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How Brown University's Pandemic Tracker is filling a gap in federal health data
How Brown University's Pandemic Tracker is filling a gap in federal health data

Boston Globe

time21-07-2025

  • Health
  • Boston Globe

How Brown University's Pandemic Tracker is filling a gap in federal health data

Nuzzo told the Globe how the Pandemic Tracker, which has nearly 10,000 subscribers, has become a go-to resource for Get Rhode Island News Alerts Sign up to get breaking news and interesting stories from Rhode Island in your inbox each weekday. Enter Email Sign Up Q. The has garnered public attention. Why do you think people look to the newsletter for information? Advertisement Nuzzo: People are worried about potential threats and what it means for them. They're looking for trusted information and unfortunately these days I think people are questioning whether the information coming out of our health agencies is correct. ... One of the reasons why we are also tracking this information is because there had been … a lot of change in terms of what data federal health agencies were sharing. We decided to start going directly to state health departments for information. Advertisement Pandemic Center Director Jennifer Nuzzo at a meeting for a new edition of the Tracking Report. Foreground: Research Assistant Alice Im. Kenneth Zirkel How has data changed since COVID-19? Where I do see a difference is that the How is the information you present different than the CDC website? I don't want to give the sense something nefarious is happening. It's not nefarious. Where we have concerning discrepancies is in interpretation of data. There's a period of time where the Secretary of Health and Human Services, Robert F. Kennedy Jr., when getting questions about these Initially, the CDC was only showing a very cursory summary of measles cases. It wasn't showing the breakdown, whether they're hospitalized, or you know, the vaccination status. ... There's now better data on CDC's website, but initially there wasn't. Part of why we're doing this exercise is if something changes we're ready to fill in the gaps. Why is it so surprising that this measles outbreak is happening? United States eliminated measles in 2000. There is no good reason why any country with the technical and financial resources of the United States should have measles, period. It's not to say that other countries haven't struggled with measles outbreaks — they have — including, other high-income countries like us, but measles elimination status is determined by how quickly you respond and contain the outbreaks. Advertisement The latest Pandemic Tracker highlights measles, mpox, avian influenza, cholera, seasonal influenza, COVID-19, and pertussis. What is the importance of tracking these diseases? It's based on what's going on in the world. For instance, a few months ago, we were very actively tracking Are you seeing an influx of people who are craving good, scientific information? I think there's always going to be a role for independent expert voices. People want to hear from people in their community. I do think, now, that people are very worried about the integrity of our health agencies, about funding cuts that make it harder to do the important work and research that keeps people healthy. ... The American people, despite the headlines, trust scientists, they value scientific research, and they want more of it. On the Pandemic Tracker website, you have a program called . Talk about the global pandemic early warning system intended to 'rapidly detect future outbreaks of infectious diseases with epidemic or pandemic potential?' It's part of the Global Health Exemplars Program. We're studying really interesting approaches to surveillance in four low- and middle-income countries. What we're learning is applicable to all countries, but these are countries who are doing things with surveillance that are starting to allow them not to just understand when an outbreak happens and figure that out early, but perhaps to give them a better sense of what are the conditions that make outbreaks more likely to occur. And then, perhaps, take action to prevent them from occurring in the first place. Advertisement Can you talk a little bit about use of wastewater testing? I think one important innovation that came out of the pandemic … is wastewater surveillance and the increased understanding of it as a potential tool for monitoring infections in a community. We are now using wastewater to monitor other things: influenza, mpox, and it's now just starting to be used for measles. We have been seeing signals of measles infections in states that hadn't yet reported measles cases. This is important because we think that measles cases are being under-detected in the US and wastewater data is giving us even more indication of that. On the site there is a 'testing playbook' for biological emergencies. Can you share more about preparedness and response to these emergencies? If we have to think of what's the single biggest thing that went wrong in the US response to COVID, it was that we didn't quickly establish and scale up the availability of testing. It was a well-acknowledged challenge and yet in 2022 when the mpox outbreaks started happening in the United States, yet again, we were hearing clinicians saying, 'I can't get my patient tested.' There were tests available, but it just wasn't where the patients were. We decided to write the testing playbook to better clarify the different approaches to testing to give busy decision-makers a better set of questions to be asking in response to a biological emergency. Advertisement Here are a few ways to follow Brown University SPH's Pandemic Tracker: Pandemic Center Pandemic Center Tracking Report Newsletter This interview has been edited for length and clarity. The Boston Globe's weekly Ocean State Innovators column features a Q&A with Rhode Island innovators who are starting new businesses and nonprofits, conducting groundbreaking research, and reshaping the state's economy. Send tips and suggestions to reporter Alexa Gagosz at . Carlos Muñoz can be reached at

