The Public's Perceptions About Cognitive Health and Alzheimer's Disease Among the U.S. Population: A
By: Lynda A. Anderson, PhD, Kristine L. Day, MPH, Renée L. Beard, PhD, Peter S. Reed, MPH, PhD, and
Bei Wu, PhD
Anderson, L. A., Beard, R., Day, K. L., McConnell, S., Reed, P. S., Wu, B. (2009). The Public's Perceptions About
Cognitive Health and Alzheimer's Disease Among the U.S. Population: A National Review. The
Gerontologist, Special Issue, 49, S3-S11.
Made available courtesy of Oxford University Press:
***Note: Figures may be missing from this format of the document
The present review assesses the public's perceptions about cognitive health and Alzheimer's disease among
adults in the United States. We searched the published literature and Internet, and contacted experts in the field
to locate surveys assessing the public's perceptions about cognition. We found 10 eligible surveys and
abstracted data concerning the public's knowledge, beliefs, concerns, and sources of information. Most of the
surveys were conducted in the 2000s and focused on Alzheimer's disease rather then cognitive health. Based on
the findings from the surveys, most adults were found to be aware of Alzheimer's disease but lacked specific
information about the disease and its treatments. Most respondents did not perceive themselves as being very
knowledgeable about Alzheimer's disease. Although we could classify the findings into several overarching
domains, such as knowledge, we found considerable variability among surveys in the questions asked.
Additional work is needed to understand the public's perceptions about cognitive health. Moreover, we also lack
studies that help us understand perceptions about cognition across diverse demographic and cultural groups.
Only by addressing these gaps can we develop targeted and effective strategies to enhance knowledge and
beliefs about cognitive impairment and health.
During the past several decades, we have witnessed significant scientific progress in understanding cognition
and dementia, including Alzheimer's disease (Anderson & McConnell, 2007; Hendrie et al., 2006;
Khachaturian, 2006). For example, the National Institutes of Health's Cognitive and Emotional Project (Hendrie
et al., 2006), which reviewed the scientific evidence on factors that influence the maintenance of cognitive and
emotional health, points out the importance of specific risk factors such as cardiovascular risk factors and
cognitive function. Given these scientific developments, there are several compelling reasons for conducting a
review of the literature on efforts to assess the public's perceptions about cognitive health and Alzheimer's
disease among the adults in the United States.
There are increased calls to understand the public perceptions about cognition. Indeed, the first-priority
recommendation of the Healthy Brain Initiative: A National Public Health Road Map to Maintaining Cognitive
Health (www.cdc.gov/healthybrain) is to “determine how diverse audiences think about cognitive health and its
association with lifestyle factors.” A National Public Health Road Map to Maintaining Cognitive Health serves
to focus the nation's attention to guide action and to develop a coordinated approach to move cognitive health
into public health practice (Centers for Disease Control and Prevention [CDC] & Alzheimer's Association,
2007). The recommendations of the Road Map reflect the culmination of an 18-month process involving
stakeholders at the national, state, and local levels. The rationale underlining this recommendation was to help
promote the development of messages and inform the design and implementation of strategies addressing
Another compelling reason to understand the public's perceptions about cognition is because of the lack of
consensus on how to define cognition (Hendrie at al., 2006). However, most experts agree that the components
of healthy cognitive functioning include language, thought, memory, executive function, judgment, attention,
perception, remembered skills, and ability to live a purposeful life (National Research Council, 2000). Much
like physical health, cognitive health can be viewed along a continuum—from normative functioning to mild
cognitive impairment to severe dementia. Similarly, the definitions of “mild cognitive impairment” or
“cognitive impairment no dementia,” both terms coined in 1997, have not reached consensus yet (Gaines &
Whitehouse, 2006; Golomb, Kluger, Garrard, & Ferris, 2001; Graham et al., 1997; Peterson et al., 1997, 2001;
Plassman et al., 2008; Richie & Touchon, 2000; Whitehouse & Moody, 2006). Generally, these terms refer to a
condition in which a person has problems with memory, language, or other mental function severe enough to be
noticeable to other people and to show up on tests but not serious enough to interfere with daily life.
