This transcript is auto generated and unedited.
>> Howard Bauchner: Hello and welcome to Conversations with Dr. Bauchner. Once again, it is Howard Bauchner, Editor and Chief of JAMA. And what a privilege today to be joined by Nancy Messonnier. I've had many requests from the JAMA family to have Nancy on, so Nancy thank you for joining me today.
>> Nancy Messonnier: It's a real pleasure to be with you.
>> Howard Bauchner: So, Nancy is the Director of the National Center for Immunization and Respiratory Diseases and probably knows as much about respiratory diseases and vaccines as anyone in the world. So, Nancy I want to start with-- I was-- I got up yesterday, I was reading the newspaper, and on one column it said J and J vaccine successful against and they named a variant. An opposite article said, numerous vaccines failing against variants. I'm assuming you've read the same reports. As one of the world's experts, how do you think about that, how do you think the public thinks about that?
>> Nancy Messonnier: Yeah, really interesting and of course timely question. You know, viruses mutate. We know they mutate. And so, the appearance of mutants of COVID-19 shouldn't surprise any of us. But of course, one of the important things to know is that our mitigation measures, wearing a mask, socially distancing, those things look like they work just as well against these variants. The question on everyone's mind, of course, is how does this impact the effectiveness of the vaccines that we have and the vaccines that are coming down the pike? There's been some research, in vitro, looking at this, that suggest that the mRNA vaccines may work, but of course it's in vitro data, and what you really want is real-world data. For the J and J vaccines, there's some data against some variants that were part of what was seen during the clinical trial, but of course the virus is continuing to change and we don't know what the variants that evolve will be like tomorrow. For me, frankly, I think that what we need to do now and what we need to be communicating to our patients is we need to be full steam ahead in vaccination. Right now, there is no reason to have any confidence that the variants will impact the effectiveness of the vaccine, and so we need to keep moving forward with increasing vaccination coverage. But at the same time, we need to be doing the careful studies to evaluate the effectiveness of vaccine and to see if it's going to impact our vaccine recommendations.
>> Howard Bauchner: Nancy, have you been surprised at the speed with which the variants have emerged? I mean, B117, B351, the P variant from South America, and now this new E variant that I don't quite understand. Have you been surprised about the rapidity with which these variants of concern have emerged?
>> Nancy Messonnier: Yeah, I don't think I'm surprised. I do think that one of the things that's happening now is everyone across the world is increasing their sequencing efforts, and that's great. That's what we need to give us better situational awareness, but it also is going to mean that we're going to find more variants. The trick is understanding the clinical impact of those variants and if they impact transmission, if they impact severity of disease, and of course, if they impact the effectiveness of vaccine. There's a lot of unanswered questions and, you know, every time we stump ourselves, we have to go back and remember that this is a virus that didn't exist a year ago in our consciousness, so we're going to continue to accumulate knowledge. We're going to continue to accumulate wisdom and it may change our recommendations, but for now we need to keep moving.
>> Howard Bauchner: In the short run, the next few weeks to the next few months, is the goal to stay the course? So, we have two mRNA vaccines that have been approved, two doses each, 21 and 28 days apart. I know you've broken away from hearing the J and J presentation and I really want to thank you, but I'm assuming it will be approved, and so that would be then the third vaccine. The advisory committee on immunization practices will weigh in because we'll get to some of the questions about two mRNA vaccines and the J and J vaccine. Is it to stay the course, just to continue with Moderna and Pfizer and then hopefully the J and J, and at the moment not be conscious of which variants are emerging where and what do we know about that vaccine and that variant?
>> Nancy Messonnier: I might say it a little differently, but I agree.
>> Howard Bauchner: Okay.
>> Nancy Messonnier: There is a huge, robust, international effort to study these variants and that needs to keep going full steam ahead. On the other side, on the vaccine side, we need to continue with our vaccine program, but stay the course isn't the word I would use.
>> Howard Bauchner: Okay.