The US hasn't seen a human bird flu case in 3 months. Experts are wondering why
The US hasn't seen a human bird flu case in 3 months. Experts are wondering why

Yahoo

time20-05-2025

  • Health
  • Yahoo

The US hasn't seen a human bird flu case in 3 months. Experts are wondering why

Health officials are making a renewed call for vigilance against bird flu, but some experts are puzzling over why reports of new human cases have stopped. Has the search for cases been weakened by government cuts? Are immigrant farm workers, who have accounted for many of the U.S. cases, more afraid to come forward for testing amid the Trump administration's deportation push? Is it just a natural ebb in infections? 'We just don't know why there haven't been cases,' said Jennifer Nuzzo, director of the Pandemic Center at Brown University. 'I think we should assume there are infections that are occurring in farmworkers that just aren't being detected.' The H5N1 bird flu has been spreading widely among wild birds, poultry and other animals around the world for several years, and starting early last year became a problem in people and cows in the U.S. In the last 14 months, infections have been reported in 70 people in the U.S. — most of them workers on dairy and poultry farms. One person died, but most of the infected people had mild illnesses. The most recent infections confirmed by the Centers for Disease Control and Prevention were in early February in Nevada, Ohio and Wyoming. California had been a hotspot, with three-quarters of the nation's infections in dairy cattle. But testing and cases among people have fallen off. At least 50 people were tested each month in late 2024, but just three people were tested in March, one in April and none in May so far, state records show. Overall, the state has confirmed H5N1 infections in 38 people, none after Jan. 14. During a call with U.S. doctors this month, one CDC official noted that there is a seasonality to bird flu: Cases peak in the fall and early winter, possibly due to the migration patterns of wild birds that are primary spreaders of the virus. That could mean the U.S. is experiencing a natural — maybe temporary — decline in cases. It's unlikely that a severe human infection, requiring hospitalization, would go unnoticed, said Michael Osterholm, a University of Minnesota expert on infectious diseases. What's more, a patchwork system that monitors viruses in sewage and wastewater has suggested limited activity recently. New infections are still being detected in birds and cattle, but not as frequently as several months ago. 'Given the fact that the number of animal detections has fallen according to USDA data, it's not surprising that human cases have declined as well,' the CDC said in a statement. Dr. Gregory Gray said he wasn't concerned about the CDC not identifying new cases in months. 'I don't think that anybody's hiding anything,' said Gray, an infectious disease speicialist at the University of Texas Medical Branch in Galveston. But Osterholm and some other experts think it's likely that at least some milder infections are going undetected. And they worry that the effort to find them has been eroding. Resignations at the U.S. Department of Agriculture and the Food and Drug Administration's Center for Veterinary Medicine could slow the government's bird flu monitoring, said Keith Poulsen, director of the Wisconsin Veterinary Diagnostic Laboratory. Three of 14 experts accepted deferred resignation offers at the National Animal Health Laboratory Network, which responds to disease outbreaks with crucial diagnostic information, he said. They are among more than 15,000 USDA staff to accept the offers, an agency spokesperson said. And dozens of staff were fired at the FDA's Veterinary Laboratory Investigation and Response Network, which investigates animal diseases caused by problems including contaminated pet food. Cats in several states have been sickened and died after eating raw pet food found to contain poultry infected with H5N1. Angela Rasmussen, a virologist at the University of Saskatchewan in Canada, said 'targeted surveillance has really dropped off precipitously since Trump took office.' She wonders if immigrant farmworkers are too scared to come forward. 'I can't argue with anyone who would be risking getting shipped to a Salvadoran gulag for reporting an exposure or seeking testing,' she said. The CDC characterizes the risk to the general public as low, although it is higher for people who work with cattle and poultry or who are in contact with wild birds. Earlier this month, an agency assessment said there is a 'moderate risk' that currently circulating strains of bird flu could cause a future pandemic, but the CDC stressed that other emerging forms of bird flu has been similarly labeled in the past. Still, research is continuing. Texas A&M University scientists have collected blood samples from dairy workers in multiple states to test for signs of past H5N1 exposure, said David Douphrate, a workplace health and safety expert leading the project. The yearlong study is funded by a nearly $4 million grant from the CDC and is expected to conclude in July. Douphrate said he leveraged two decades of relationships with dairy producers and workers to gain access to the farms. 'We have had very good participation,' Douphrate said. 'They have been very willing.' Similar surveillance is 'urgently needed' among domestic cats, said Kristen Coleman, a researcher at the University of Maryland at College Park who studies emerging animal diseases. She recently released a paper reviewing bird flu in infections in cats between 2004 and 2024. Barn cats that died after drinking raw milk were one of the first signs that dairy cows were becoming infected with bird flu in 2024. Since then, the Agriculture Department has confirmed more than 120 domestic cats infected with the virus across the U.S. Infections have mostly been found in cats that died. Less is known about milder infections, whether cats can recover from bird flu — or whether the virus can spill over into people. Coleman has been collecting blood samples from cats across the U.S. to see if they have evidence of previous exposure to the virus. But the process is slow and research funding is uncertain. 'It's easy to downplay something because that's usually what humans do,' she said. 'But what we really need to be doing is ramping up.'