Occasionally, the minimal decline is noticed primarily by the person him/herself. Because the problems do not
interfere with daily activities, the person does not meet criteria for being diagnosed with dementia. In specialty
clinics, however, diagnoses such as mild cognitive impairment and cognitive impairment no dementia are
rendered to patients with these very minor and as yet not agreed upon categorizations of cognitive decline. As a
result, important issues to examine are the public's perceptions of such terms and development of language that
communicates current knowledge and advances being made in these areas.
Finally, given the focus of this special issue of The Gerontologist, “Promoting Cognitive Health in Diverse
Populations of Older Adults,” our review summarizes what is currently known and was proposed to help set the
stage for the articles that follow. Our review summarizes the current state of the science regarding what is
known about the U.S. public's perceptions about cognition. We include perceptions about cognitive health as
well as Alzheimer's disease. As part of this review, we summarize the research designs, populations studied,
and the major domains and findings related to cognition. We also provide recommendations for advancing work
in this area.
We used an iterative approach to identifying eligible reports for this review. Our approach involved a search of
the published literature in consultation with experts in the field. Given that our interest was in describing the
state of the evidence on what is known about the U.S. public's perceptions of cognition, we included both
published studies and reports that provided original data (e.g., reports on the Internet). Eligible reports were
published in English and conducted in the United States. We did not impose any restrictions with respect to
publication date. The end date for inclusion of eligible studies to our review was June 19, 2008. Reports or
surveys concerning the perceptions of health care providers; family caregivers (defined as unpaid family
members, friends, or neighbors) providing care to someone who is, to some degree, incapacitated and needs
help (Family Caregiver Alliance, 2005); and persons diagnosed with any form of cognitive impairment were
Two strategies were used to identify potentially relevant reports. First, we conducted a database search using
PubMed, which includes and other life science journals for biomedical articles that searches back to the 1950s
(www.ncbi.nlm.nih.gov/pubmed), and PsycInfo. Key words for searches focused on cognition (i.e., brain health,
cognitive health, dementia, Alzheimer's disease, cognition, cognitive decline, or cognitive impairment),
knowledge, beliefs, attitudes or perceptions, and the general public (i.e., the public, laypersons). We also
conducted an Internet search for reports of surveys identified by experts and accessible in the public domain.
After we identified published articles and reports, we reviewed references of relevant articles to retrieve any
possible additional studies.
For each eligible survey, information was collected on the following: (a) the study design, including type of
study (i.e., qualitative or quantitative, market research, or academic study), data collection method(s), and study
period; (b) sample (i.e., number of participants, demographic characteristics, sampling [sampling and weighting
of data]; and (c) study findings related to four categories (knowledge, beliefs, concerns, and sources of
information). Two authors (Kristine L. Day and Lynda A. Anderson) independently reviewed all eligible
studies. We then characterized study findings into four domains: (a) knowledge, (b) beliefs, (c) concerns, and
(d) sources of information. Knowledge refers to awareness about an idea or proposition (Griffin & Ohlsson,
2001). Examples of such findings include reports of “being aware of Alzheimer's disease” and “Alzheimer's
disease is not the term for normal memory loss as they get older.” Within the knowledge category, issues were
subgrouped to examine the focus of the question, including awareness of Alzheimer's disease or facts about
cognition or Alzheimer's disease. Beliefs (i.e., prospective beliefs, distinct from perceptions about being an
actual caregiver) refer to the perceptions about the truth-value associated with the proposition or object (Griffin
& Ohlsson). Examples of findings related to beliefs were, “I believe there is nothing a person can do to help
maintain a healthy memory” and “I am well-prepared for handling a diagnosis of Alzheimer's disease.” Beliefs
were further subgrouped to examine perceptions about Alzheimer's disease, risk factors, and lifestyle
modifications to avoid cognitive impairment, or potentially caring for someone with a cognitive impairment
(i.e., prospective beliefs, distinct from perceptions about being an actual caregiver). Concerns refer to emotional
responses such as fears or worries related to cognition, as in the following example: “I am very afraid of
developing Alzheimer's disease.” Concerns were further subgrouped to examine as concerns about declines in
cognition, Alzheimer's disease, or potentially caring for someone with the disease. The final category,
informational sources, refers to places or people used to gain knowledge related to cognition.
A total of 10 surveys are summarized in this review article. The Connell, Roberts, and McLaughlin's (2007)
data were taken from the Alzheimer's Association survey of 2003 (Alzheimer's Association, 2003). We cite data
from both reports but to avoid duplication, we only report on distinct nonduplicative findings from the
Alzheimer's Association survey and the Connell and colleagues‟ publication. Copies of the surveys are available
from the authors.
