HCMSG - Hepatitis C Mentor & Support Group, Inc.
Search
  • About Us
    • Our Mission
    • Board of Directors
    • Medical Advisors
  • Resources
    • Corona Virus
    • Hep C Facts & Stats
    • Medications and Treatments >
      • Patient Assistance Programs
    • Reading
    • Links
  • Programs/Training
    • The Circle Model >
      • THE CIRCLE Registration
      • Group and Facilitator Guide
    • Hepatitis C Online Training
    • The Hepatitis C Education and Support Group Assistance Program
    • Healthcare Provider Training
  • Newsletter
  • Blog
  • Support Us
    • Holiday 2020
  • Contact Us

 Half Of Hepatitis C Patients Face Major Health Risks Because of  Incomplete Testing-CDC Report

5/16/2013

5 Comments

 


  
About 3 million Americans are infected with hepatitis C, according to CDC statistics, and up to
  75 percent of them have no idea. "Hepatitis C has few noticeable symptoms, and left undiagnosed
 it threatens the health of far too many Americans -- especially  baby boomers," Dr. John Ward, director
of CDC's Division of Viral Hepatitis,  said in the news release. "Identifying those who are currently
infected is  important because new effective treatments can cure the infection
better than  ever before, as well as eliminate the risk of transmission to
others." Only 51  percent of people in the U.S. who test positive for hepatitis
C received the  necessary follow- up to determine if they require medical care,
that is a viral  load test called HCV-RNA, according to the Centers for Disease
Control and  Prevention. The HCV-RNA viral load test tells one exactly how much,
if any,  virus is in the blood. A significant percent of individuals who have
been  exposed to HCV & thus would test positive to an HCV antibody test can
clear  HCV spontaneously but they need the HCV RNA test to determine this and
determine  if they need to followup by seeing a care provider, a doctor or nurse
who  specializes in hepatitis C care & treatment, today most major hospitals
have  a special hepatitis clinic that provides care & treatment, or smaller
  clinics can run the test, its just an ordinary blood test, and refer you to a
  specialist for care. The follow-up test, called an RNA test, determines whether
  a patient is infected and requires medical treatment. About 20 percent of
people  with antibody-positive tests clear the virus on their own, but most
remain  infected and go on to have health problems, the CDC said. Although this
report  as does the CDC in general refer to this disease, HCV, as one affecting
'baby  boomers': "persons were most likely to have been born during 1945-1965
(58.5% of  those who were HCV antibody positive only; 67.2% of those who were
HCV RNA  positive), and "The highest percentage of these deaths occurred among
persons  aged 50-59 years (44.8%), and most deaths (71.5%) were among those born
during  1945-1965, compared with other years". It is a fully characterize who
can be  affected, it is important to realize 30-50% are not from the baby boomer
  generation......Baby boomers, in fact, are five times more likely to have
  hepatitis C, according to the CDC. The disease is spread mostly through contact
  with infected blood, and some adults may have gotten infected before widespread
  blood screening was enforced in 1992. Other high-risk groups that should get
  tested include people who received blood products with clotting factor prior to
  1987, people with HIV, people who have been on kidney dialysis for several
  years, health and public safety workers who have been struck with a needle or
  people who have injected drugs -- even if it was only once a long time ago, and
  sexual transmission is possible although it occurs infrequently & the risk
  is low, sexual transmission can be facilitated when one sex partner has an STD
  which includes HIV.

"Many people who test
positive  on an initial hepatitis C test are not receiving the necessary
follow-up test to  know if their body has cleared the virus or if they are still
infected," CDC  Director Dr. Tom Frieden said in an agency news release.
"Complete testing is  critical to ensure that those who are infected receive the
care and treatment  for hepatitis C that they need in order to prevent liver
cancer and other  serious and potentially deadly health consequences."


