A Case Study of Biosafety Considerations and Solutions for Work with Highly Pathogenic Avian Influenza Virus with Large-Scale Equipment in High Biocontainment.

A Case Study of Biosafety Considerations and Solutions for Work with Highly Pathogenic Avian Influenza Virus with Large-Scale Equipment in High Biocontainment - PMC Skip to main content An official website of the United States government Here's how you know Here's how you know Search Log in Primary site navigation Search Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. Learn more: PMC Disclaimer | PMC Copyright Notice Appl Biosaf . 2025 Jun 5;30(2):132–138. doi: 10.1089/apb.2024.0061 A Case Study of Biosafety Considerations and Solutions for Work with Highly Pathogenic Avian Influenza Virus with Large-Scale Equipment in High Biocontainment Nicholas J Chaplinski 1 , Nancy Mead 1 , David Haley 1 , Erica Spackman 2, * Author information Article notes Copyright and License information 1 USDA-ARS (Agricultural Research Service), U.S. National Poultry Research Center, Athens, Georgia, USA. 2 Exotic and Emerging Avian Viral Diseases Unit, USDA-ARS (Agricultural Research Service), U.S. National Poultry Research Center, Athens, Georgia, USA. * Address correspondence to: Erica Spackman, USDA-ARS (Agricultural Research Service), U.S. National Poultry Research Center, Exotic and Emerging Avian Viral Diseases Unit, 934 College Station Road, Athens, GA 30605, USA, Erica.Spackman@usda.gov Collection date 2025 Jun. Copyright 2025, ABSA International 2025 PMC Copyright notice PMCID: PMC12179349  PMID: 40548087 Abstract Introduction: Highly pathogenic avian influenza virus (HPAIV), a potential pandemic pathogen (PPP), was discovered in a new species, cattle, in March 2024 in the United States. Soon thereafter it was discovered that infectious virus could be present in milk at very high titers (up to 10 log 10 50% egg infectious doses per mL). Therefore, “emergency” testing to confirm that current milk processing methods used to reduce bacterial pathogens were sufficient to inactivate HPAIV was needed. Continuous flow pasteurization (CFP) is the industry standard, and the conditions defined in the Pasteurized Milk Ordinance of the U.S. Food and Drug Administration needed to be validated with HPAIV. To accomplish this, biosafety procedures for an experimental design that required a pilot-scale CFP with high volumes of HPAIV-contaminated milk needed to be developed. Methods: Numerous information sources, including subject matter experts, were utilized to acquire information for risk assessments and to develop procedures for a new, large-scale piece of equipment that required 5L of a PPP at a high titer per test. Results: Application-specific equipment such as sample and waste vessels with sealed ports, tubing with valved connection, and high efficiency particulate air-filtered vents were designed with corresponding safety procedures, such as seal integrity testing of the sample vessels. Conclusions: The use of high volumes of infectious material, the scale of the equipment, and time constraints presented unique challenges to balance biosafety and research objectives. Innovative engineering and procedural approaches allowed the research to be completed successfully in a time-sensitive manner while mitigating biosafety risk. Keywords: highly pathogenic avian influenza virus, large-scale equipment biosafety, ABSL-3Ag, influenza biosafety, high-containment biorisk management Introduction In March 2024, dairy cows in the United States were found to be infected with H5N1 highly pathogenic avian influenza virus (HPAIV) of the clade 2.3.4.4b sublineage of the goose/Guangdong/1996 H5 lineage. 1 The clade 2.3.4.4b HPAIV is considered to be a potential pandemic pathogen (PPP) because the virus has a wide host range and can cause disease in humans, and avian and mammalian animal species. 2 Cows infected with HPAIV presented with mastitis, and poor milk quality and production. 1 , 3 Subsequent testing showed that milk from individual infected cows contained infectious viruses that could reach extremely high titers (as much as 10 log 10 50% egg infectious doses [EID 50 ] per mL [Spackman, unpublished data]). Initial studies of bulk storage tank milk reported infectious virus titers up to 6.3 log 10 EID 50 per mL. 4 Therefore, although pasteurization was expected to inactivate HPAIV, it was crucial to rapidly conduct time-sensitive research to determine whether pasteurization conditions in the U.S. regulatory standards, 5 especially the minimum high-temperature short time (HTST) condition of 72°C for 15 s, would achieve an adequate log reduction of virus in milk bound for the food supply. Continuous flow pasteurization (CFP) is the most common method used for commercial fluid milk processing and the heat transfer and thermal ramp times are difficult to replicate on the benchtop using heat blocks or water baths. Therefore, to simulate