GENE THERAPY FOR NEUROLOGICAL DISORDERS

Release Date:  July 19, 2001

RFA:  RFA-NS-02-007

National Institute of Neurological Disorders and Stroke
National Institute of Child Health and Human Development
National Institute on Aging
National Institute of Diabetes and Digestive and Kidney Diseases
National Institute on Deafness and Other Communications Disorders

Letter of Intent Receipt Date:  October 15, 2001
Application Receipt Date:       November 16, 2001

THIS RFA USES "MODULAR GRANT" AND "JUST-IN-TIME" CONCEPTS.  USE THE MODULAR 
BUDGET INSTRUCTIONS THAT BEGIN ON PAGE 13 IN THE PHS 398 (REVISION 5/2001) 
AVAILABLE AT http://grants.nih.gov/grants/funding/phs398/phs398.html.

PURPOSE

The goal of this Request for Applications (RFA) is to accelerate the 
translation of gene transfer methodologies into the clinic.  Gene therapy 
holds tremendous promise for the treatment of neurological disorders.  
Despite recent advances in this area however, specific scientific, 
technological, and safety goals must be achieved before gene transfer becomes 
a viable therapeutic alternative.   Current needs include more effective 
methods for controlling the expression of therapeutic transgenes in the 
brain, better strategies for vector delivery and monitoring transgene 
expression, more studies addressing the toxicity of specific vector/transgene 
combinations, and greater knowledge of the long term effects of expressing 
specific transgenes in the nervous system.  This RFA is intended to encourage 
research projects that address these or related translational issues in the 
context of specific neurological disorders.

RESEARCH OBJECTIVES

Background

Gene transfer methodologies may ultimately be used to treat a broad spectrum 
of diseases that affect the nervous system. These include neurodegenerative 
disorders (Parkinson’s disease, Alzheimer’s disease, amyotrophic lateral 
sclerosis, Huntington’s disease, etc.), stroke, epilepsy, and many genetic 
diseases (lysosomal storage disorders, muscular dystrophies, 
neurofibromatosis, etc.).  There is also significant potential for the 
application of gene therapy to the neural periphery, such as the auditory 
system, since a number of genes that cause sensorineural deafness have been 
isolated. For all these disorders, gene therapy could be used to supply gene 
products that prevent disease onset or progression.  Gene therapy also holds 
great promise for the treatment of injury to the brain or spinal cord, as 
well as for the amelioration of chronic pain.

The brain and nervous system present unique challenges to achieving 
successful gene transfer.  Because the brain contains many distinct cell 
types and is regionally heterogeneous, determining how to deliver therapeutic 
genes effectively is critical.  The presence of the blood-brain barrier, 
limited access to the brain, and the post-mitotic state of brain cells make 
introducing genes and ensuring that they are correctly expressed difficult.  
Finally, although the brain is comparatively isolated from immunological 
surveillance, immune and inflammatory responses can occur, thereby damaging 
neural tissue.

Recent studies indicate that, despite these problems, gene transfer has great 
potential as a therapeutic modality.  Through genetic manipulation, the 
identification of spontaneous mutations, and drug treatment, investigators 
have developed animal models for a variety of neurological disorders.  Using 
modified viral vectors, liposomes, genetically-modified cells, or direct DNA 
transfer, researchers have delivered a variety of therapeutic genes into 
these animal models.  Among these have been genes encoding growth factors, 
enzymes, anti-apoptotic proteins, anti-oxidant molecules, and anti-
angiogenesis factors. Researchers have attempted gene replacement therapy in 
animals lacking a particular gene product, and have used antisense or 
ribozyme technologies to reduce the expression of dominantly acting gene 
products.  Many of these pre-clinical experiments have been extremely 
successful.  For example, in a recent NINDS-sponsored workshop (Gene Therapy 
for Neurological Disorders, October 23-24, 2000), investigators described the 
successful treatment of animal models of Parkinson’s disease and of specific 
lysosomal storage disorders.  A summary of this meeting has been published 
(see Molecular Therapy 3: 3-7, 2001).