US hasn't seen human bird flu case in 3 months, experts wondering why
US hasn't seen human bird flu case in 3 months, experts wondering why

Time of India

time20-05-2025

  • Health
  • Time of India

US hasn't seen human bird flu case in 3 months, experts wondering why

New York: Health officials are making a renewed call for vigilance against bird flu, but some experts are puzzling over why reports of new human cases have stopped. Has the search for cases been weakened by government cuts? Are immigrant farm workers, who have accounted for many of the US cases, more afraid to come forward for testing amid the Trump administration's deportation push? Is it just a natural ebb in infections ? "We just don't know why there haven't been cases," said Jennifer Nuzzo, director of the Pandemic Center at Brown University. "I think we should assume there are infections that are occurring in farmworkers that just aren't being detected." The H5N1 bird flu has been spreading widely among wild birds, poultry and other animals around the world for several years, and starting early last year became a problem in people and cows in the US. In the last 14 months, infections have been reported in 70 people in the US - most of them workers on dairy and poultry farms. One person died, but most of the infected people had mild illnesses. The most recent infections confirmed by the Centers for Disease Control and Prevention were in early February in Nevada, Ohio and Wyoming. California had been a hotspot, with three-quarters of the nation's infections in dairy cattle. But testing and cases among people have fallen off. At least 50 people were tested each month in late 2024, but just three people were tested in March, one in April and none in May so far, state records show. Overall, the state has confirmed H5N1 infections in 38 people, none after January 14. The possible natural reason bird flu cases are down During a call with US doctors this month, one CDC official noted that there is a seasonality to bird flu: Cases peak in the fall and early winter, possibly due to the migration patterns of wild birds that are primary spreaders of the virus. That could mean the US is experiencing a natural - maybe temporary - decline in cases. It's unlikely that a severe human infection, requiring hospitalisation, would go unnoticed, said Michael Osterholm, a University of Minnesota expert on infectious diseases. What's more, a patchwork system that monitors viruses in sewage and wastewater has suggested limited activity recently. New infections are still being detected in birds and cattle, but not as frequently as several months ago. "Given the fact that the number of animal detections has fallen according to USDA data, it's not surprising that human cases have declined as well," the CDC said in a statement. Are government cuts affecting bird flu monitoring? Dr. Gregory Gray said he wasn't concerned about the CDC not identifying new cases in months. "I don't think that anybody's hiding anything," said Gray, an infectious disease specialist at the University of Texas Medical Branch in Galveston. But Osterholm and some other experts think it's likely that at least some milder infections are going undetected. And they worry that the effort to find them has been eroding. Resignations at the US Department of Agriculture and the Food and Drug Administration's Center for Veterinary Medicine could slow the government's bird flu monitoring, said Keith Poulsen, director of the Wisconsin Veterinary Diagnostic Laboratory . Three of 14 experts accepted deferred resignation offers at the National Animal Health Laboratory Network, which responds to disease outbreaks with crucial diagnostic information, he said. They are among more than 15,000 USDA staff to accept the offers, an agency spokesperson said. And dozens of staff were fired at the FDA's Veterinary Laboratory Investigation and Response Network, which investigates animal diseases caused by problems including contaminated pet food. Cats in several states have been sickened and died after eating raw pet food found to contain poultry infected with H5N1. Angela Rasmussen, a virologist at the University of Saskatchewan in Canada, said "targeted surveillance has really dropped off precipitously since Trump took office." She wonders if immigrant farmworkers are too scared to come forward. "I can't argue with anyone who would be risking getting shipped to a Salvadoran gulag for reporting an exposure or seeking testing," she said. CDC says the risk to the general public remains low The CDC characterises the risk to the general public as low, although it is higher for people who work with cattle and poultry or who are in contact with wild birds. Earlier this month, an agency assessment said there is a "moderate risk" that currently circulating strains of bird flu could cause a future pandemic, but the CDC stressed that other emerging forms of bird flu has been similarly labeled in the past. Still, research is continuing. Texas A&M University scientists have collected blood samples from dairy workers in multiple states to test for signs of past H5N1 exposure, said David Douphrate, a workplace health and safety expert leading the project. The yearlong study is funded by a nearly USD 4 million grant from the CDC and is expected to conclude in July. Douphrate said he leveraged two decades of relationships with dairy producers and workers to gain access to the farms. "We have had very good participation," Douphrate said. "They have been very willing." Similar surveillance is "urgently needed" among domestic cats, said Kristen Coleman, a researcher at the University of Maryland at College Park who studies emerging animal diseases. She recently released a paper reviewing bird flu in infections in cats between 2004 and 2024. Barn cats that died after drinking raw milk were one of the first signs that dairy cows were becoming infected with bird flu in 2024. Since then, the Agriculture Department has confirmed more than 120 domestic cats infected with the virus across the US. Infections have mostly been found in cats that died. Less is known about milder infections, whether cats can recover from bird flu - or whether the virus can spill over into people. Coleman has been collecting blood samples from cats across the US to see if they have evidence of previous exposure to the virus. But the process is slow and research funding is uncertain. "It's easy to downplay something because that's usually what humans do," she said. "But what we really need to be doing is ramping up."