industrial practices as closely as possible, it was determined that testing raw milk artificially contaminated with HPAIV in a pilot-scale CFP (MicroThermics, Inc., Raleigh, NC) ( Figure 1 ) was necessary. Figure 1. Open in a new tab Pilot-scale continuous flow pasteurizer installed in ABSL-3Ag. (A) Front view. (B) Front view with cabinet open showing the product pump, heaters, hold tube, product cooler, and sample apparatus (yellow arrows) which runs through a coil in a canister of cold water to chill the material where it is collected in a septum bottle from the outlet tube. ABSL-3, Animal Biosafety Level 3 Agriculture. An additional consideration was that the raw milk needed to be homogenized prior to virus inoculation and pasteurization to prevent separated fat from clogging the CFP. A homogenization step was also important to replicate the actual industry practice where fluid milk is homogenized inline with CFP (unpasteurized homogenized raw milk will go rancid rapidly). Because homogenization requires high pressure (10–25 MPa), homogenizing raw milk containing infectious HPAIV presented a risk for aerosolization and leakage if there was a mechanical failure. Using a CFP to evaluate HPAIV inactivation, even at a pilot scale, presents some unique challenges for biosafety and biosecurity. First, milk in batches of a minimum of 5 L per run would need to be inoculated with high quantities of virus potentially up to 8 log 10 EID 50 per mL. Also, numerous 5 L replicates would be needed. The milk would require safe handling and disposal. Second, despite extensive expertise with the virus, there was no local experience with a CFP or similar equipment. Information on continuous flow pasteurization and viruses was also very limited in the literature and only one similar study evaluating the inactivation of foot-and-mouth disease virus in milk by CFP was identified. 6 However, the study used a much smaller CFP, and due to the unique nature of high-containment laboratories, their approach, which used biosafety cabinets and running the post-treatment milk hose through a wall penetration was not possible here. An additional challenge was that the data were needed as soon as it could be produced; the work was considered emergency research, so the timeline to develop and attain approval for a biosafety plan had to be compressed by redirecting safety personnel to this project. Similar to a report by Kercher et al., which addresses initiating work with a novel pathogen (SARS-CoV-2), 7 the objective of this report is to present a case study of how this novel situation was navigated to identify and mitigate biosafety and biosecurity risks associated with a complex novel procedure requiring large quantities of a high-consequence pathogen. Ideally, the risks of working with HPAIV could be mitigated by elimination or substitution. However, these were not viable options. First, no surrogate agent to replace HPAIV has been defined that meets all of the necessary criteria: (1) has an identical thermal stability profile to influenza A; (2) is nonvirulent for humans and animals; (3) has the ability to replicate to adequate titers in culture; and (4) is detectable in a highly sensitive viability assay; to replace HPAIV has been defined. The next option would have been to substitute HPAIV for a low pathogenic (LP) AIV isolate. However, despite increased safety for some animal species, LPAIV can be infectious for humans. Also, LPAIV does not replicate adequate titers in culture to achieve the high viral titers in the large quantities of milk needed that simulate what is occurring naturally. Therefore, HPAIV was determined to be the scientifically appropriate agent, and risk mitigations needed to be addressed through engineering, administrative procedures, and personal protective equipment (PPE). Risk Assessment, Critical Control Points and Solutions The primary biosafety and biosecurity goals were to safely test large volumes of milk (5 L per test run and the total over the course of the experiment was expected to approach 100 L) containing HPAIV titers potentially up to 8 log 10 EID 50 per mL in a CFP, a piece of equipment with which the researchers had no experience. The HPAIV strain utilized was a well-characterized isolate, A/turkey/Indiana/22-003707-003/2022 H5N1, which replicates to high titers in embryonated chicken eggs when propagated using standard methods 8 (therefore, concentration of the virus was not necessary). Importantly, any procedures where HPAIV is handled must be able to address that HPAIV is a high-consequence animal pathogen, is potentially infectious to humans, and was a regulated Select Agent when the experiments were conducted. Administrative Approach Normal administrative processes for new procedures with an infectious agent are reviewed by the Institutional Biosafety Committee (IBC) but because most of the procedures to operate the CFP were out of the expertise