Scope

This RFA is intended to encourage projects that, if successful, will overcome 
obstacles blocking the translation of gene transfer techniques into the 
clinic.  Proposed projects should relate directly to a neurological disorder 
relevant to the research missions of NINDS, NICHD, NIA, NIDCD or NIDDK.
These missions are described at:
http://www.ninds.nih.gov/about_ninds/plans/strategic_plan.htm (NINDS) 
http://www.nichd.nih.gov/strategicplan/cells (NICHD) 
http://www.nih.gov/nia/research/extramural/neuroscience/programs.htm and 
http://www.nih.gov/nia/strat-plan/2001-2005/ (NIA),
http://www.nidcd.nih.gov/about/plans/strategic/health_disp.asp (NIDCD)
http://www.niddk.nih.gov/fund/program/topicslist.htm (NIDDK)

Projects should focus on specific scientific, technological, or safety issues 
that must be addressed prior to the initiation of clinical trials.

Possible scientific/technological goals include, but are not limited to:

O The development of improved inducible vectors that permit effective 
temporal control over transgene expression.
O The design of vectors with regulatory elements that permit gene expression 
to be targeted to specific brain regions, peripheral neural tissues, or to 
other cell types of therapeutic interest.
O The development of methods that achieve higher transduction efficiencies 
and high-level, stable transgene expression in the nervous system.
O The development of techniques that permit improved focal or global delivery 
of vectors into the brain or peripheral neural tissues.
O The development of improved methods for monitoring transgene expression in 
the brain.

Safety issues, because of their paramount importance, should be addressed in 
all projects.  Possible safety-related goals include, but are not limited to:

O Toxicology studies and the determination of optimal dosage regimens for 
specific vector/transgene constructs.
O The investigation of the long-term effects of expression of specific 
therapeutic transgenes.
O The development of viral vectors that overcome problems of toxicity and 
immune response.
O The use of large animal models to address safety issues.

SPECIAL REQUIREMENTS

Plan for Dissemination of Data and Biomaterials

Sharing of data and biological materials in a timely manner is essential for 
the rapid progress of biomedical research.  NIH policy requires that 
investigators make unique research resources readily available for research 
purposes to qualified individuals within the scientific community when they 
have been published (see the NIH Grants Policy Statement at 
http://grants.nih.gov/grants/guide/notice-files/not96-184.html) 

To promote the dissemination of research results, applicants who respond to 
this RFA must propose plans for sharing data and biomaterials generated 
through the grant.  Rapid sharing of data and biomaterials is strongly 
encouraged.  The Initial Review Group will evaluate the proposed sharing plan 
and comment on its adequacy in an administrative note in the summary 
statement. NIH staff will consider the adequacy of the plan in selecting 
grants to be awarded.

National Gene Vector Laboratories

An obstacle facing gene transfer investigators is obtaining high quality 
vectors and evaluating their safety. The National Gene Vector Laboratories 
(NGVLs) were established in 1995 by the NIH to produce clinical grade vectors 
for human gene transfer protocols and perform toxicology studies using these 
vectors.  Where appropriate, investigators are encouraged to utilize the 
NGVLs (for further information, see http://www.iupui.edu/~iucc/ngvl/).

MECHANISM OF SUPPORT

This RFA will use the NIH individual research project grant (R01) and 
exploratory/developmental grant (R21) mechanisms. For this solicitation, 
participating NIH Institutes will use the NINDS guidelines for the R21 
mechanism, which can be found at 
http://www.ninds.nih.gov/funding/r21guidelines.htm. As described in these 
guidelines, R21 proposals should have the potential for groundbreaking 
impact, be restricted to a maximum of $125,000/year (direct costs), and 
limited in duration to a maximum of two years. Applicants are encouraged to 
contact program staff for advice about choosing the appropriate grant 
mechanism.

For all competing individual research project grant applications 
requesting up to $250,000 direct costs per year, specific application 
instructions have been modified to reflect "MODULAR GRANT" and "JUST-IN-TIME" 
streamlining efforts being examined by NIH.  Complete and detailed 
instructions and information on Modular Grant applications can be found at:  
http://grants.nih.gov/grants/funding/modular/modular.htm.  Applications that 
request more than $250,000 in any year must use the standard PHS 398 (rev. 
5/01) application instructions.

The total project period for an application submitted in response to this RFA 
may not exceed five years.

Responsibility for the planning, direction, and execution of the proposed 
project will be solely that of the applicant. This RFA is a one-time 
solicitation.  Future unsolicited competing continuation applications will 
compete with all investigator-initiated applications and be reviewed 
according to the customary peer review procedures.  The earliest anticipated 
award date is July 1, 2002.