"Identifying those who are currently infected is important
because new  effective treatments can cure the infection better than ever
before, as well as  eliminate the risk of transmission to others," said John
Ward, M.D., director of  CDC's division of viral hepatitisTwo rounds of testing
are needed to confirm a  diagnosis of hepatitis C. The first stage checks to see
if a person has mounted  a immune response to the virus. When this happens, a
person will produce  antibodies that recognize the germ, and these antibodies
can be detected by a  medical test.This immune response can sometimes clear the
virus in two out of 10  cases, but the majority - 3 million Americans - will
establish permanent  infections. These can only be confirmed by a follow-up
genetic screening for the  virus' RNA.Of 200,000 new hepatitis cases surveyed
for this study, over half  failed to return to their doctor's office for this
second genetic test.In  response to these findings, the CDC is issuing updated
guidelines for health  care providers on hepatitis C testing.One recommendation
is that baby boomers,  who are defined as patients born from 1945 through 1965,
and all persons at risk  should ask their doctor, nurse, or other health care
provider about getting  tested for hepatitis C."Hepatitis C has few noticeable
symptoms, and left  undiagnosed it threatens the health of far too many
Americans - especially baby  boomers," said Dr. Ward.

"You
may not remember  everything that happened in the '60s and '70s, but your liver
does," Thomas  Frieden, the director of the CDC said today in a conference call
with reporters.  "The bottom line here is if you're born between those years,
get tested."  .......Authorities say many people in the targeted group may have
been infected  in their teens and 20s, either through blood transfusions or with
experimental  drug use, and don't know they have the virus. Hepatitis C often
shows no  symptoms while it damages the liver.

Vital Signs:  Evaluation of Hepatitis C Virus Infection Testing
and Reporting - Eight U.S.  Sites, 2005-2011

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm62e0507a1.htm?s_cid=mm62e0507a1_w
  Early Release
May 7, 2013 / 62(Early Release);1-5

Abstract

Background:
Hepatitis C  virus (HCV) infection is a serious
public health problem. New infections  continue to occur, and morbidity and
mortality are increasing among an estimated  2.7-3.9 million persons in the
United States living with HCV infection. Most  persons are unaware of their
infection status. Existing CDC guidelines for  laboratory testing and reporting
of antibody to HCV do not distinguish between  past infection that has resolved
and current infection that requires care and  evaluation for treatment. To
identify current infection, a test for HCV RNA is  needed.

Methods: Surveillance data reported  to CDC from eight U.S.
sites during 2005-2011 were analyzed to determine the  proportion of persons
newly reported on the basis of a positive test result for  HCV infection.
Persons reported with a positive result from an HCV antibody test  only were
compared with persons reported with a positive result for HCV RNA and  examined
by birth cohort (1945-1965 compared with all other years), surveillance  site,
and number of reported deaths. Annual rates of persons newly reported with  HCV
infection in 2011 also were calculated for each site.

Results:
Of 217,755 persons newly reported, 107,209 (49.2%)  were HCV antibody positive
only, and 110,546 (50.8%) were reported with a  positive HCV RNA result that
confirmed current HCV infection. In both groups,  persons were most likely to
have been born during 1945-1965 (58.5% of those who  were HCV antibody positive
only; 67.2% of those who were HCV RNA positive).  Among all persons newly
reported for whom death data were available, 6,734  (3.4%) were known to have
died; deaths were most likely among persons aged 50-59  years. In 2011, across
all sites, the annual rate of persons newly reported with  HCV infection
(positive HCV antibody only and HCV RNA positive) was 84.7 per  100,000
population.

Conclusions: Hepatitis C  is
a commonly reported disease predominantly affecting persons born during
  1945-1965, with deaths more frequent among persons of relatively young age. The
  lack of an HCV RNA test for approximately one half of persons newly reported
  suggests that testing and reporting must improve to detect all persons with
  current infection.

Implications for Public
Health:  In an era of continued HCV transmission and expanding options for
curative  antiviral therapies, surveillance that identifies current HCV
infection can help  assess the need for services and link persons with infection
to appropriate care  and treatment.