of local personnel, additional reviewers included: individuals with experience with a CFP (subject matter experts included U.S. Department of Agriculture [USDA] and U.S. Food and Drug Administration personnel engaged in the response efforts for HPAIV milk and/or individuals who were identified through a combination of scientific literature and agency leadership as having relevant experience), the USDA-Agricultural research service agency biosafety officer. The CFP manufacturer and CFP users' manual were used to identify critical control points and procedures of concern ( Table 1 ). Also, a risk assessment and standard operating procedure (SOP) was produced by the biosafety and research teams at the institution in addition to the other required documentation that was submitted to the IBC as part of the review and eventual approval process. Table 1. Critical biosafety control points and engineering solutions Concern Engineering solution Primary containment for large equipment Install equipment in ABSL-3Ag Work with large volumes of liquid with high titers of infectious virus Use small single-use sized aliquots of virus Use sealed buckets with valved hoses, a sample port, and HEPA-filtered vents to transport and hold milk Add virus to the milk immediately prior to pasteurization Feeding contaminated milk into the pasteurizer Use a cordless drill powered peristaltic pump. Sample collection Use self-sealing septum bottles Pasteurizer discharge milk would be potentially contaminated Collected in sealed buckets with hoses with valved connectors and HEPA-filtered vents Treat with disinfectant prior to disposal and final treatment by the EDS Potential for drips at connections Pans with disinfectant positioned at hose junctions Buckets held in secondary spill containers with 3× capacity of the bucket Spill kits that could accommodate the fluid volume in use in work area Potential for leakage from the pasteurizer Spill kits and sorbents that could accommodate the fluid volume in use in work area Spray bottles of disinfectant in the work area Open in a new tab ABSL-3Ag, Animal Biosafety Level 3 Agriculture; EDS, effluent decontamination system. All personnel that would work with the equipment received the location-specific biosafety and lab safety training which included hazard communication and emergency response procedures. An additional module on PPE use/donning and doffing specific to the Animal Biosafety Level 3 Agriculture (ABSL-3Ag) space was also required. At all times, personnel with the entity-specific BSL-3 laboratory certification for unescorted access were required to be present and actively escort individuals, such as visiting scientists who were pasteurization experts who were assisting with the experiments. Visiting scientists who were pasteurization experts were added to the entity’s Select Agent registration and completed all training required for the entity to meet Select Agent regulations under 9 CFR 121. Visiting scientists were escorted at all times by institution Security Risk Assessment approved individuals who also possessed the entity-specific BSL-3 laboratory certification for unescorted access. Visiting scientists were also required to provide medical clearance to be fit for duty, as well as clearance to wear a Powered Air Purifying Respirator (PAPR). Engineering Approach The workflow for the experiments was complex and required specific timing and coordination of numerous people to: (1) acquire fresh milk from a local dairy; (2) homogenize the milk at a specific temperature; (3) add sufficient virus to the milk to achieve adequate starting titers; (4) pasteurize the milk and collect the necessary samples from the CFP; (5) dispose of waste from the pasteurizer; and (6) transport and process the samples in a laboratory. A major concern was that the equipment would not fit in any available primary containment. The first step was to separate the homogenization and pasteurization steps. Homogenization was conducted with clean raw milk in a pilot poultry processing plant at the facility then was immediately transported to the CFP which was installed in an ABSL-3Ag suite. Minor plumbing and electrical work had to be done to accommodate the utility needs of the CFP, so pressure decay testing was conducted to confirm envelope integrity before infectious work could begin. Another concern was whether the CFP could leak under pressure. The risk for leakage from the CFP was expected to be negligible because the plumbing is soldered or welded and nonsoldered/welded junctions are tested during the quality control testing by the manufacturer. Importantly the flow rate is also low at 0.5–1 L/min. The risk of thermal injury is minimized by the insulation on the CFP, and milk samples were collected from a port with a cooling coil ( Figure 1 ). The CFP manufacturer also provided onsite training with the equipment prior to the experimental work. Procedures then