• FluTrackers.com Inc. does not provide medical advice. Information on this web site is collected from various internet resources, and the FluTrackers board of directors makes no warranty to the safety, efficacy, correctness or completeness of the information posted on this site by any author or poster. The information collated here is for instructional and/or discussion purposes only and is NOT intended to diagnose or treat any disease, illness, or other medical condition. Every individual reader or poster should seek advice from their personal physician/healthcare practitioner before considering or using any interventions that are discussed on this website. By continuing to access this website you agree to consult your personal physican before using any interventions posted on this website, and you agree to hold harmless FluTrackers.com Inc., the board of directors, the members, and all authors and posters for any effects from use of any medication, supplement, vitamin or other substance, device, intervention, etc. mentioned in posts on this website, or other internet venues referenced in posts on this website.
  • We are not asking for any donations. Do not donate to any entity who says they are raising funds for us.

Discussion thread: H5N1 avian flu in US dairy cows including human cases (poultry, dairy workers) - March 24, 2024 +

Also, just thinking out loud.. If the pasteurised milk has fragments of virus in it, but it is not viable, would this safe exposure cause a serological response in anyone that drinks it? Looking at the last person to catch the virus in the US, their response to it was not that bad at all. One would think that, if the farmer was drinking the milk, it may have given him pre exposure and one would also think that if the cows had pre exposure from the birds / chickens on the farm, they wouldn't have a bad response to it either.

Just thinking here, I am not a virologist either. If this was to be correct, though, the authorities might let everyone just drink the milk and the US population would survive a pandemic better than any other... In the UK, at least, they are not testing at all. Of course, I could be way off and often I am..

It would be interesting to do serological testing on the general public.
 
Texas veterinarian helps crack the mystery of bird flu in cows

JONEL ALECCIA
THE ASSOCIATED PRESS
PUBLISHED 55 MINUTES AGO


The first calls that Dr. Barb Petersen received in early March were from dairy owners worried about crows, pigeons and other birds dying on their Texas farms. Then came word that barn cats – half of them on one farm – had died suddenly.

Within days,.....
The samples tested positive for a bird flu vi...
At the same time, on almost every farm with sick animals, Petersen said she saw sick people, too.

“We were actively checking on humans,” Petersen said. “I had people who never missed work, miss work.”

.......

Daskalakis said CDC has seen no unusual flu trends in areas with infected cows, but some experts wonder if anecdotal reports of sick workers mean more than one person caught the virus from the animals.

Petersen said some workers had symptoms consistent with flu: fever and body aches, stuffy nose or congestion. Some had conjunctivitis, the eye inflammation detected in the Texas dairy worker diagnosed with bird flu.

Dr. Gregory Gray, an infectious disease epidemiologist at the University of Texas Medical Branch in Galveston, has been taking samples from livestock and people on two Texas farms. On farms with confirmed cattle infections, there have also been reports of mild illnesses among the workers, he said.

His research has been difficult. .....
Without confirmation, no one knows if the sick workers were infected with the bird flu virus or something unrelated, Gray said.

“They seem to be linked in time and space, so one would say it’s biologically plausible,” said Gray.

Some of the workers who fell ill sought treatment and were offered oseltamivir, an antiviral drug sold under the brand name Tamiflu, Petersen said.

Some farm workers who were exposed to infected animals or people were offered the medication, CDC spokesman Jason McDonald said. State health officials are responsible for evaluating and providing treatment, according to federal guidelines.

Health officials in Texas provided Tamiflu to the person known to be infected with H5N1 and family members, plus two people on a second dairy farm who were exposed to infected animals, said Chris Van Deusen, a spokesman for the Texas Department of State Health Services. He said he wasn’t sure if others had been offered the antiviral.

Farmers have been hesitant to allow health officials onto their land, said Dr. Kay Russo, a Colorado veterinarian who consulted about the outbreak with Petersen.

“This particular disease is looked at as a scarlet letter,” Russo said. “It has this stigma associated with it right now.”

Russo called for wider testing of cattle, people and milk.

“We do not know what we do not measure,” she said. “Unfortunately, the horse left the barn and took off a lot faster than we were able to mobilize.”

.....

The reluctance of workers and farmers to allow testing is “greatly hampering” understanding of how the virus spreads, how large the outbreak is now and how quickly it may grow, Gray said.