Introduction

In the United
States, hepatitis C virus (HCV) infection is a common  bloodborne infection.
Based on data from national surveys, an estimated 3.2 (95%  confidence interval
[CI] = 2.7-3.9) million persons in the United States are  living with hepatitis
C (1). Once infected, approximately 80% of persons remain  infected (i.e.,
chronically infected) and are at risk for substantial morbidity  and mortality
in later life (2). Although treatment can be curative, an  estimated 45%-85% of
infected persons are unaware of their HCV infection (3).  HCV infection is a
major cause of liver disease, including cirrhosis and liver  cancer (4-7), and
in the United States, is the leading indication for liver  transplantation (8).
Moreover, rates of liver cancer and deaths from HCV  infection have increased
over time; approximately 15,000 HCV-associated deaths  were recorded in 2007
(4,9). In addition, considerable costs are associated with  HCV infection, both
in lost productivity and health-care expenditures (10-11).  CDC guidelines for
HCV laboratory testing and reporting, published in 2003, do  not focus on
identifying persons with current infection (12); therefore,  depending on the
HCV test used, reports to surveillance programs can include  persons with a test
result indicating past HCV infection that has resolved and  also persons with a
test result that identifies current HCV infection. Analysis  of state and local
surveillance data can be used to assess the proportion of  persons who might
need additional testing to discriminate previous resolved  infection from
current infection. Analysis of such data also can estimate the  number of
persons with current HCV infection requiring clinical assessment for  treatment,
as well as guide prevention strategies. In addition, these  surveillance data
can serve as a baseline for indirectly evaluating use of the  recent HCV testing
recommendations to identify HCV infection among persons born  during 1945-1965,
a group that demonstrates the highest prevalence of infection,  compared with
those born in other years (3). Finally, examining mortality  patterns among
persons reported with current HCV infection can improve  understanding of the
natural history of the disease.

Methods

In 2011, CDC
supported  surveillance for HCV infection at eight U.S. sites (Colorado,
Connecticut,  Minnesota, New Mexico, New York City, New York state, Oregon, and
San  Francisco). CDC began receiving data in 2005 from four sites (Colorado,
  Minnesota, New York state and Oregon), one site in 2006 (New Mexico), two sites
  in 2008 (New York City and San Francisco), and one site in 2009 (Connecticut).
  For all sites, clinical laboratories reported only positive test results of HCV
  infection (i.e., from HCV antibody testing or from HCV RNA testing); health
  departments did not require reporting of negative results.

Reports were reviewed and de-duplicated to ensure that persons with
  newly reported positive HCV test results were included only once in the
  surveillance database.

For this analysis,
persons  reported to CDC during 2005-2011 were categorized as 1) reported with
only a  positive test result for HCV antibody (HCV antibody positive only) or 2)
  reported with a positive HCV RNA result from HCV nucleic acid testing or HCV
  genotyping (HCV RNA positive). Persons who tested HCV antibody positive only
  were considered as having had a past HCV infection that had resolved, a
  false-positive test result, or current HCV infection. Persons who tested HCV
RNA  positive were considered currently HCV infected. Although no laboratory
test  exists to distinguish acute from chronic HCV infection, for the purpose of
this  study all persons determined to be currently infected were considered to
have  chronic infection.

Each group (HCV
antibody positive  only and HCV RNA positive) was examined by birth cohort
(1945-1965 compared with  all other birth years) and surveillance site. Annual
rates of all persons newly  reported per 100,000 population in 2011 also were
calculated for each site using  denominators available from U.S. Census
population estimates (available at  http://www.census.gov/compendia/statab). In
addition, seven of the sites  reported the frequency of known deaths from any
cause among persons newly  reported with HCV infection. Sites matched their
hepatitis C databases with  vital records at the person level. Death status was
examined by sex, age group,  birth cohort, and type of test result (HCV antibody
positive only or HCV RNA  positive).




Results

During 2005-2011,  among the eight sites, a total of 217,755 persons
were newly reported with a  positive test result for HCV infection. Of these,
107,209 (49.2%) were HCV  antibody positive only and 110,546 (50.8%) were HCV
RNA positive. In both  groups, persons were more likely born during 1945-1965.
Persons born during  these years accounted for 58.5% of those who were HCV
antibody positive only and  67.2% of those who were HCV RNA positive (Table 1).


The distribution of persons reported on the
basis of positive HCV  antibody only varied by site, ranging from 76% in New
Mexico to 23% in Minnesota  (Figure). Among sites reporting deaths, 6,734 (3.4%)
of 197,844 persons newly  reported with HCV infection were known to have died.
The highest percentage of  these deaths occurred among persons aged 50-59 years
(44.8%), and most deaths  (71.5%) were among those born during 1945-1965,
compared with other years. The  percentage of deaths among persons reported with
HCV antibody positive only  (4.6%) was significantly higher than among those
reported as HCV RNA positive  (2.4%; p<0.01). In 2011, the annual rate of all
persons newly reported with  HCV infection (positive HCV antibody only and HCV
RNA positive) across all sites  was 84.7 per 100,000 population (range: 36.0 in
Minnesota to 239.2 in San  Francisco) (Table 2).