had to be developed to minimize open containers of virus, potential large volume spills/drips, and leaks with high quantities of infectious virus. The minimum volume that could be run in the CFP was 5 L, and multiple replicates were needed for each pasteurization condition. Each 5 L replicate needed to contain sufficient HPAIV to provide a margin of safety relative to the quantities of viable virus found in raw milk being processed, so target starting quantities were 7–8 log 10 EID 50 per mL. Both contaminated supply milk and milk processed through the CFP needed to be contained for decontamination prior to disposal for treatment by the facility’s effluent decontamination system (EDS). Finally, the contaminated milk had to be supplied to the CFP through tubing and similarly discharged waste milk had to be piped through tubing into a sealed waste container. To contain infectious milk prior to pasteurization and discharged milk after treatment, sealed buckets with HEPA filtered vents, valved connectors, and high-temperature-rated tubing were designed ( Figure 2 ). Food grade, 5 gallon (18.9 L) polyethylene buckets with waterproof sealable lids (S-20606, Uline, Pleasant Prairie, WI), were acquired. The lids were modified with waterproof ports (sealed with caulk and polytetrafluoroethylene [PTFE]) thread seal tape for hoses (ZUSA-HT-712, USA Industrials, Buffalo, NY) to attach to the CFP with a valved connector (HFCD17639M and HFCD22639M, CPC Worldwide, Arden Hills, MN) and a HEPA-filtered vent (HEPA-VENT 6723-5000, Cytiva Whatman, Marlborough, MA) ( Figure 2 ). The buckets to supply the contaminated milk (i.e., product) also had a draw tube to the bottom of the bucket and a sample port where the virus could be added and pretreatment samples could be collected ( Figure 2 ). This port was also used to add disinfectant to waste milk. Hoses were sealed by clamps ( Figure 2 ). Hoses with the valved connectors were then fit to the supply and discharge ports of the CFP ( Figure 3 ). A hot water carboy with high-temperature-rated hoses was added so that a hot water loop could be made for the sanitize-in-place (SIP) procedures for the CFP after samples were run ( Figure 3 ). Figure 2. Open in a new tab Configuration of lids of 5 gallon, sealable buckets with HEPA-filtered vents (yellow arrows), sample ports, and valved connectors (dark blue arrows) for tubing. Bulkheads are sealed with PTFE tape and hose clamps (light blue arrows). Red bars are handles built into the gasketed bucket lid which allow for a tight seal. All fittings are high-temperature stable. (A) Top view with ports labeled. The product port connects to the tubing that carries the milk to or from the pasteurizer (in product supply buckets this is connected to a rigid tube that draws material from the bottom of the bucket). (B) Close-up of valved connectors and the bucket lid from the side. (C) Side view of HEPA filter and clamped connections. Figure 3. Open in a new tab Front view of the continuous flow pasteurizer with a high-temperature carboy (white arrow) used to create a sealed loop for sterilize-in-place (SIP) procedures after each batch of samples and the valved connectors (light blue arrow) used for product supply and SIP. The pan under the connectors was filled with disinfectant during use. Although all studies took place in an ABSL-3Ag suite and all users utilized respiratory protection in the form of a PAPR, the goal was to minimize aerosols and eliminate open containers of infectious material. Therefore, the buckets were tested for seal integrity by utilization of a pressure decay test. A ball valve was connected to the intake valve above the lid of each bucket. Before the HEPA filter was placed on the vent valve, a pressure gauge was installed. Air was introduced into the bucket via an air compressor to 1 pound per square inch (psi) (0.07 kg/cm 2 ), and the ball valve was then closed. The pressure gauge was then observed for a period of 5 min to test seal integrity by monitoring for any pressure decay. The acceptance criterion for the seal integrity test was zero pressure loss (i.e., it did not drop below 1 psi) over 5 min. Buckets that did not meet the seal integrity test criterion were resealed and retested until they passed. The result was that the infectious material was sealed at all times except when the virus was added to the milk, when prepasteurization milk samples were collected, and when the bucket sample port was opened to add disinfectant to the discharged waste milk. One challenge the sealed buckets created was how to monitor the fluid level in the buckets, so a flashlight was used to illuminate the bucket from the side which provided a clear visual of the fluid level. Monitoring the volume in the buckets was required by the procedure SOP to prevent overflow of discharge buckets. Another problem was that the air needed to be purged from the feed hoses to prevent damage to the CFP. A