The US hasn't seen a human bird flu case in 3 months. Experts are wondering why

time19-05-2025

  • Health

The US hasn't seen a human bird flu case in 3 months. Experts are wondering why

Health officials are making a renewed call for vigilance against bird flu, but some experts are puzzling over why reports of new human cases have stopped. Has the search for cases been weakened by government cuts? Are immigrant farm workers, who have accounted for many of the U.S. cases, more afraid to come forward for testing amid the Trump administration's deportation push? Is it just a natural ebb in infections? 'We just don't know why there haven't been cases,' said Jennifer Nuzzo, director of the Pandemic Center at Brown University. 'I think we should assume there are infections that are occurring in farmworkers that just aren't being detected.' The H5N1 bird flu has been spreading widely among wild birds, poultry and other animals around the world for several years, and starting early last year became a problem in people and cows in the U.S. In the last 14 months, infections have been reported in 70 people in the U.S. — most of them workers on dairy and poultry farms. One person died, but most of the infected people had mild illnesses. The most recent infections confirmed by the Centers for Disease Control and Prevention were in early February in Nevada, Ohio and Wyoming. California had been a hotspot, with three-quarters of the nation's infections in dairy cattle. But testing and cases among people have fallen off. At least 50 people were tested each month in late 2024, but just three people were tested in March, one in April and none in May so far, state records show. Overall, the state has confirmed H5N1 infections in 38 people, none after Jan. 14. During a call with U.S. doctors this month, one CDC official noted that there is a seasonality to bird flu: Cases peak in the fall and early winter, possibly due to the migration patterns of wild birds that are primary spreaders of the virus. That could mean the U.S. is experiencing a natural — maybe temporary — decline in cases. It's unlikely that a severe human infection, requiring hospitalization, would go unnoticed, said Michael Osterholm, a University of Minnesota expert on infectious diseases. What's more, a patchwork system that monitors viruses in sewage and wastewater has suggested limited activity recently. New infections are still being detected in birds and cattle, but not as frequently as several months ago. 'Given the fact that the number of animal detections has fallen according to USDA data, it's not surprising that human cases have declined as well,' the CDC said in a statement. Dr. Gregory Gray said he wasn't concerned about the CDC not identifying new cases in months. 'I don't think that anybody's hiding anything,' said Gray, an infectious disease speicialist at the University of Texas Medical Branch in Galveston. But Osterholm and some other experts think it's likely that at least some milder infections are going undetected. And they worry that the effort to find them has been eroding. Resignations at the U.S. Department of Agriculture and the Food and Drug Administration's Center for Veterinary Medicine could slow the government's bird flu monitoring, said Keith Poulsen, director of the Wisconsin Veterinary Diagnostic