For the purposes of this article, we organized the study findings by domains: knowledge, beliefs, concerns, and
informational resources. Of the 10 eligible surveys, 7 examined knowledge, 4 surveyed beliefs, 8 investigated
concerns, and 2 explored informational resources (Table 1). Of the 10 surveys, half (n = 5) addressed only one
of the four overarching categories, examining either concerns or knowledge. The majority of surveys involved
telephone interviews conducted by marketing agencies. All the surveys were cross-sectional using convenience
samples. Based on the available reports, we could find no information on sampling frames or weighting of the
data for national estimates. Sample sizes ranged from 209 participants to more than 3,000 participants. The age
range of respondents varied across the surveys, starting at 18 years of age and older.
Study Characteristics by Categorization of Study Findings
Author(s) (year): name of the
Study type and
Sample and characteristics
Categories of study findings
Knowledge Beliefs Concerns Information
Steckenrider (1993): What people
know about Alzheimer's disease:
A study of public knowledge
N = 1,498; age: 45+ years
Ayalon & Aréan (2004):
Knowledge of Alzheimer's
disease in four ethnic groups of
N = 209; race/ethnicity: 48%
White, 18% Hispanic, 14% Asian,
15% African American, 5%
ethnically unidentified; age: 55+
years; English or Spanish
Alzheimer's Association (2003)a:
Alzheimer's Association survey of
American's knowledge and
opinions about Alzheimer's
Market research from
survey; December 2003
N = 600; age: 35+ years
X X X
Connell et al. (2007a): Public
opinion about Alzheimer's
disease among Blacks,
Hispanics, and Whites
Market research from
2003; 3,815 households
Market research from
N = 1,176 household members;
criteria: English speaking; age:
35+ years. Oversampled: 55+
years; Hispanic and African
N = 1,008 adults; age: 18+ years;
sex: 50% female
* * *
American Society on Aging and
MetLife Foundation (2006):
X X X
Author(s) (year): name of the
Study type and
Sample and characteristics
Categories of study findings
Knowledge Beliefs Concerns Information
Attitudes and awareness of brain
Alzheimer's Association and
American Heart Association
(2008): Findings from the African
American heart and brain health
MetLife Foundation (2006):
Americans fear Alzheimer's more
than heart disease, diabetes or
stroke, but few prepare
Richard Day Research;
online survey; February
N = 2,214 adults; 1,210 African
Americans and 1,004 non-African
X X X
Market research from
N = 1,000 residents; age: 42+
X X X X
Roberts et al. (2003): Differences
between African Americans and
Whites in their perceptions of
N = 452; 61% White, 39% African
American; age: 22–90 years,
mean age 47 years; 78% women;
median education level: college
N = 3,048; age: 18+ years;
female = 1,708. Oversampled:
older adults (65+ years) and
Cutler et al. (2000): American
Perceptions of Aging in the 21st
December 1999 to
Market research from
survey; September 2004
Alzheimer's Association (2004):
Alzheimer's disease and
American's fears. National survey
(2006): What Americans think
about aging and health
Note: aFindings are based on the same dataset.
N = 1,020 adults; no descriptive
Public opinion poll
N = 1,000; age: 18+ years
*Same categories as the Alzheimer's Association (2003).
X indicates that a specific category of study findings were identified from a report or published study and classified into
a specific domain by the study authors.
In terms of awareness of Alzheimer's disease, Steckenrider (1993) reported that 90.7% of respondents aged 45
years and older had heard of Alzheimer's disease, which is similar to the survey findings reported elsewhere
(MetLife Foundation, 2006). The MetLife Foundation found that 93% of respondents aged 45 years and older
were aware of Alzheimer's disease. The survey reported by the Alzheimer's Association (2003) also examined
knowledge about Alzheimer's disease. The Alzheimer's Association found that 75% of respondents aged 35
years and older correctly stated that Alzheimer's disease is not the term for normal memory loss as they get
older. They also found that 44% of respondents correctly reported knowing that there are several treatments
available to ease the symptoms of persons with Alzheimer's disease. Connell and coworkers (2007) publication,
which analyzed data from the Alzheimer's Association 2003 survey, reported no differences across racial or
ethnic groups with the exception of the following: “Alzheimer's is the term for normal memory loss as we get
older.” For this statement, White respondents were significantly more likely to answer correctly (67.3%)
compared with African Americans (41.1%) and Hispanics (49.5%).