peristaltic pump on a cordless drill that was vented with an aerosol barrier pipet was used to purge the air from the hosing that supplied the infectious milk to the CFP from the sealed bucket. Treated milk samples were collected for virus viability testing from dedicated sample ports on the CFP using 60 mL Polyethylene terephthalate glycol (PETG) septum bottles (03-313-901, Thermo Fisher Scientific, Waltham, MA); the sample tube was inserted through the septum which seals around the tube as the sample is collected and self-heals once removed from the sample tube. WetGrip™ tags (GRLA-1050, Diversified Biotech, Dedham, MA) were applied to the tops of the septum bottles during transport as an additional seal. Sample vessels were also placed in a sealed plastic bag inside a leakproof hard-sided tote (Duraporter™, Heathrow Scientific, Vernon Hills, IL) for transport to a laboratory for processing. The surfaces of the sample vessels (septum bottles), sealable bags, and tote were treated with disinfectant prior to transport. Potential spills were limited by holding any buckets with infectious (pretreatment milk) or potentially infectious milk (discharged waste milk) in 15 gallon (56.7 L) livestock feed pans. Two biohazard spill kits (PLS 1850, New Pig, Tipton, PA) and additional sorbents (S-7247, Uline) were kept in the work area. To catch drips at hose connections and sample ports shallow pans with disinfectant were placed under the connections ( Figure 3 ). When removed, the sealed valve at the end of the hose was treated with disinfectant. Freshly prepared disinfectant was on hand in spray bottles. Waste milk that had been processed through the CFP was treated by adding disinfectant through the sample port into the buckets to achieve the concentration recommended by the manufacturer, and the time was logged on the bucket to ensure complete contact time. The goal was that all infectious material would be inactivated prior to disposal into pipeline for the EDS. Once testing was completed each day, a high-temperature SIP cycle with water was run and after the final testing had been completed a manufacturer-recommended clean-in-place (CIP) procedure was also run with a caustic (HC-10 Chlorinated Kleer-Mor, Ecolab, St. Paul, MN) and an acid (Heavy-Duty Acid LC-30, Ecolab). Water cycled through the CFP after the final SIP and CIP cycles was tested for viable virus using two passages in embryonating chicken eggs as described for milk samples. 9 The entirety of the ABSL-3Ag room with the CFP was decontaminated at the room level via vaporized hydrogen peroxide. This process was verified by a previously developed validation process confirmed with Geobacillus stearothermophilus biological indicators (NA333, Spordex Vaporized VH2O2 Biological Indicators, Steris, Mentor, OH). Finally, an overall workflow plan was developed so that infectious work would be concentrated in as small an area of the room as possible and with a dedicated area for personnel decontamination prior to exiting the containment area. The personnel decontamination procedure included removing outer gloves, spraying down the barrier suit and PAPR (wiping off the PAPR fan unit) with disinfectant, timing to achieve the full contact time, removing gloves and hand washing in a dedicated sink, then stepping through a disinfectant footbath, to a “clean material only” area where the coveralls and boots were removed before the individual could exit the room and remove respiratory protection. Personal Protective Equipment The PPE requirement for the room was a full shroud HEPA-filtered PAPR (Versaflo™, 3M, Maplewood, MN), a full moisture barrier high-density polyethylene fiber coverall (i.e., Tyvek®, Dupont de Nemours Inc., Wilmington, DE) over room dedicated scrubs, rubber boots, and double gloves. Personnel would shower out of the ABSL-3Ag room after doffing PPE (after disinfection, gloves, coveralls, and boots were removed in an area designated for PPE removal at the exit from the ABSL-3Ag room immediately before entering the ante-room for the shower and respiratory protection was removed in the ante-room to the shower). An additional shower was required to exit the building. Conclusions Using large-scale equipment with high volumes of a PPP (and at the time of this study H5 HPAIV was listed as a select agent by USDA) presented some unique challenges. In addition, because of the public health implications of the research results, the experiments were considered the highest priority and needed to be completed as soon as feasible. To balance the research needs with biosafety concerns, the biosafety and research teams identified the salient elements of the project that were necessary to accomplish the research with valid methods. This allowed for the development of a risk assessment in collaboration with subject matter experts who were able to provide input that was critical to the success of the experiment and the