For administrative reasons, all applications received in response to this 
solicitation will be assigned initially to NINDS.  After discussions among 
the participating Institutes following review, applications will be 
reassigned to the Institute(s) that are programmatically most appropriate.  
Because the scope of the research proposed in response to this RFA 
encompasses the interests of several NIH Institutes, applications may receive 
dual assignments based on the established PHS guidelines.  Awards will be 
made and managed by one of the participating NIH institutes.

FUNDS AVAILABLE

The participating Institutes intend to commit a total of approximately 
$5,000,000 in FY 2002 to fund approximately 8 to 12 new grants submitted in 
response to this RFA. Because the nature and scope of the research proposed 
may vary, it is anticipated that the size of each award will also vary. 
Although the financial plans of the Institute provide support for this 
program, awards pursuant to this RFA are contingent upon the availability of 
funds and the receipt of a sufficient number of meritorious applications. 

ELIGIBILITY REQUIREMENTS

Applications may be submitted by domestic and foreign, for-profit and non-
profit organizations, public and private, such as universities, colleges, 
hospitals, laboratories, units of State and local governments, and eligible 
agencies of the Federal government. Investigators from foreign institutions 
are encouraged to contact program staff before preparing applications.  
Racial/ethnic minority individuals, women, and persons with disabilities are 
encouraged to apply as Principal Investigators.

INQUIRIES

Inquiries concerning this RFA are encouraged.  The opportunity to clarify any 
issues or answer questions from potential applicants is welcome.

Direct inquiries regarding programmatic issues to:

Dr. Robert Finkelstein
NINDS
Neuroscience Center, Rm 2143
6001 Executive Blvd.
Bethesda, MD  20892-9527
Telephone:  (301) 496-5745
FAX:  (301) 402-1501
Email:  finkelsr@ninds.nih.gov

Dr. Mary Lou Oster-Granite
Mental Retardation and Developmental Disabilities Branch
NICHD
6100 Executive Boulevard, Rm 4B09D, MSC 7510
Bethesda, MD 20892-7510
Telephone: (301) 435-6866
FAX: (301) 496-3791
E-mail: mo96o@nih.gov

Dr. Bradley C. Wise
Neuroscience and Neuropsychology of Aging Program
NIA
Gateway Building, Suite 3C307
7201 Wisconsin Avenue MSC 9205
Bethesda, MD 20892-9205
Telephone: (301) 496-9350
FAX: (301) 496-1494
Email: WiseB@nia.nih.gov

Dr. Thomas M. Johnson
Scientific Programs Branch
NIDCD
Executive Plaza South-400C
6120 Executive Blvd.
Bethesda, MD 20892-7180
Telephone: 301-402-3461
FAS: 301-402-6251
Email: tj65y@nih.gov

Dr. Catherine McKeon
Division of Diabetes, Endocrinology and Metabolic Diseases
NIDDK
6707 Democracy Blvd.
Rm 6103, MSC 5460
Bethesda, MD 20892-5460
Telephone: (301) 594-8810
FAX:  (301) 480-3503
Email: Catherine.McKeon@nih.gov

Direct inquiries regarding review issues to:

Dr. Lillian Pubols
Scientific Review Branch
NINDS
Neuroscience Center, Rm 3208
Bethesda, MD 20892
Telephone: (301) 496-9223
FAX: (301) 402-0182
Email: LP28E@nih.gov


Direct inquiries regarding fiscal matters to:

Ms. Tina Carlisle
Grants Management Branch
NINDS
6001 Executive Boulevard, Rm 3290
Bethesda, MD 20892
Telephone: (301) 496-3938
Email: carlislt@ninds.nih.gov

LETTER OF INTENT

Prospective applicants are asked to submit a letter of intent that includes a 
descriptive title of the proposed research, the name, address, and telephone 
number of the Principal Investigator, the identities of other key personnel 
and participating institutions, and the number and title of the RFA in 
response to which the application may be submitted.  Although a letter of 
intent is not required, is not binding, and does not enter into the review of 
a subsequent application, the information that it contains allows IC staff to 
estimate the potential review workload and plan the review.

The letter of intent is to be sent to Dr. Robert Finkelstein (see Inquiries) 
by the date listed below.