Of the four surveys employing knowledge “tests” or facts, Steckenrider (1993) reported that the mean number
of questions answered correctly was 9.1, or 54% (of a maximum of 17). She further divided questions into
general knowledge and specific knowledge, and found that about 72% of respondents had general knowledge,
whereas only 11% of respondents had specific knowledge about Alzheimer's disease. Connell and colleagues
(2007) reported that about 50% of respondents answered the five knowledge questions correctly. Additionally,
several surveys also explored whether there were differences in knowledge between identified racial and ethnic
groups. Roberts and colleagues (2003) reported that White respondents endorsed more knowledge items
correctly compared with African American respondents. Ayalon and Aréan (2004), studying adults aged 55
years and older in clinical settings, examined racial and ethnic differences in knowledge about Alzheimer's
disease. They reported that White respondents had a higher mean total score on knowledge of Alzheimer's
disease (10.41) compared with African Americans (8.36), Asians (4.96), and Hispanics (4.56).
In terms of beliefs, two surveys examined perceptions about Alzheimer's disease. In the report by Connell and
colleagues (2007), they found that 13.6% of respondents “believed they were very knowledgeable about what
causes Alzheimer's disease.” The MetLife survey (MetLife Foundation, 2006) found that 74% of respondents
aged 18 years and older reported knowing little or nothing about Alzheimer's disease. In terms of differences
between racial and ethnic groups, Connell and colleagues found no significant differences, reporting that 17.2%
of African Americans, 15.8% of Hispanics, and 10.5% of Whites considered themselves “very knowledgeable”
about what causes Alzheimer's disease.
Three reports looked at beliefs about modifying lifestyles related to “brain health” or avoiding the development
of Alzheimer's disease. The Alzheimer's Association (2003) reported that 17% of respondents believed there is
“nothing a person can do to help maintain a healthy memory and reduce the chance of Alzheimer's disease.” In
subsequent analysis, Connell and colleagues (2007) reported that 25.6% of respondents indicated making
changes to their diet or lifestyle to avoid developing Alzheimer's disease. The survey reported by the American
Society on Aging and MetLife (ASA-MetLife) found that 88% of respondents aged 42 years and older believed
they could do something to keep their “brains fit” (ASA-MetLife, 2006). Subsequently, the survey by the
Alzheimer's Association and American Heart Association (AA-AHA) found that 50% of respondents to an
online survey reported “doing things in their lives specifically for brain health” (AA-AHA, 2008). In both the
ASA-MetLife and the AA-AHA surveys, respondents identified participating in mental activities (puzzles) and
eating a healthy diet as among the types of activities they believed were helpful for brain health.
Regarding beliefs about being prepared to handle a diagnosis of Alzheimer's disease in a family member,
Connell and colleagues (2007) discovered that about 23% of respondents reported believing they were “well
prepared.” Another survey found that 81% of respondents believed it was important to have a plan to address
the possibility of having Alzheimer's disease (MetLife Foundation, 2006).
Three surveys examined concerns about declines in cognition or memory, with two of these surveys focusing on
memory loss or lost mental capacity. Cutler, Whitelaw, and Beattie (2002) reported that 61% of respondents
aged 18 years and older were “very or somewhat worried” about memory loss at age 75. Across selected
subgroups of age, sex, race/ethnicity, and education level, memory loss was consistently reported as producing
the most worry. Similarly, the PARADE/Research!America (2006) public opinion poll reported that 62% of
respondents aged 18 years and older feared losing their mental capacity compared with 29% who feared having
diminished physical ability. The third survey, reported by ASA-MetLife (, 2006), found that 30% of
respondents believe “most people start to worry about their memory between the ages of 41 and 60 years old.”
Among the three surveys examining concerns about Alzheimer's disease (Alzheimer's Association, 2004; AA-
AHA, 2008; Connell et al., 2007), the percentage of respondents concerned about developing Alzheimer's
disease ranged from 26% to 49%. The MetLife survey found that 20% of respondents identified Alzheimer's
disease as the most feared illness out of five major conditions, including cancer, heart disease, stroke, and
diabetes (MetLife Foundation, 2006).