development of safe procedures. Then the biosafety team addressed the concerns through innovative approaches which included developing application-specific sample vessels that resulted in the infectious material being contained in sealed vessels for almost all steps of the experiment. Also, the use of an ABSL-3Ag room, which was designed to be primary containment with animals in an open floor pen, worked well as primary containment after some minor modifications to the utilities to accommodate the CFP. All procedures and biosafety mitigations were reviewed and approved by the IBC prior to the initiation of the experiment. During the course of the study, a total of about 80 L of milk was processed through the CFP, and it was shown that HTST pasteurization was able to inactivate around 6.7 log 10 EID 50 of HPAIV in raw milk. 4 No spills occurred and only small droplets (<0.5 mL per event) were observed when the hose supplying milk to the CFP was disconnected to initiate the SIP procedures. These droplets were captured in the pan of disinfectant under the connection ( Figure 3 ), and the connectors were immediately treated at each end with disinfectant. Importantly, no potential exposures occurred during the course of the work. The research here attempted to simulate the technical conditions for milk pasteurization at a milk processing facility in the United States. Conditions to which workers are exposed at dairies or milk processing plants were not replicated. Therefore, biosafety practices here may not directly apply to real-world facilities. Furthermore, risk at dairies may not be equivalent to risk at processing facilities. The USDA and the U.S. Centers for Disease Control and Prevention each have online guidelines for PPE and biosecurity for HPAIV in cattle and dairy facilities that are kept updated. 10 , 11 An essential lesson learned is that the complexity of the process required considerable time from the biosafety and research teams to plan and execute the project. Additionally, walking through the procedures with no infectious material was crucial to identifying procedures with potential risk for exposure or spills and determining solutions. Also, regardless of the high-priority nature of the work, following a systematic approach that involved: input from individuals with diverse expertise, developing a risk assessment, review and approval by the IBC and agency leadership, and hands-on training could not be compromised; each step had to be fully addressed. Through this process, we were able to successfully achieve the research objectives with experimental design integrity while ensuring the work was safe. Acknowledgments The authors gratefully thank Joe Kozlovac, Sydney Birge-Hales, Suzanne DeBlois, Edna Espinoza, Jesse Gallagher, Jessica Gladney, Nathan Anderson, Stephen Walker, Anne Hurley-Bacon, Tarrah Bigler, Lindsay Killmaster, Scott Lee, Stephen Norris, Phil Paxton, Melinda Vonkungthong, and Ricky Zoller for technical assistance with this work. The authors are also very grateful to the University of Georgia Dairy for supplying fresh raw milk, and The Pennsylvania State University, Department of Food Science for providing the homogenizer. Authors’ Contributions N.J.C.: Conceptualization, resources, project administration, formal analysis, methodology, validation, investigation, writing reviewing, and editing. N.M.: Conceptualization, formal analysis, methodology, writing reviewing, and editing. D.H.: Conceptualization, formal analysis, methodology, validation, writing reviewing, and editing. E.S.: Conceptualization, resources, funding acquisition, investigation, project administration, and writing—original draft. Authors’ Disclosure Statement The authors declare they have no conflicts of interest. Funding Information U.S. Department of Agriculture (USDA) Agricultural Research Service Project No. 6040-32000-081-00D and the U.S. Food and Drug Administration by IAA 60-6040-4-005. References 1. 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Available from: https://www.aphis.usda.gov/livestock-poultry-disease/avian/avian-influenza/hpai-detections/livestock/enhance-biosecurity [Last accessed: December 2, 2024]. [ Google Scholar ] Articles from Applied Biosafety: Journal of the American Biological Safety Association are provided here courtesy of ABSA International and Mary Ann Liebert, Inc. ACTIONS View on publisher site PDF (945.4 KB) Cite Collections Permalink RESOURCES Similar articles Cited by other articles Links to NCBI Databases Follow NCBI NCBI on X (formerly known as Twitter) NCBI on Facebook NCBI on LinkedIn NCBI on GitHub NCBI RSS feed Connect with NLM NLM on X (formerly known as Twitter) NLM on Facebook NLM on YouTube National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894 Web Policies FOIA HHS Vulnerability Disclosure Help Accessibility Careers NLM NIH HHS USA.gov Back to Top

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