“It’s a negative, very negative, effect,” he said.....:tiphat:

https://www.theglobeandmail.com/wor...helps-crack-the-mystery-of-bird-flu-in-cows/​
 
Scientists call new measures to control bird flu in cows ‘a drop in the bucket’

As restrictions take effect, new data show virus is pervasive in herds
Too little and too late—that’s how many scientists see a set of measures ordered by the U.S. Department of Agriculture (USDA) to slow the unprecedented outbreak of the H5N1 avian influenza virus in dairy cows. The order, which took effect on 29 April, 1 month after the first reported cases, bans the transport of infected cows from state to state. But with the virus already infecting farms in at least nine states, “It’s a drop in the bucket,” says evolutionary biologist Mike Worobey of the University of Arizona.

Scientists are also troubled by the lack of widespread testing for the virus, a strain known as clade 2.3.4.4b that has devastated birds and some wild mammals. “We are still looking under streetlights,” Lauren Sauer, a health emergencies researcher at the University of Nebraska Medical Center, told a briefing organized by Brown University on 26 April. “We’re not looking where we don’t already see indicators that the virus is there, and that never gives us enough information.”
​.......
A unpublished study by Andrew Bowman of Ohio State University and colleagues suggests the virus is already very widespread. They used the ultrasensitive polymerase chain reaction (PCR) to look for genetic material from the virus in 150 samples of commercial milk from 10 states and found that 58 tested positive. “There’s a lot more virus out there than we’ve given it credit for,” Bowman says.

.....
have been testing samples from 190 wastewater plants in 41 states for influenza A, the type to which H5N1 and some human flu strains belong. They saw the seasonal wave caused by human flu subside in February, but a new wave began in March or April at 44 wastewater plants across 18 states.

The team also analyzed samples from three wastewater plants in Texas near known dairy outbreaks and found high levels of a marker for H5N1. They think the virus likely came from effluents from processing plants for milk or beef. The marker was not present in samples taken before March.
​......

​​​​​​Scientists say much more could be done. “At milk processing plants, every incoming tanker load of milk is checked for adulterants, including antibiotics, and quality and safety standards,” says veterinarian Kay Russo, who played a key role in the first detection of H5N1 at dairy farms. Testing for H5N1 as well could reveal “the pervasiveness of this virus almost overnight.”

.....

​​​​​​ Microscopic analysis of tissue from sick cows showed the virus infects cells in the alveoli, the millions of tiny milk-producing sacs in udders. That explains the very high levels of virus shed in the milk, the authors say....

​​​​​​Scientists worry about H5N1’s next moves. Experiments at Richt’s lab have shown that pigs can easily become infected with a different 2.3.4.4b virus. Although it does not grow well in pigs, Richt shares the long-standing concern that pigs can serve as “mixing vessels,” in which avian viruses can reassort with other influenza viruses to produce new, more transmissible strains that could also infect humans. “That’s the danger,” he says.

:tiphat:
​​​​​​https://www.science.org/content/art...m_source=Twitter&utm_campaign=NewsfromScience
 
from post #123 above:
  • Petersen said some workers had symptoms consistent with flu: fever and body aches, stuffy nose or congestion. Some had conjunctivitis, the eye inflammation detected in the Texas dairy worker diagnosed with bird flu.
Click to expand...
  • ​ .....now we need to check on family and friends, of those farm workers... let's keep a spotlight on that aspect.
 
Raj Rajnarayanan
@RajlabN
·
3h
#H5N1 #Preliminary Updates Had a quick look at the 87 sequences uploaded (4/29/24) by
@USDA
#NVSL 10 #Cattle, 1 #Pigeon & 2 #Cat sequences have PB2 M631L (+M676A) - likely related to the recent Dairy Cattle Outbreak 6 #Skunk & 6 #Turkey seqs have PB2 E627K (+M676T)


Raj Rajnarayanan
@RajlabN
·
3h
PB2 M676 is mutated to 676T in ~82% of the 87 samples (which also includes E627K adaptation signature in the Skunks/Turkeys); rest of the sequences have 676A (which also includes M631L adaptation signature in Cattle, Pigeon & Cats) Hope we get metadata with dates/location​

​
 
Last edited:
Avian flu: Time to rethink on-farm surveillance?

