot.
>> Thank you.
Another question we have is regarding what species
of Ebolavirus type does the PCR detect compared to the RDT?
>> Yeah, so the RDT detects Bundibugyo,
Zaire, and Sudan Ebolavirus.
>> And the rRT-PCA assay detects the Zaire Ebolavirus.
>> The CDC assay correct.
>> Thank you.
Another question is for clinicians that have
to submit samples to the agency.
Can you please talk again about the procedure?
If they should contact CDC directly or if they should reach
out to their health departments first.
>> This is Dr. Joel Montgomery.
Please communicate with your state
and local health departments first.
>> Thank you for that clarification.
And what is the earliest time that samples can be submitted.
Is it three days after patient shows symptoms?
Or can they be submitted sooner than that?
>> Hi, this is Dr. Katelyn Casiboom [assumed spelling]
with Viral Special Pathogens Branch.
Specimens that are collected from suspect Ebola patients,
if they're collected within 72 hours after symptom onset,
and the result is negative, and clinical suspicion remains,
it's important that they are, another specimen is collected
after 72 hours and retested.
>> Thank you.
Another question, comparing the different diagnostics asks,
what's the estimated turnaround time of the RT-PCR process done
at an LRN site compared to the use of RDT
at a healthcare facility.
>> So, this is Julie Villeneuve,
the RDP result is relatively rapid, and I would need
to consult package insert to give you the exact,
within 30 minutes, thank you.
The turnaround time at and LRN laboratory will vary.
But on average a real-time RT-PCR test itself takes
approximately four hours.
But please consider that specimens need to be received,
accessioned and data needs to be reviewed
and analyzed before a report is sent.
So that would be variable and you would need
to contact your state and local public health authorities
for more detailed information.
>> Thank you for that clarification.
Another inquirer is wondering
if there are CDC-based trainings available
to assist clinical labs
with safely packaging shipping specimens
to public health labs and/or to CDC.
Or if there is a resource available
that you can direct them to.
>> Commander Khan can you please repeat the question?
Commander Kahn could you please repeat the last question?
>> Yes, my apologies for the technical difficulties.
The question asks does the CDC have available training
or resources that will allow clinical labs to learn how
to safely package and ship specimens to public health labs.
>> So, this is Julie Villeneuve, there is guidance
on the CDC website that you can refer to.
If you go to the main Ebola page, if you click
on for laboratorians and there's a guidance
on specimen collection and transport.
I would also encourage you to contact your state
and local public health authorities
who can also assist you with this.
>> Thank you.
Another question asks during your presentation you mentioned
the criteria of patients without risk factors
when it comes to RDT.
Can you please elaborate on that?
>> So, this is Julie Villeneuve.
Patients without risk factors, signs of symptoms associated
with Ebolavirus disease should not be tested using any Ebola
diagnostic tests.
>> Thank you.
Another question is regarding biosafety precautions
or personal protective equipment requirements for RDT.
That's first part.
The second part is who do you recommend should perform
the testing?
>> Hi, this is Ryan Fagan
from CDC Division of Healthcare Quality Promotion.
I'll answer the first part of that,
which is any person entering the room
to collect the specimen should be following the same personal
protective equipment guidance
that other healthcare personnel would be following.
And that's consistent
with what's currently posted on the CDC website.
And there's also a link to the PPE guidance
from the specimen collection page
that Dr. Villeneuve just referenced.
In terms of who performs the test, I'll defer that to others.
>> So, this is Julie Villeneuve.
Again, I encourage you to read the instructions for use
from the manufacturer for more details.
But again, the personal protective equipment that's
outlined for anyone that manages a specimen should be consistent
for safety reasons.
And yeah. Yeah.
And again, sorry the other thing I wanted to add is
that training is required.
And the manufacturer can provide you more information
about the training associated with that test.
>> Thank you.
Next question asks do you have a recommended course of action
if the rapid test is negative,
but the patient has clinical symptoms suggestive
of Ebola infection.
>> Hi, this is Julie Villeneuve.
Regardless of the result of the rapid test, and if signs
and symptoms are associated with Ebolavirus disease
and the patient meets epidemiological risk factors,
a specimen should be tested for Ebolavirus
at the LRN laboratory.
>> Thank you.
A follow-up question on that is can that sort
of confirmatory testing be done at a hospital,
or do you recommend LRN specifically.
>> So, the CDC recommends that all
of those specimens are tested
within a Laboratory Response Network or at CDC.
>> Thank you.
Another question is regarding the need to use the RDT
since there are 69 LRN locations.
Can you explain when or what the benefit of having the RDT is.
>> So, this is Capt.
Montgomery.
The RDT I think has a lot of use
in resource constrained settings, which is being used
in DRC right now in cadaver surveillance
for safe and dignified burial.
Beyond the current setting in DRC,
we would again strongly recommend
that you use the LRN network
or CDC using the advanced molecular diagnostics.
>> Another question, similar lines is the RDT approved
for use at bedside?
>> It is a point-of-care test.
So, it could be used at bedside.
>> And our final question asks does CDC have data
on how many Ebolavirus disease diagnostic requests the agency
has received since this outbreak began?
>> We've received 49 requests and we've tested 1 to date.
>> Thank you.
And this concludes our question-and-answer session.
If you were unable to ask a question please submitted via
email to coco@cdc.gov and we will provide you
with a response from our presenters.
On behalf of COCA, I would
like to once again thank our audience for joining us today.
And I would also like to thank our presenters.
The recording of this call will be posted
within the next few days to the COCA website and available
on demand in a few days at emergency.cdc.gov/coca.
Again, that web address is emergency.cdc.gov/coca.
All continuing education protocols are issued online
through TCE online.
The CDC training and continuing education online system
at www.cdc.gov/TCEonline.
Those who participated in today's COCA call and wish
to receive continuing education should complete the online
evaluation by January 20, 2020 with the course core WC 2922.
The access code is COCA121919.
Those who will participate in the on-demand activity and wish
to receive continuing education should complete the online
evaluation between January 20, 2020 and January 21,
2022 and use course core WD2922.
The access code is COCA121919.
These instructions are also available on our coca webpage.
Please join us for our next COCA call that will be held
on Thursday, January 30, 2020 at 2 PM Eastern time.
Where the topic will HHS guidance
on patient centered dosage reduction or discontinuation
of long-term opioid analgesics.
To receive information on upcoming COCA calls
or other COCA products and services,
join the COCA mailing list by visiting the COCA webpage
at emergency.cdc.gov/coca and click
on join the COCA mailing list link.
To stay connected to the latest news from COCA before to like
and follow us on Facebook
at facebook.com/CDC clinician outreach
and communication activity.
Again, thank you for joining us
for today's webinar and have a great day.