>> Nancy Messonnier: I would say we need to continue to build momentum. You know, it shouldn't be surprising that it's taking us a little while to build momentum. We're doing an unprecedented thing trying to vaccinate the entire country in a really short period of time, with vaccines that providers haven't seen and used before, and vaccines that are slightly complicated. So, it's not surprising that there have been bumps in the road and that the initial rollout was a little slower than some folks wanted. Providers getting more used to the vaccine, getting more used to the storage and handling requirements, and the public is getting the information they need to build confidence. So, in my mind, what we're doing is building momentum. And as the vaccine supply increases, I hope we'll continue to build that momentum. So, it's not stay the course, it's let's keep-- let's keep building.
>> Howard Bauchner: About 10 days ago, before the weather really struck the U.S., we had finally reached about 1.5 to 1.7 injections a day. It's not people, because it's an odd count. And then it dipped over the last week or so because, in part because of the very poor weather and I-- the last two or three days have been more encouraging. Do you think we can consistently get above 1.5 million injections given a day?
>> Nancy Messonnier: Yeah, I think we can even do better than that. Folks need to realize that the limitations in vaccine supply remain an issue. I hear every day from people, from providers who say if you can give me more vaccine, I could go faster. And so, what I'm really hoping is that over the next month we see a growth in the number of doses of vaccine available every week and that we're able to meet that with programs that are really revving up. We've started a whole series of programs at a low level now so that we're ready when vaccine supply increases. What I don't ever want is vaccine-- vaccines sitting on a shelf because we don't have the mechanisms in which to administer it.
>> Howard Bauchner: Is your information for Moderna and Pfizer, and I don't know what you know or what you can say, that the supply will increase over the next month or two, and that J and J can then deliver I read a report 20 million doses by the end of next month. What's your notion of the supply form the, what would be then the three manufacturers?
>> Nancy Messonnier: Yeah, what I'm told is that there will be enough supply for every American adult by summer. And so, if you kind of map that out, it means within the next couple months we see that supply build and build every week, and that's why, you know, we're locked in this setting of limited supply and needing to prioritize and all the real difficulties of doing that, we do need to focus on that now, but frankly we also need to be ready if in a month the supply unleashes and then we really need to be ready to focus on how we do it quickly.
>> Howard Bauchner: You're-- you're one of the country's experts about the challenges of truly delivering a vaccine from where its manufactured to distributing it to a clinician who can then actually immunize an individual. Where have the biggest struggles been in the U.S.?
>> Nancy Messonnier: I think every piece of that chain has been difficult and complicated because we're trying to do it fast, under unprecedented pressure, during a pandemic, with all the inherent difficulties of social distancing that make really everything so much harder. So, I think, every part of it has been really difficult. I've definitely been focused more lately on the far edge of that, which is the place where vaccine needs to be easily accessible to every part of every community. But equally, people need to be ready to roll up their sleeves when the vaccine gets there, and that means lots of education, lots of community engagement, lots of conversations to make folks-- make sure that folks are getting their questions answered by people that they trust so that when the vaccine gets there, they don't have hesitation; they're confident that it's safe and effective.
>> Howard Bauchner: I want to do one more general question, and then I want to return to some specific questions about vaccines. Israel's begun to experiment with something called the Green Pass, where there's incentives built in if people get vaccinated. And I was talking to someone who's a help officer at a university and she was trying to convince some of the college students that they need to get vaccinated, and they were saying, well you want me to get vaccinated, but then you still restrict all my activities, so why should I get vaccinated? What's the incentive? Do you have a notion that we need to begin to think for the last 20 or 25% of the population, whoever they are, who are hesitant; they're interested they want long term-- longer term follow up, they need to have a conversation with a provider. Do we need to begin to think about incentives?