By Thomas Gremillion on May 2, 2024
— OPINION —

The spread of bird flu to dairy cows, along with the discovery of viral fragments in 20 percent of retail milk samples, has turned an outbreak that long vexed poultry farmers into a source of stress for consumers. The situation is fraught with uncertainty as researchers’ understanding of the virus evolves, along with the virus itself. On one point, however, the evidence is in: the U.S. needs better surveillance of pathogens on large livestock farms.

As of this writing, the Centers for Disease Control and Prevention has reported confirmed cases of the highly pathogenic avian influenza virus A(H5N1) in domestic livestock in nine states. The virus is “highly pathogenic” to birds, and to many other animals, including seals, but for now, CDC says the risk of infection to the general public “

…..H5N1 bird flu virus was first detected in 1996, it went on to infect nearly a thousand people with over a 50 percent death rate. In 2009, an avian influenza virus that jumped to pigs—swine flu—caused an estimated 12,469 ……

lethality in wild life populations, and its widespread transmission between many species of mammals, including dairy cows, have raised concerns.

Exposure to infected dairy cows presumably caused the most recently confirmed case of human illness, reported by Texas officials on April 1. An earlier 2022 case, in Colorado, involved exposure to infected poultry. Both of those cases were reportedly mild. But influenza viruses are notorious for shapeshifting. The risk of A(H5N1) morphing into a pathogen that spreads easily between humans…….,

Unfortunately, we are missing a critical component of that surveillance — on the farm. Authorities with USDA’s Animal and Plant Health Inspection Service (APHIS) have issued an …….

authorities should be pulling samples from other species, particularly pigs, which many experts see as a critical bridge between flu viruses that kill birds and people.

more at....

​:tiphat:
https://www.foodsafetynews.com/2024/05/avian-flu-time-to-rethink-on-farm-surveillance/
 
Last edited by a moderator:
The U.S. may be missing human cases of bird flu, scientists say


MAY 2, 2024 10:01 AM ET
By

Will Stone
​
Officially, there is only one documented case of bird flu spilling over from cows into humans during the current U.S. outbreak.

But epidemiologist Gregory Gray suspects the true number is higher, based on what he heard from veterinarians, farm owners and the workers themselves as the virus hit their herds in his state.

"We know that some of the workers sought medical care for influenza-like illness and conjunctivitis at the same time the H5N1 was ravaging the dairy farms," says Gray, an infectious disease epidemiologist at the University of Texas Medical Branch in Galveston.

"I don't have a way to measure that, but it seems biologically quite plausible that they too, are suffering from the virus," he says.


.......

​​​​​​Still, epidemiologists say it's critical to track any possible cases. They're concerened some human infections could be flying under the radar, especially if they are mild and transient as was seen in the Texas dairy worker who caught the virus.

"I think based on how many documented cases in cows there are, probably some decent human exposure is occurring," says Dr. Andrew Bowman, associate professor of veterinary preventive medicine at The Ohio State University. "We just don't really know."
​
​​​​​​ Limited testing raises concerns


There have been 36 herds affected in nine states. Local and state health departments have tested about 25 people for the virus and monitored over 100 for symptoms, federal health officials said at a briefing on Wednesday.
​
​​​​​​These people are in "the footprints of where the bovine detections are," says Dr. Demetre Daskalakis, who's with the Centers for Disease Control and Prevention, although he didn't provide details on the actual locations.

"There's a very low threshold for individuals to get tested," he adds.

...........

"If the idea was to try to identify where there was spillover from these facilities to human populations, you'd want to try to test as many workers as possible," says Leibler, ....
Also, notes Gray, the virus is probably much more geographically widespread in cattle than the reported cases show, "possibly spilling over much more to humans than we knew, or then we know."

.......
​
​​​​​​"Some of the dairy herds seem to have clinically normal animals, but potentially infected and [that] makes it really hard to know where to do surveillance," says Bowman. Calls for proactive steps to track down possible human cases


.....

"I worry that if we wait until we see a spike in those systems that perhaps we would already be seeing much more widespread community transmission," says Dr. Mary-Margaret Fill, deputy state epidemiologist for the Tennessee Department of Health. Instead she says there should be proactive testing.

Fill notes there are anecdotes about farmworkers with mild illness while working with cattle in some of the areas where the virus has spread and "not enough visibility on the testing that's happening or not happening in those populations to understand what might be going on."