Conclusions and  Comment

These data show that approximately one  half of persons newly
reported with HCV infection to state or local authorities  at eight surveillance
sites did not have a report of a positive HCV RNA test;  thus, it was not
possible to determine whether the reports indicated past  resolved HCV infection
or current HCV infection. Previous studies have shown  similar results. A
separate analysis of surveillance data reported for 2006-2007  found that 47.3%
of persons reported with positive HCV antibody did not have HCV  RNA test
results (13). A multisite cohort study of patients in care for chronic  viral
hepatitis revealed that 37.7% of 9,086 patients with a positive HCV  antibody
test during 2006-2008 had no documented follow-up testing for HCV RNA  (14). A
retrospective study of HCV antibody testing in selected U.S.  primary-care
settings among persons born during 1945-1965 found that, among  patients who
were antibody positive, 32% received no follow-up HCV RNA testing  (15). In New
York City, 33% of persons reported through routine surveillance did  not have
HCV RNA testing (16).

Given these findings  and
recent developments in both HCV testing technologies and clinical care for
  persons with HCV infection, CDC is amending the guidelines for HCV laboratory
  testing and result reporting that have been in use since 2003 (12). In guidance
  accompanying this Vital Signs report, CDC recommends following a positive HCV
  antibody test with HCV RNA testing (17). This guidance is also consistent with
  that provided in the 2012 HCV testing recommendations for persons born during
  1945-1965 (3). The new guidelines will help identify persons with current HCV
  infection and provide the data necessary to link those who are infected to
care,  including preventive services, medical management, and evaluation for
antiviral  treatment.

An unexpected result was
the finding of a  significantly greater percentage of deaths among persons who
were HCV antibody  positive only compared with those who were HCV RNA positive.
Because persons in  the latter group have demonstrated current infection, they
would be expected to  fare less well than those who were HCV antibody positive
only and might or might  not be currently infected. The difference between the
groups in the percentage  of deaths might be explained by health-care access.
HCV RNA testing might not be  available in sites providing HCV antibody testing
and RNA testing requires  successful referral to a health-care provider. Thus,
this finding could suggest  that persons reported on the basis of a positive HCV
antibody test only might  have had less opportunity to access health care or
might have accessed health  care less often than those with current
infection.

This study also revealed a high rate
of reported HCV infection at  these U.S. sites, especially among persons born
during 1945-1965. These findings  reinforce recent CDC recommendations for HCV
antibody testing of persons born  during 1945-1965, and linkage to care for
those with a follow-up positive result  after HCV RNA testing (3). These data
further showed that deaths were more  likely among persons aged 50-59 years and
among persons born during 1945-1965  compared with those born in other years,
illustrating the important impact of  HCV infection on years of life lost.

The findings in  this report are subject to at
least five limitations. First, state and local  health departments only report
positive HCV test results to CDC.

Thus, it was
not known whether persons who were  reported HCV antibody positive only might
actually have been tested for HCV RNA  with a negative result. Another
possibility is that HCV RNA testing was  performed with a positive result, but
was not reported. Second, some positive  HCV antibody test results might have
been false-positives. However, the high  specificity of 3rd generation HCV
antibody assays used during the period of  study would have minimized the number
of false positives (18). Third, among  sites, there was variation in reporting
by health-care providers, laboratories,  and health departments, which might
affect the consistency of the information  reported. For example, the
Connecticut hepatitis C surveillance system did not  enter HCV RNA results for
persons reported with a positive antibody test that  previously had been
confirmed to be positive for antibody to HCV by another  laboratory test.
Fourth, some sites began reporting surveillance data to CDC in  2006 or 2008,
and in one case, 2009, thereby underestimating the number of cases  reported
during the entire 2005-2011 study period. In contrast, the number of  deaths
reported was from all-cause mortality, and therefore was likely an
  overestimation of HCV-attributable mortality. Finally, HCV surveillance data
  might not be representative of all persons with HCV infection, and the findings
  from these eight sites might not be representative of other U.S. cities and
  states.