>> Nancy Messonnier: Yeah, I think that's an interesting question. If you look at the range of people on a scale from people who are absolutely going to get the vaccine the minute, they're eligible to, at the far end, some people that will never get the vaccine because they have too much fear or too many questions that are unanswerable. There are many people in the middle, and I really hope that as we build the programs in the U.S. and as people see their neighbors and friends and colleagues getting vaccinated safely and effectively, it'll start building that societal confidence in vaccines. In the nearer term, I think you're asking a really important question, which is many of us are asking ourselves, if I'm fully vaccinated, does that mean that I can go visit my family and friends without a mask and without keeping social distancing. The issue of course is that what you want to know is whether the vaccine will protect you, not only from getting the disease, but will also protect you from transmitting to somebody else. These vaccines are very effective. No vaccine is absolutely 100% effective and with this conversation around variants, of course, there's a concern about the impact of variants on vaccine effectiveness. That being said, I do agree that it would motivate a lot of people to get vaccinated if they felt like they could-- they could let loose some of those restrictions and get back to seeing and hugging their family and friends. There are active conversations going on about just that at CDC, and I'm really hoping within the next few weeks that there will be more information to share.
>> Howard Bauchner: Now let's go through some of the questions that always come across my desk, either as submission or when I do livestreams. It's come up repeatedly, but because of who you are I really would like you to weigh in on this debate, this discussion about one way of getting more supply is to double or triple the time between the Moderna and Pfizer first and second doses. What's your sense of that, Nancy?
>> Nancy Messonnier: Yeah, so those conversations, I think, are rooted in the moment that we're at now, which is the limitations of vaccine supply. So, I understand that everyone wants to be able to maximize the available doses. But there also are many other things going on at the same time, and specifically, as we were just talking about, the questions of how variants would impact the vaccine effectiveness. For me, right now, the vaccines have been studied and approved, authorized, recommended, as a two-dose schedule, our programs are built on that, we've communicated that to the public, and I just don't think there's enough science yet to tell us that it's a moment to change what we know to be an effective regimen. I also think that we need to remember that the efficacy that we need is not just efficacy today, it's also efficacy that's going to endure, and folks don't to just be protected themselves; we also all want to contribute to herd immunity. So, for me, right now, it's the wrong moment to dial back. We're looking at the science carefully. There will be additional discussion of these issues at Monday's advisory committee on immunization practices meeting, and we're certainly watching to see as [inaudible].
>> Howard Bauchner: Just as a follow up, it's come in as a question. Mike Berkowitz is sending it to me on my phone, so I'm looking down, I apologize. The notion that if someone knows that they've had COVID-19, whether it's documented in the medical record or not, I think most people would want it to be documented in the medical record. Firstly, should they wait to be vaccinated a certain period of time? And then secondly, would they only need a single dose of Moderna or Pfizer?
>> Nancy Messonnier: So, there is some data that says that after somebody has symptomatic COVID and they get a single dose of vaccine they have really high antibody levels, leading to the question of whether one dose is enough and the other question is will you experience more side effects if you get vaccinated in close proximity to the time that you have had COVID? I can tell you those are two also really complicated questions, and for me, that's one of the reasons that we have an advisory committee on immunization practices, to wrestle with those kind of questions for us. Both of those things are going to be discussed at Monday's ACIP meeting.
>> Howard Bauchner: Yet another question crosses my desk, has come in through the telephone. Moderna and Pfizer, 95% reportedly, whatever J and J is, it will be less. They'll all have different effects visa vi the variants, but let's say J and J is 70%, Moderna, Pfizer are 95% in protecting against serious disease or death. Can you imagine recommendations that Moderna and Pfizer be reserved for the highest risk individuals and potentially J and J for those that are less high risk? And this may hopefully come to be true in a few weeks. So, this is not a question for six months away. This is not a theoretical question, and the only reason for me to think about the question now is so that when J and J is immediately provided that we've already thought through who we want to prioritize in getting which vaccine.
>> Nancy Messonnier: Yeah, I can understand where that question's coming from. You know, one of the things about the U.S. system is that we have a very transparent system where we wrestle with these things in plain air, and so the FDA's VRBPAC meeting is televised so anyone can listen in and I expect this afternoon for there to be active discussion about exactly those issues.
>> Howard Bauchner: Okay.