To get ahead of the virus, Leibler says not only do workers need to be screened but also their family members and others in the community, in the event that the virus does evolve to spread easily among humans.

..............
​​​​​​
Gray says it can be hard to detect and measure the illness in these rural workers for many reasons — their remote location, a reluctance to seek out health care, a lack of health insurance, concerns about immigration status, and a reticence among farmers "to wave the flag" that there are infections.

The farms he works with consider protecting workers and curbing the spread of this virus "a huge priority," but right now they bear all the risks of going public, he says.

Dr. Fred Gingrich says this is a major barrier to closer cooperation between federal health officials and the industry during the current crisis.

Dairy cattle farmers currently don't get compensated for reporting infections in their herds — unlike poultry farmers who receive indemnity payments for losses related to culling birds when they find cases, says Gingrich, executive director of the American Association of Bovine Practitioners.

"So what is their incentive to report?" he says, "It's the same virus. It just doesn't kill our cows."

....

What concerns him most is the possibility the outbreak could wind up at another kind of farm.

"We know when it hits the poultry farms because the birds die, but the pigs may or may not manifest severe illness," he says, "The virus can just churn, make many copies of itself and the probability of spilling over to those workers is much greater."
​:tiphat:
​​​​​​https://www.npr.org/sections/health...issing-human-cases-of-bird-flu-scientists-say
 
Romney Calls for Action to Stop Rapid Spread of Bird Flu Virus

In letter to FDA, USDA, and CDC, Senator urges interagency effort to quickly understand and contain outbreak

WASHINGTON—U.S. Senator Mitt Romney (R-UT), member of the Senate Health, Education, Labor, and Pensions (HELP) Committee, today sent a letter to U.S. Food and Drug Administration (FDA) Commissioner Robert Califf, U.S. Department of Agriculture (USDA) Secretary Tom Vilsack, and U.S. Centers for Disease Control and Prevention (CDC) Director Mandy Cohen raising concern with the agencies’ inaction to understand and contain the outbreak of the bird flu virus (H5N1)—especially given the lessons learned from the COVID-19 pandemic and recent baby formula shortage. In the letter, Romney calls on the agency heads to work swiftly to fill existing gaps in public health knowledge and quickly disseminate accurate information to reassure the American public that they remain safe.

“I am alarmed by reports about the rapid spread of the bird flu virus (H5N1), and concerned that your agencies are not moving quickly enough to understand and contain the outbreak. It is critical that you work swiftly to get ahead of this emerging situation and reassure the American public that they—and our food supply—remain safe,” Senator Romney wrote. “Given your agencies’ recent experience with the COVID-19 pandemic and baby formula shortage, I am concerned that once again our federal government and its interagency process appears to be caught flat-footed.”

“The responsibility of protecting American consumers and livestock from threats like bird flu is a joint effort between the USDA, the FDA, and the CDC,” Romney continued. “Critical questions remain unanswered regarding the transmission and spread of the virus, requirements for testing livestock, and the safety of our milk and beef supply in the United States.”

The full text of the letter can be found below....

....Please submit your agency’s responses to the following questions as soon as possible, and no later than May 10, 2024.
  1. What specific steps are your agencies currently taking to contain the bird flu outbreak and ensure it does not spread further among humans?
  2. Are your agencies confident that the commercial milk and beef supply is safe for consumption? If not, what additional testing is necessary to confirm that this is the case and when will that testing be completed?
  3. What risks do the high levels of inactivated virus found in milk pose to humans? Could the virus be reactivated?
  4. USDA is currently only mandating testing in lactating cattle prior to interstate transport.
    1. Why has USDA limited testing only prior to interstate transport?
    2. What percentage of dairy cattle are not transported across state lines? Are the current testing requirements missing a critical percentage of infected cattle and allowing the outbreak to spread?
    3. USDA announced that it is testing beef samples, but only in states with confirmed outbreaks. Given confirmed asymptomatic infections and other indications that the outbreak may be more widespread than we know, why is USDA not rapidly testing beef in all 50 states?
  1. Are USDA, FDA, and CDC conducting proactive, joint surveillance and sharing information across agencies to proactively detect unusual bird flu activity in wild animals, livestock, or humans? Are there federal programs, like the CDC’s National Wastewater Surveillance System (NWSS), that are tracking or have the capacity to track existing and emerging infectious diseases on farms?
  3. What steps are you taking to proactively inform and protect agricultural frontline workers on H5N1 precautionary measures, actions needed in the case of an exposure, and symptoms?
  4. Federal researchers have identified a genetic mutation in a recently confirmed case of bird flu in a dairy cow that suggests the current strain of H5N1 in the U.S. has adapted to spread better in mammals.
    1. Which federal agencies are currently conducting assessments on the capability of H5N1 to continue mutating and present increased risk to humans?
    2. Are studies being conducted on the likelihood of genetic adaptation that allows for human-to-human transmission?
​:tiphat:
​​​​​​https://www.romney.senate.gov/romney-calls-for-action-to-stop-rapid-spread-of-bird-flu-virus/
 