SCHEDULE SUMMARY

Letter of Intent Receipt Date:    October 15, 2001
Application Receipt Date:         November 16, 2001
Peer Review Date:                 February, 2002
Council Review:                   May, 2002
Earliest Anticipated Start Date:  July 1, 2002

APPLICATION PROCEDURES

The modular grant concept establishes specific modules in which direct costs 
may be requested as well as a maximum level for requested budgets. Only 
limited budgetary information is required under this approach.  The just-in-
time concept allows applicants to submit certain information only when there 
is a possibility for an award. It is anticipated that these changes will 
reduce the administrative burden for the applicants, reviewers and NIH 
staff.  The research grant application form PHS 398 (rev. 5/2001) at 
http://grants.nih.gov/grants/funding/phs398/phs398.html is to be used in 
applying for these grants, with modular budget instructions beginning on page 
13 of the application instructions.  Applicants are permitted, however, to 
use the 4/1998 revision of the PHS 398 for scheduled application receipt 
dates until January 9, 2002.  If you are preparing an application using the 
4/1998 version, please refer to the step-by-step instructions for Modular 
Grants available at http://grants.nih.gov/grants/funding/modular/modular.htm 
.

SPECIFIC INSTRUCTIONS FOR MODULAR GRANT APPLICATIONS

The modular grant concept establishes specific modules in which direct costs 
may be requested as well as a maximum level for requested budgets. Only 
limited budgetary information is required under this approach.  The 
just-in-time concept allows applicants to submit certain information only 
when there is a possibility for an award. It is anticipated that these 
changes will reduce the administrative burden for the applicants, reviewers 
and NIH staff.  The research grant application form PHS 398 (rev. 5/2001) at 
http://grants.nih.gov/grants/funding/phs398/phs398.pdf is to be used in 
applying for these grants, with the modifications noted below.  Applicants 
are permitted, however, to use the 4/1998 revision of the PHS 398 for 
scheduled application receipt dates until January 9, 2002.  If you are 
preparing an application using the 4/1998 version, please refer to the step-
by-step instructions for Modular Grants available at 
http://grants.nih.gov/grants/funding/modular/modular.htm.

The RFA label available in the PHS 398 (rev. 5/2001) application form 
(http://grants.nih.gov/grants/funding/phs398/labels.pdf) must be affixed to the 
bottom of the face page of the application.  Type the RFA number on the label.  
Failure to use this label could result in delayed processing of the application such 
that it may not reach the review committee in time for review.  In addition, 
the RFA title and number must be typed on line 2 of the face page of the 
application form and the YES box must be marked.

Submit a signed, typewritten original of the application, including the 
Checklist, and three signed, photocopies, in one package to:

CENTER FOR SCIENTIFIC REVIEW
NATIONAL INSTITUTES OF HEALTH
6701 ROCKLEDGE DRIVE, ROOM 1040, MSC 7710
BETHESDA, MD  20892-7710
BETHESDA, MD  20817 (for express/courier service)

At the time of submission, two additional copies of the application must be 
sent to:

Dr. Lillian M. Pubols
Scientific Review Branch, NINDS
6001 Executive Blvd.
NSC Rm 3208, MSC 9529
Bethesda, MD 20892-9529
(for courier delivery use: Rockville, MD 20852)

Applications must be received by the application receipt date listed in the 
heading of this RFA.  If an application is received after that date, it will 
be returned to the applicant without review.
  
The Center for Scientific Review (CSR) will not accept any application in 
response to this RFA that is essentially the same as one currently pending 
initial review, unless the applicant withdraws the pending application.  The 
CSR will not accept any application that is essentially the same as one 
already reviewed. This does not preclude the submission of substantial 
revisions of applications already reviewed, but such applications must 
include an introduction addressing the previous critique.

REVIEW CONSIDERATIONS

Upon receipt, applications will be reviewed for completeness by the CSR and 
responsiveness by NIH staff.  Incomplete and/or non-responsive applications 
will be returned to the applicant without further consideration.

Applications that are complete and responsive to the RFA will be evaluated 
for scientific and technical merit by an appropriate peer review group 
convened by the NINDS Scientific Review Branch in accordance with the review 
criteria stated below.  As part of the initial merit review, all applications 
will receive a written critique and undergo a process in which only those 
applications deemed to have the highest scientific merit, generally the top 
half of the applications under review, will be discussed, assigned a priority 
score, and receive a second level review by the appropriate National Advisory 
Council or Board.