Laboratory. Three of 14 experts accepted deferred resignation offers at the National Animal Health Laboratory Network, which responds to disease outbreaks with crucial diagnostic information, he said. They are among more than 15,000 USDA staff to accept the offers, an agency spokesperson said. And dozens of staff were fired at the FDA's Veterinary Laboratory Investigation and Response Network, which investigates animal diseases caused by problems including contaminated pet food. Cats in several states have been sickened and died after eating raw pet food found to contain poultry infected with H5N1. Angela Rasmussen, a virologist at the University of Saskatchewan in Canada, said "targeted surveillance has really dropped off precipitously since Trump took office." She wonders if immigrant farmworkers are too scared to come forward. "I can't argue with anyone who would be risking getting shipped to a Salvadoran gulag for reporting an exposure or seeking testing,' she said. The CDC characterizes the risk to the general public as low, although it is higher for people who work with cattle and poultry or who are in contact with wild birds. Earlier this month, an agency assessment said there is a 'moderate risk' that currently circulating strains of bird flu could cause a future pandemic, but the CDC stressed that other emerging forms of bird flu has been similarly labeled in the past. Still, research is continuing. Texas A&M University scientists have collected blood samples from dairy workers in multiple states to test for signs of past H5N1 exposure, said David Douphrate, a workplace health and safety expert leading the project. The yearlong study is funded by a nearly $4 million grant from the CDC and is expected to conclude in July. Douphrate said he leveraged two decades of relationships with dairy producers and workers to gain access to the farms. 'We have had very good participation,' Douphrate said. 'They have been very willing.' Similar surveillance is 'urgently needed' among domestic cats, said Kristen Coleman, a researcher at the University of Maryland at College Park who studies emerging animal diseases. She recently released a paper reviewing bird flu in infections in cats between 2004 and 2024. Barn cats that died after drinking raw milk were one of the first signs that dairy cows were becoming infected with bird flu in 2024. Since then, the Agriculture Department has confirmed more than 120 domestic cats infected with the virus across the U.S. Infections have mostly been found in cats that died. Less is known about milder infections, whether cats can recover from bird flu — or whether the virus can spill over into people. Coleman has been collecting blood samples from cats across the U.S. to see if they have evidence of previous exposure to the virus. But the process is slow and research funding is uncertain. 'It's easy to downplay something because that's usually what humans do,' she said. 'But what we really need to be doing is ramping up.' ___ The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute's Science and Educational Media Group and the Robert Wood Johnson Foundation. The AP is solely responsible for all content.

US hasn't seen human bird flu case in 3 months, experts wondering why
US hasn't seen human bird flu case in 3 months, experts wondering why