Two surveys reported on respondent's concerns about developing Alzheimer's disease among different racial
and ethnic groups. Roberts and colleagues (2003), with a mean sample age of 47, reported that Whites
perceived Alzheimer's disease as a greater threat compared with African Americans, whereas the online survey
reported by AA-AHA (2008) reported no differences between racial/ethnic groups.
In terms of concerns about caring for others with Alzheimer's disease, the Alzheimer's Association (2004)
reported that 49% of respondents to a telephone survey were equally afraid of taking care of a loved one with
Alzheimer's disease as of getting the disease themselves. The 2006 MetLife survey reported that 63% of the
respondents to the telephone survey were concerned about having to provide care for someone with Alzheimer's
Sources of Information
Two surveys explored the number of sources and where respondents would seek out information. The survey
reported by ASA-MetLife (2006) found that the top two sources of information “about the brain and how to
keep it fit” were “medical professionals” (72%) and “the media” (59%). Roberts and colleagues (2003) reported
that Whites listed a larger number of information sources (4.6) than African Americans (3.1).
What does this review tell us about what is known about the U.S. public's perceptions about cognition?
Although we found one published study from the early 1990s, most of the identified surveys were conducted in
the past few years. Generally, this body of work documented that most adults in the United States are aware of
Alzheimer's disease. About 90% of adults reported having heard about Alzheimer's disease in 1985 when the
first survey was conducted (Steckenrider, 1993) as a more recent survey conducted 20 years later (MetLife
Foundation, 2006). Although we could classify the findings into several overarching domains, such as
knowledge, we found considerable variability among studies in the questions asked. Additionally, we found that
most surveys focused on Alzheimer's disease rather than cognitive health. The majority of studies indicated that
the U.S. public lacks specific information about Alzheimer's disease and current treatments. Consistent with
these findings, most studies reported that the respondents did not perceive themselves as very knowledgeable
about Alzheimer's disease, with generally 75% of respondents reporting not being knowledgeable. Although
several reports documented that survey respondents expressed a great deal of concern about the disease, both
from a personal perspective and the potential of caring for someone else, the perceived impact of cognitive
impairment in U.S. households is still not clear.
Caution is needed in comparing the findings across surveys. The research included a variety of age groups, with
several surveys including persons 18 years of age, whereas others included only persons 55 years and older. The
differences in populations studied in addition to the age group comparisons within studies made it impossible to
contrast these findings across studies. Most reports did not examine demographic variables, such as education
or income, that may be associated with the public's perceptions about cognition. Most of the surveys were cross-
sectional and provided only descriptive statistics. Other factors, such as wording of the survey questions and
different data collection methods, could also yield various study results. Most reports did not account for
oversampling among specific groups due to convenience sampling. Future work must focus on the research
methods to establish critical baseline data that can be used to monitor the public's perceptions about cognition
and its impact on households in the United States over time.
Despite these limitations, this review was critical in identifying gaps that future research needs to address. One
gap is that we lack consistent or well-defined terms or validated measures regarding perceptions about
cognition. For example, several of the studies examined concerns about “memory loss,” whereas other studies
explored concerns about Alzheimer's disease specifically. Given that memory loss was not defined for
participants, or information provided about how participants conceptualized this concept, it is not possible to
compare across studies. Additionally, we found few items assessing respondents‟ beliefs about cognitive health
compared with perceptions about Alzheimer's disease. Although this might be in part because of the recently
evolving science about cognitive health (Anderson & McConnell, 2007), this is clearly an area in need of
further attention. Data on how the public defines cognitive health and their perceptions about it could help
inform population-based messages and communication interventions. In addition, the use of qualitative methods
or the combined use of qualitative and quantitative methods is necessary to illuminate work in this area.