EPISODE 156 Podcast

OSTERHOLM UPDATE

Episode 156: H5N1: An Impending Crisis?

May 2, 2024

In "H5N1: An Impending Crisis," Dr. Osterholm and Chris Dall discuss the spread of H5N1 avian influenza in US
dairy cows, cover the latest COVID-19 trends, review two articles on long COVID, and answers a listener question about the safety of raw milk and other dairy products. Dr. Osterholm also shares a timely "This Week in Public Health History" segment and interviews the final two members of the podcast team.
​...:tiphat:
https://www.cidrap.umn.edu/covid-19/episode-156-h5n1-impending-crisis
 
Tracking bird flu virus changes in cows is stymied by missing data, scientists say

By Helen Branswell
May 2, 2024
​
​​​​​​Another upload of genetic sequence data from the H5N1 bird flu outbreak in dairy cattle has exacerbated the scientific community’s frustration with the U.S. Department of Agriculture after the agency again failed to include basic information needed to track how the virus is changing as it spreads.

Like a large tranche of sequences that the USDA uploaded to a public database on April 21, this week’s data dump did not include information about where and when the sequenced samples were obtained from cows or other sequenced animals. All are simply labeled with “USA” and “2024.”..........
​:tiphat:

​​​​​​https://www.statnews.com/2024/05/02/bird-flu-in-cows-h5n1-virus-changes-missing-data/
 
Bird flu outbreak in dairy cows fails to deter US raw milk sellers

By Lisa Baertlein, Julie Steenhuysen and Tom Polansek
May 2, 20241:29 PM CST
Updated 21 hours ago

LOS ANGELES/CHICAGO, May 2 (Reuters) - U.S. sellers of raw milk appear undeterred by federal health warnings for consumers to avoid drinking unpasteurized milk in light of a bird flu outbreak that has affected dairy herds in nine states and sickened at least one dairy farm worker.

Thirty of the 50 U.S. states permit the sale of raw milk...
...
Dr. Gigi Gronvall, an immunologist at the Johns Hopkins Center for Health Security in Baltimore, said drinking raw milk is already a "crapshoot" because of the risk of diseases such as brucellosis...

"It's even riskier now. It's just not a good practice for so many reasons," Gronvall said.
...
"Our sales have never been higher," said McAfee, without providing figures.
...
Nevertheless, products from Raw Farm and its predecessor company, Organic Pastures Dairy, have been tied to outbreaks of foodborne illness. Last year, the dairy recalled raw milk after it was linked to a Salmonella outbreak that caused illness in at least 19 people in California.
...
This summer, Raw Farm will start national sales of frozen raw milk labeled for pets, McAfee said. The company's fans are already sharing social media posts about how they buy pet products to get around laws that limit raw milk sales for human consumption.
...
https://www.reuters.com/world/us/bi...ES/CHICAGO, May 2,least one dairy farm worker.
 
CDC’s top flu scientist says the risk to the public from H5N1 is low, but she isn’t sleeping well. Here’s why

​​​​​By Helen Branswell May 3, 2024
​

snip

Can I ask about your personal read on the risk here? If this virus gets seeded into the cow population and it evolves in cows, what do you think this does to the human risk from H5N1?

[Dugan grimaced.] I think it would definitely impact the risk, for sure. Our current assessment of the risk to the general public health is low. That could change. And so I think we’re remaining very vigilant — if anything, more vigilant in this space.