Monitoring current HCV infection in
states  and localities can help gauge what interventions and services are needed
to  identify persons with HCV infection and effectively link them to appropriate
  care and treatment. This is of particular importance now in an era of continued
  HCV transmission and rapidly improving therapeutic options for persons living
  with HCV infection. To help identify persons with current HCV infection, public
  health and clinical care providers can offer HCV antibody testing to persons
  born during 1945-1965, in addition to those with other HCV risk factors, and
  test for HCV RNA those persons who test positive for HCV antibody. Laboratories
  can ensure that test results are reported to state and local health
authorities,  and health departments can develop strategies to monitor and
increase the use of  HCV RNA testing of persons who are HCV antibody
positive.

Reported by

Katherine
Bornschlegel,  MPH, New York City Dept of Health and Mental Hygiene, New York,
New York.  Deborah Holtzman, PhD, R. Monina Klevens, DDS, John W. Ward, MD, Div
of Viral  Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB
  Prevention, CDC. Corresponding contributor: Deborah Holtzman,
dholtzman@cdc.gov,  404-718-8555.

Acknowledgments

Terry Bryant,
New Mexico Department of Health; Kashif  Iqbal, Division of Viral Hepatitis,
National Center for HIV/AIDS, Viral  Hepatitis, STD, and TB Prevention; Emily
McGibbon, New York City Department of  Health and Mental Hygiene; Elena M.
Rizzo, New York State Department of Health;  Melissa Sanchez, San Francisco
Department of Public Health; Suzanne Speers,  Connecticut Department of Public
Health; Kristin Sweet, Minnesota Department of  Health; Ann Thomas, Oregon
Public Health Division; Candace Vonderwahl, Colorado  Department of Public
Health and Environment.

References

1. Armstrong GL, Wasley  A, Simard EP, McQuillan
GM, Kuhnert WI, Alter MJ. The prevalence of hepatitis C  virus infection in the
United States, 1999 through 2002. Ann Intern Med  2006;144:705-14.


2. Ghany MG, Strader DB, Thomas DL,  Seeff LB, American
Association for the Study of Liver Diseases. Diagnosis,  management, and
treatment of hepatitis C: an update. Hepatology  2009;49:1335-74.

3. CDC.  Recommendations for the identification of chronic
hepatitis C virus infection  among persons born during 1945-1965. MMWR
2012;61(No. RR-4)
.

4. Kanwal F,
Hoang T, Kramer JR, et al. Increasing  prevalence of HCC and cirrhosis in
patients with chronic hepatitis C virus  infection. Gastroenterology
2011;140:1182-8.

5.  Everhart JE, Ruhl CE.
Burden of digestive diseases in the United States Part  III: liver, biliary
tract, and pancreas. Gastroenterology 2009;136:1134-44.

6. Yang JD, Kim WR, Coelho R, et al. Cirrhosis is  present in most
patients with hepatitis B and hepatocellular carcinoma. Clin  Gastroenterol
Hepatol 2011;9:64-70.

7. Simard EP,  Ward EM,
Siegel R, Jemal A. Cancers with increasing incidence trends in the  United
States: 1999 through 2008. CA Cancer J Clin 2012;62:128.

8. Kim WR, Terrault NA, Pedersen RA, et al. Trends in  waiting list
registration for liver transplantation for viral hepatitis in the  United
States. Gastroenterology 2009;137:1680-6.

9.  Ly
KN, Xing J, Klevens RM, Jiles RB, Ward JW, Holmberg SD. The increasing burden
  of mortality from viral hepatitis in the United States between 1999 and 2007.
  Ann Intern Med. 2012;156:271-8.

10. Su J, Brook
RA,  Kleinman NL, Corey-Lisle P. The impact of hepatitis C virus infection on
work  absence, productivity, and healthcare benefit costs. Hepatology
  2010;52:436-42.

11. Davis KL, Mitra D,
Medjedovic J,  et al. Direct economic burden of chronic hepatitis C virus in a
United States  managed care population. J Clin Gastroenterol 2011;45:17-24.

12. CDC. Guidelines for  laboratory testing and result reporting of
antibody to hepatitis C virus. MMWR  2003;52(No. RR-3)
.


13. Klevens RM, Miller J,  Vonderwahl C et al. Population-based
surveillance for hepatitis C virus, United  States, 2006-2007. Emerg Infect Dis
2009;15:1499-502.

14. Moorman AC, Gordon SC,
Rupp LB, et al. Baseline characteristics  and mortality among people in care for
chronic viral hepatitis: The Chronic  Hepatitis Cohort Study. Clin Infect Dis
2013;56:40-50.