Another research gap is assessing the public's perceptions of cognition across various social and cultural
perspectives. As demonstrated by this review, relatively little is known about the perceptions of different ethnic
groups within the United States. Although we must be careful not to make generalizations within diverse
population groups in the United States, there is a clear need to better understand how social and cultural beliefs
influence perceptions about cognition. For example, as Elliott and colleague (1996) point out that traditional
Chinese explanations of dementia contrast sharply with the Western biomedical model, with symptoms
interpreted as reflecting an imbalance of “yin” and “yang” energy forms, and treatment is sought through
herbalists or acupuncturists rather than physicians. There has also been a limited amount of research conducted
on cultural perceptions of dementia among American Indians. An interesting qualitative study by Henderson
(1994) with the Oklahoma Choctaw population suggested the following beliefs to be part of its cultural
explanatory model of dementia: the notion that dementia is a part of the normal aging process, and the idea that
dementia-related behaviors are a means by which the older person communicates with the afterlife in a period
of transition to the next world. Within the African American population, “folk” beliefs about memory loss and
aging have been demonstrated to vary considerably from those of their White counterparts (Fox, Hinton, &
Levkoff, 1999). More studies with diverse populations are clearly needed to advance our understanding.
Several efforts to address the gaps in knowledge about cognitive health have already begun, initiated, and
sponsored by a variety of organizations and agencies. The Centers for Disease Control and Prevention (CDC) in
collaboration with the Alzheimer's Association and several stakeholders are in the process of developing a set of
measures to monitor the public's perceptions of the impact of cognitive impairment that could be included in a
state-based surveillance system (www.cdc.gov/BRFSS). The National Institute on Aging is pursuing research
on factors influencing cognitive health and cognitive impairment, and developing a toolkit for researchers on
measures to assess cognitive performance. Another set of studies are being undertaken the Healthy Aging
Research Network (HAN), a network of Prevention Research Centers supported by CDC's Healthy Aging
Program. The HAN has recently completed formative research to identify how diverse groups of older adults,
caregivers, and health care providers understand cognitive health. The results of some of that research are
reported in this special issue.
Several national efforts are taking place that are designed to promote awareness of cognitive health, an area
where there is an emerging research base. We provide a few examples of these efforts. The Alzheimer's
Association is continuing to offer their basic awareness workshop, Maintain Your Brain®, through their
chapters (www.alz.org). More recently, they have launched a 5-year community-based demonstration project to
promote cognitive health designed to affect knowledge and attitudes among African American baby boomers.
The AARP is also partnering with the Dana Alliance for Brain Health to increase awareness about cognitive
health through their Staying Sharp® program (www.aarp.org).
Several factors should be considered when addressing the findings of this review. Although we used
complementary approaches to identify surveys, it is possible that we did not uncover every item concerned with
cognition in the literature. We consulted with experts who conducted seminal surveys in this field and
facilitated contact with other survey researchers who provided additional studies. Thus, the likelihood that we
missed surveys that contained data that were significantly different from those that we characterized is small. It
is important to note that we excluded studies that examined potential discrimination about persons with
Alzheimer's disease and experimental studies concerned with memory and aging stereotypes (Hawley, Cherry,
Su, Chiu, & Jazwinski, 2006; Ryan, 1992; Ryan & See, 1993; Werner, 2005). Another consideration is that we
only characterized surveys that were performed in English, and our findings might not apply to surveys that
were directed toward non-English speakers. Finally, our review reflects the data on U.S. samples, and we did
not characterize studies from other countries. Based on our review of the literature, we found several
investigations on the public's perceptions that were conducted in numerous countries, such as Australia, Canada,
the United Kingdom, Brazil, Israel, Norway, and Turkey. Other investigators might consider reviewing the
broader literature. However, given the current limitations in survey methods among U.S. studies, such a review
presents several potential methodological challenges.
Critical next steps are needed to better understand knowledge, beliefs, and concerns about cognition among the
general public, particularly in diverse social and cultural groups. Additionally, this research should be expanded
to examine issues such as early diagnosis and care-seeking behavior. Future work is also needed to understand
the perceptions of health care providers and family caregivers. Only by addressing what people know and
understanding their perceptions can we develop targeted and effective strategies to enhance knowledge and
beliefs about cognitive impairment and health. If the public's cognitive “health literacy” is not improved, this
may impede public acceptance and successful implementation of evidence-based strategies addressing cognitive
health, as well as early diagnosis, treatment, and management of cognitive impairment.
Funding was made possible in part by cooperative agreements U58 DP-525058, 1-U48-DP-000048, and 1-U48-
DP-000052, and Special Interest Project 8-06 from the CDC.
Conflict of Interest
The findings and conclusions in this report are those of the authors and do not necessarily represent the official
position of the CDC or other institutions with which the authors are affiliated.
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