​
https://www.statnews.com/2024/05/03/bird-flu-why-h5n1-keeping-awake-cdc-top-flu-scientist/
 
sharon sanders said:
CDC’s top flu scientist says the risk to the public from H5N1 is low, but she isn’t sleeping well. Here’s why

​​​​​By Helen Branswell May 3, 2024
​

snip

Can I ask about your personal read on the risk here? If this virus gets seeded into the cow population and it evolves in cows, what do you think this does to the human risk from H5N1?

[Dugan grimaced.] I think it would definitely impact the risk, for sure. Our current assessment of the risk to the general public health is low. That could change. And so I think we’re remaining very vigilant — if anything, more vigilant in this space.

​
https://www.statnews.com/2024/05/03/bird-flu-why-h5n1-keeping-awake-cdc-top-flu-scientist/
Click to expand...


Apparently none of the affected states have invited the CDC in. The CDC is taking a back seat to all this.

Wow...and super groan. It appears the state industries are running the show. In small states this is a big deal. Only the larger states have the economic power to ignore a particular industry.

Thanks Helen for doing this interview. Very informative.
 
Bolding is mine

CDC A(H5N1) Bird Flu Response Update

​May 3, 2024 – CDC continues to respond to the public health challenge posed by a multistate outbreak of avian influenza A(H5N1) virus, or “A(H5N1) virus,” in dairy cows and other animals in the United States. CDC is working in collaboration with the U.S. Department of Agriculture (USDA), the Food and Drug Administration (FDA), state public health and animal health officials, and other partners using a One Health approach. Currently, one human case has been confirmed in a person with exposure to presumably infected dairy cows reported by Texas on April 1, 2024[SUP] [1][2][/SUP].

CDC’s response to this outbreak of influenza A(H5N1) virus in dairy cattle and other animals most recently includes:
  • Continuing to support states that are monitoring people with exposure to cows, birds, or other domestic or wild animals infected, or potentially infected with, avian influenza A(H5N1) viruses. Testing of symptomatic people who have exposures is being done by state or local officials, and CDC is conducting confirmatory testing when needed.
    • Monitoring and testing data are now being reported, and will be updated weekly on Fridays. Since March 2024, at least 220 people have been monitored for A(H5N1) after relevant exposures and at least 30 people have been tested.
  • Having ongoing discussions with multiple states about state-led field investigations to explore key scientific and public health questions related to the ongoing outbreak. CDC is playing a coordinating role with regard to investigation protocols so that data collection can be standardized across states and results can be pooled. In addition, CDC has multilingual and multidisciplinary epidemiological field teams ready to deploy to support on-site studies if requested.
  • Continuing work to better characterize the virus from the human case in Texas.
    • Beginning cell and animal laboratory studies, including to:
      • Learn how the virus reproduces in both human and cow respiratory tract epithelial cells and cow mammary epithelial cells.
      • Assess the severity of illness and transmissibility of the virus under different scenarios by infecting ferrets and assessing the outcome. Ferrets are used as a model for people because they get sick and spread influenza viruses in a manner similar to humans.
    • Testing human sera (blood) from people previously vaccinated with pre-pandemic A(H5) vaccines during clinical trials to see how their antibodies cross-react to the virus isolated from the human case in Texas. Data to date – including genetic analysis and testing of ferret antisera from multiple clade 2.3.4.4b candidate vaccine viruses (CVVs) (Reference table below[SUP][3][/SUP]) – suggest vaccination will offer good cross-protection against cattle outbreak viruses. (The human case in Texas was a 2.3.4.4b virus). Antigenic characterization of the virus isolated from the human case in Texas (A/Texas/37/2024) with ferret antisera produced against existing pre-pandemic CVVs confirmed clade 2.3.4.4b A(H5) CVVs have good cross-reactivity to this virus.
​Continued: https://www.cdc.gov/flu/avianflu/spotlights/2023-2024/avian-situation-update-05032024.htm
 
For the past 18 years, I've tracked the path of H5N1 and it was the boots on the ground approach that I felt was the answer for monitoring an outbreak that would be life changing to our world. Now, I find myself in the crossroads of this dangerous virus, with no direction for detecting early outbreaks. I'm just floundering, aimlessly. I never ever imagined this scenario. It seems I cannot count on the CDC, for prompt early detection. The pandemic preparation in this Country is dismal.
 
You must log in or register to reply here.
Back
Top