15. Rein DB, Wagner D, Brown K,
et al. Hepatitis C antibody testing  and follow-up in primary care settings: a
retrospective study of four large,  primary care service centers. Programs and
abstracts of the National Summit on  HIV and Viral Hepatitis Diagnosis,
Prevention and Access to Care, November  26-28, 2012, Washington, DC.


16. McGibbon E,  Bornschlegel K, Balter S. Half a diagnosis: gap
in confirming infection among  hepatitis C antibody-positive patients. Am J Med.
In press 2013. 17. CDC.  Testing for HCV infection: An update of guidance for
clinicians and  laboratorians. MMWR 2013;62(18).

18. Stramer SL,  Dodd RY, Brodsky JP. The value of screening
signal-to-cutoff ratios for  hepatitis C virus antibody confirmation.
Transfusion. November 26, 2012. Epub  ahead of print.

Key
Points


· CDC guidelines for laboratory
testing and result reporting of  antibody to hepatitis C virus (HCV) published
in 2003 and developed in the era  of limited treatment options fail to identify
many persons with current HCV  infection. As such, about one half of persons
newly reported with hepatitis C  lack HCV RNA results, which are necessary to
identify current infection.

· In 2011, the
overall annual rate of persons newly  reported with hepatitis C was 84.7 per
100,000 population; rates varied by  site.

· The
highest percentage of persons with  current HCV infection and the highest
percentage of deaths among all persons  newly reported with hepatitis C were
among those born during 1945-1965,  particularly those aged 50-59 years.

· Additional  information is available at http://www.cdc.gov/vitalsigns.
 

 

 


 




















 

View Older
  Articles

 
Back to
Top

 
www.natap.org
  
 
 
 
 
 
5 Comments
superiorpapers.com reviews link
7/26/2013 10:47:20 pm

Nice information.. i really interest with your blog, keep it up!

Reply
Stephen in Florida link
8/21/2013 02:17:29 pm

Thanks for sharing this information. Although, I would have thought that it could be an even higher number of hepatitis C patients that faced major health risks. However, I could just be thinking more about the people who have hep C, but it has yet to be diagnosed.

Reply
best term paper reviews link
3/19/2015 07:39:24 pm

Excellently written papers for you!

Reply
paper writing link
4/23/2015 04:50:48 pm

To my mind it's a terible disease. Ill people need urgent help in order to recover.

Reply
buying college essays link
7/9/2015 12:12:24 am

Great article! Thanks for the information.

Reply

Your comment will be posted after it is approved.


Leave a Reply.

    Archives

    January 2021
    December 2020
    November 2020
    October 2020
    September 2020
    August 2020
    July 2020
    June 2020
    May 2020
    April 2020
    March 2020
    February 2020
    January 2020
    December 2019
    November 2019
    October 2019
    August 2019
    July 2019
    June 2019
    May 2019
    April 2019
    March 2019
    February 2019
    January 2019
    December 2018
    November 2018
    October 2018
    September 2018
    August 2018
    July 2018
    June 2018
    May 2018
    April 2018
    March 2018
    February 2018
    January 2018
    December 2017
    November 2017
    October 2017
    September 2017
    August 2017
    July 2017
    June 2017
    May 2017
    April 2017
    March 2017
    February 2017
    January 2017
    December 2016
    November 2016
    October 2016
    September 2016
    August 2016
    July 2016
    June 2016
    May 2016
    April 2016
    March 2016
    February 2016
    January 2016
    December 2015
    November 2015
    October 2015
    September 2015
    August 2015
    July 2015
    June 2015
    May 2015
    April 2015
    March 2015
    February 2015
    January 2015
    December 2014
    November 2014
    October 2014
    September 2014
    August 2014
    July 2014
    June 2014
    May 2014
    April 2014
    March 2014
    February 2014
    January 2014
    December 2013
    November 2013
    October 2013
    September 2013
    August 2013
    July 2013
    June 2013
    May 2013
    April 2013
    March 2013
    February 2013
    January 2013
    December 2012
    November 2012
    October 2012
    September 2012
    August 2012
    July 2012
    June 2012
    May 2012
    April 2012
    March 2012
    February 2012
    January 2012
    December 2011
    November 2011
    October 2011
    September 2011
    August 2011
    July 2011
    June 2011
    May 2011

    Categories

    All

    RSS Feed

Privacy Policy