Time of India

time19-05-2025

  • Health
  • Time of India

US hasn't seen human bird flu case in 3 months, experts wondering why

Health officials are making a renewed call for vigilance against bird flu , but some experts are puzzling over why reports of new human cases have stopped. Has the search for cases been weakened by government cuts? Are immigrant farm workers, who have accounted for many of the US cases, more afraid to come forward for testing amid the Trump administration's deportation push? Is it just a natural ebb in infections ? "We just don't know why there haven't been cases," said Jennifer Nuzzo, director of the Pandemic Center at Brown University. "I think we should assume there are infections that are occurring in farmworkers that just aren't being detected." The H5N1 bird flu has been spreading widely among wild birds, poultry and other animals around the world for several years, and starting early last year became a problem in people and cows in the US. by Taboola by Taboola Sponsored Links Sponsored Links Promoted Links Promoted Links You May Like Villas Prices In Dubai Might Be More Affordable Than You Think Villas In Dubai | Search Ads Get Quote Undo In the last 14 months, infections have been reported in 70 people in the US - most of them workers on dairy and poultry farms. One person died, but most of the infected people had mild illnesses. The most recent infections confirmed by the Centers for Disease Control and Prevention were in early February in Nevada, Ohio and Wyoming. Live Events California had been a hotspot, with three-quarters of the nation's infections in dairy cattle. But testing and cases among people have fallen off. At least 50 people were tested each month in late 2024, but just three people were tested in March, one in April and none in May so far, state records show. Overall, the state has confirmed H5N1 infections in 38 people, none after January 14. The possible natural reason bird flu cases are down During a call with US doctors this month, one CDC official noted that there is a seasonality to bird flu: Cases peak in the fall and early winter, possibly due to the migration patterns of wild birds that are primary spreaders of the virus. That could mean the US is experiencing a natural - maybe temporary - decline in cases. It's unlikely that a severe human infection, requiring hospitalisation, would go unnoticed, said Michael Osterholm, a University of Minnesota expert on infectious diseases. What's more, a patchwork system that monitors viruses in sewage and wastewater has suggested limited activity recently. New infections are still being detected in birds and cattle, but not as frequently as several months ago. "Given the fact that the number of animal detections has fallen according to USDA data, it's not surprising that human cases have declined as well," the CDC said in a statement. Are government cuts affecting bird flu monitoring? Dr. Gregory Gray said he wasn't concerned about the CDC not identifying new cases in months. "I don't think that anybody's hiding anything," said Gray, an infectious disease specialist at the University of Texas Medical Branch in Galveston. But Osterholm and some other experts think it's likely that at least some milder infections are going undetected. And they worry that the effort to find them has been eroding. Resignations at the US Department of Agriculture and the Food and Drug Administration's Center for Veterinary Medicine could slow the government's bird flu monitoring, said Keith Poulsen, director of the Wisconsin Veterinary Diagnostic Laboratory . Three of 14 experts accepted deferred resignation offers at the National Animal Health Laboratory Network, which responds to disease outbreaks with crucial diagnostic information, he said. They are among more than 15,000 USDA staff to accept the offers, an agency spokesperson said. And dozens of staff were fired at the FDA's Veterinary Laboratory Investigation and Response Network, which investigates animal diseases caused by problems including contaminated pet food. Cats in several states have been sickened and died after eating raw pet food found to contain poultry infected with H5N1. Angela Rasmussen, a virologist at the University of Saskatchewan in Canada, said "targeted surveillance has really dropped off precipitously since Trump took office." She wonders if immigrant farmworkers are too scared to come forward. "I can't argue with anyone who would be risking getting shipped to a Salvadoran gulag for reporting an exposure or seeking testing," she said. CDC says the risk to the general public remains low The CDC characterises the risk to the general public as low, although it is higher for people who work with cattle and poultry or who are in contact with wild birds. Earlier this month, an agency assessment said there is a "moderate risk" that currently circulating strains of bird flu could cause a future pandemic, but the CDC stressed that other emerging forms of bird flu has been similarly labeled in the past. Still, research is continuing. Texas A&M University scientists have collected blood samples from dairy workers in multiple states to test for signs of past H5N1 exposure, said David Douphrate, a workplace health and safety expert leading the project. The yearlong study is funded by a nearly USD 4 million grant from the CDC and is expected to conclude in July. Douphrate said he leveraged two decades of relationships with dairy producers and workers to gain access to the farms. "We have had very good participation," Douphrate said. "They have been very willing." Similar surveillance is "urgently needed" among domestic cats, said Kristen Coleman, a researcher at the University of Maryland at College Park who studies emerging animal diseases. She recently released a paper reviewing bird flu in infections in cats between 2004 and 2024. Barn cats that died after drinking raw milk were one of the first signs that dairy cows were becoming infected with bird flu in 2024. Since then, the Agriculture Department has confirmed more than 120 domestic cats infected with the virus across the US. Infections have mostly been found in cats that died. Less is known about milder infections, whether cats can recover from bird flu - or whether the virus can spill over into people. Coleman has been collecting blood samples from cats across the US to see if they have evidence of previous exposure to the virus. But the process is slow and research funding is uncertain. "It's easy to downplay something because that's usually what humans do," she said. "But what we really need to be doing is ramping up."

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