Review Criteria

The goals of NIH-supported research are to advance our understanding of 
biological systems, improve the control of disease, and enhance health.  In 
the written comments reviewers will be asked to discuss the following aspects 
of the application in order to judge the likelihood that the proposed 
research will have a substantial impact on the pursuit of these goals.  Each 
of these criteria will be addressed and considered in assigning the overall 
score, weighting them as appropriate for each application.  Note that the 
application does not need to be strong in all categories to be judged likely 
to have major scientific impact and thus deserve a high priority score.  For 
example, an investigator may propose to carry out important work that by its 
nature is not innovative but is essential to move a field forward.

(1) Significance:  Does this study address an important problem? If the aims 
of the application are achieved, how will scientific knowledge be advanced?  
What will be the effect of these studies on the concepts or methods that 
drive this field?

(2) Approach:  Are the conceptual framework, design, methods, and analyses 
adequately developed, well-integrated, and appropriate to the aims of the 
project?  Does the applicant acknowledge potential problem areas and consider 
alternative tactics?

(3) Innovation:  Does the project employ novel concepts, approaches or 
method? Are the aims original and innovative?  Does the project challenge 
existing paradigms or develop new methodologies or technologies?

(4) Investigator:  Is the investigator appropriately trained and well suited 
to carry out this work?  Is the work proposed appropriate to the experience 
level of the principal investigator and other researchers (if any)?

(5) Environment:  Does the scientific environment in which the work will be 
done contribute to the probability of success?  Do the proposed experiments 
take advantage of unique features of the scientific environment or employ 
useful collaborative arrangements?  Is there evidence of institutional 
support?

(6) Sharing plan:  Has the investigator proposed an adequate plan to make all 
data and biological materials collected and produced as a result of the 
proposed research accessible in a timely manner to the biomedical research 
community?

(7) R21 applications only:  Does this project have the potential for 
groundbreaking impact?  If successful, will this project achieve at least one 
of the following goals: 1) generate pilot data to assess the feasibility of a 
novel avenue of investigation? 2) involve high risk experiments that could 
lead to a breakthrough in a particular field? or 3) demonstrate the 
feasibility of new technologies that could have major impact in a specific 
area?

In addition to the above criteria, in accordance with NIH policy, all 
applications will also be reviewed with respect to the following:

o  The adequacy of plans to include both genders, minorities and their 
subgroups, and children as appropriate for the scientific goals of the 
research.  Plans for the recruitment and retention of subjects will also be 
evaluated.

o  The reasonableness of the proposed budget and duration in relation to the 
proposed research.

o  The adequacy of the proposed protection for humans, animals or the 
environment, to the extent they may be adversely affected by the project  
proposed in the application.

AWARD CRITERIA

Award criteria that will be used to make award decisions include:

o  scientific merit (as determined by peer review)
o  availability of funds
o  programmatic priorities
o  adequacy of proposed sharing plan

INCLUSION OF WOMEN AND MINORITIES IN RESEARCH INVOLVING HUMAN SUBJECTS

It is the policy of the NIH that women and members of minority groups and 
their sub-populations must be included in all NIH-supported biomedical and 
behavioral research projects involving human subjects, unless a clear and 
compelling rationale and justification are provided indicating that inclusion 
is inappropriate with respect to the health of the subjects or the purpose of  
the research.  This policy results from the NIH Revitalization Act of 1993 
(Section 492B of Public Law 103-43). 

All investigators proposing research involving human subjects should read the 
UPDATED "NIH Guidelines for Inclusion of Women and Minorities as Subjects in 
Clinical Research," published in the NIH Guide for Grants and Contracts on 
August 2, 2000 
(http://grants.nih.gov/grants/guide/notice-files/NOT-OD-00-048.html); 
a complete copy of the updated Guidelines are available at 
http://grants.nih.gov/grants/funding/women_min/guidelines_update.htm.  The 
revisions relate to NIH defined Phase III clinical trials and require: a) all 
applications or proposals and/or protocols to provide a description of plans 
to conduct analyses, as appropriate, to address differences by sex/gender 
and/or racial/ethnic groups, including subgroups if applicable; and b) all 
investigators to report accrual, and to conduct and report analyses, as 
appropriate, by sex/gender and/or racial/ethnic group differences.

INCLUSION OF CHILDREN AS PARTICIPANTS IN RESEARCH INVOLVING HUMAN SUBJECTS

It is the policy of NIH that children (i.e., individuals under the age of 21) 
must be included in all human subjects research, conducted or supported by 
the NIH, unless there are scientific and ethical reasons not to include them.  
This policy applies to all initial (Type 1) applications submitted for 
receipt dates after October 1, 1998.

All investigators proposing research involving human subjects should read the 
"NIH Policy and Guidelines" on the Inclusion of Children as Participants in 
Research Involving Human Subjects that was published in the NIH Guide for 
Grants and Contracts, March 6, 1998, and is available at the following URL 
address: http://grants.nih.gov/grants/guide/notice-files/not98-024.html
Investigators also may obtain copies of these policies from the program staff 
listed under INQUIRIES.  Program staff may also provide additional relevant 
information concerning the policy.

URLS IN NIH GRANT APPLICATIONS OR APPENDICES

All applications and proposals for NIH funding must be self-contained within 
specified page limitations.  Unless otherwise specified in an NIH 
solicitation, internet addresses (URLs) should not be used to provide 
information necessary to the review because reviewers are under no obligation 
to view the Internet sites.  Reviewers are cautioned that their anonymity may 
be compromised when they directly access an Internet site.

PUBLIC ACCESS TO RESEARCH DATA THROUGH THE FREEDOM OF INFORMATION ACT

The Office of Management and Budget (OMB) Circular A-110 has been revised to 
provide public access to research data through the Freedom of Information Act 
(FOIA) under some circumstances.  Data that are (1) first produced in a 
project that is supported in whole or in part with Federal funds and (2) 
cited publicly and officially by a Federal agency in support of an action 
that has the force and effect of law (i.e., a regulation) may be accessed 
through FOIA.  It is important for applicants to understand the basic scope 
of this amendment.  NIH has provided guidance at:
http://grants.nih.gov/grants/policy/a110/a110_guidance_dec1999.htm

Applicants may wish to place data collected under this RFA in a public 
archive, which can provide protections for the data and manage the 
distribution for an indefinite period of time.  If so, the application should 
include a description of the archiving plan in the study design and include 
information about this in the budget justification section of the 
application. In addition, applicants should think about how to structure 
informed consent statements and other human subjects procedures given the 
potential for wider use of data collected under this award.

REQUIRED EDUCATION ON THE PROTECTION OF HUMAN SUBJECT PARTICIPANTS

NIH policy requires education on the protection of human subject participants 
for all investigators submitting NIH proposals for research involving human 
subjects.  This policy announcement is found in the NIH Guide for Grants and 
Contracts Announcement dated June 5, 2000, at the following website:  
http://grants.nih.gov/grants/guide/notice-files/NOT-OD-00-039.html.

HEALTHY PEOPLE 2010

The Public Health Service (PHS) is committed to achieving the health 
promotion and disease prevention objectives of "Healthy People 2010," a PHS-
led national activity for setting priority areas.  This Request for 
Applications (RFA), Gene Therapy for Neurological Disorders, is related to 
many of the priority areas.  Potential applicants may obtain a copy of 
"Healthy People 2010" at http://www.health.gov/healthypeople/.

AUTHORITY AND REGULATIONS

This program is described in the Catalog of Federal Domestic Assistance No. 
93.853 (NINDS), 93.865 (NICHD), 93.866 (NIA), 93.173 (NIDCD), and 93.847 
(NIDDK).  Awards are made under authorization of Sections 301 and 405 of the 
Public Health Service Act as amended (42 USC 241 and 284) and administered 
under NIH grants policies and Federal Regulations 42 CFR 52 and 45 CFR Parts 
74 and 92.  This program is not subject to the intergovernmental review 
requirements of Executive Order 12372 or Health Systems Agency review.

The PHS strongly encourages all grant recipients to provide a smoke-free 
workplace and promote the non-use of all tobacco products.  In addition, 
Public Law 103-227, the Pro-Children Act of 1994, prohibits smoking in 
certain facilities (or in some cases, any portion of a facility) in which 
regular or routine education, library, day care, health care, or early 
childhood development services are provided to children.  This is consistent 
with the PHS mission to protect and advance the physical and mental health of 
the American people.


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