>> Nancy Messonnier: The problem in this situation is there is not a clinical trial that compares the same-- compares the three vaccines in a single study. And so, the evaluation that you're doing is basically across different studies with different end points and different study designs, and I really think we need to be careful not to read into the data to look across the studies when they are so different, but instead to take each vaccine individually and try to look at its best-- it's best evaluation. I think, as you look at the vaccines, there are a variety of factors that might impact how you use it. Certainly, of course, efficacy and the safety data, but also, frankly the operational components of these vaccines are quite different. The J and J, being a single dose vaccine makes it operationally easier in lots of contexts. And I expect that a lot of the considerations that our state health departments are having around these vaccines is more about the ease of use of the J and J vaccine and how it might be better suited to some populations where, for example, logistics of getting into a community is harder or getting folks to come back for a second dose might be harder. And so, I think we can all imagine situations where that might be logistically easier. I'd also say that while the adverse event profiles look similar, it is only a single dose. And so, you know, you can imagine populations where that might be such an advantage. So, I really think that this is something that's going to be quite complicated, but let's let the VRBPAC and the ACIP finish their process, you know, before we-- before we get to our own conclusions about how to use these vaccines.
>> Howard Bauchner: There's about 3.8 million pregnant persons a year in the United States. We did a livestream a couple weeks ago. You spent quite a bit of your career trying to understand the safety of influenza vaccine in pregnant persons. How do you think obstetricians and pregnant persons should think about COVID-19 vaccination during pregnancy?
>> Nancy Messonnier: Yeah, thanks for bringing that up. This was a question that we anticipated. Like many other vaccine trials, pregnant persons were not included in the clinical trial, I think something that is undergoing a lot of discussion. But we knew that, and therefore we really started working early with the ACOG and AP and the other organizations that represent mothers and babies to make sure we lock step with them in considering these issues. Both the science of it, but also the implications of it, and the bottom line is that they and we don't believe that pregnancy should be a contraindication to getting vaccinated; that is, pregnant persons should be offered these COVID vaccines and be able to have a discussion with their healthcare provider about their individual risk and the potential benefit of vaccination. CDC has on its website, as does ACOG, toolkits to help providers and patients have that conversation. Equally important, we have a pregnancy registry. It's really important that we gather information about the impact of these vaccines and pregnant persons and the safety profile. It's a platform called VSAFE that we're asking pregnant persons to enroll in and thankfully many of them are. There is data going to be presented from that system on Monday's ACIP meeting. I don't want to get ahead of those discussions, but I think that folks should watch that data because I think it will really hopefully start to answer some of those questions.
>> Howard Bauchner: The corollary just crossing my desk now, at a much faster rate, are so called immunocompromised individuals and there's millions in the United States. And the extent of being immunocompromised varies. For example, we know that adults with Down Syndrome are at much greater risk and have some immunologic struggles with disease. So, someone had asked me a question about whether their child who has down syndrome should get vaccinated. We know that individuals on certain drugs or chemotherapy certainly are immunocompromised. And there's many other medical conditions that lead to individuals being immunocompromised. Any information emerging that you've seen that would give comfort to individuals who are immunocompromised about being vaccinated?
>> Nancy Messonnier: So that reminds me to say that in the clinical development of these vaccines, while things have gone fast, there haven't been shortcuts taken, and so the size and the scope of the clinical trials are consistent with what you would see with any vaccine development effort. In those clinical trials there are some groups of adults with underlying illness, but not enough people to answer the questions that you're asking because there are so many nuances in those groups. And so, the two different questions. One is are there any safety signals that would be a deterrent to people to get vaccinated? The answer to that is we haven't seen them yet. That's why we're continuing to study these vaccines, as we do with every vaccine, to make sure that there aren't, as we roll it out in the entire population, adverse events that we didn't anticipate. So, we're not seeing that yet. The second question is do we know how effective these vaccines are in all those populations? Similarly, we're-- we have a whole series of studies looking at vaccine effectiveness, but it will be some time before we really have answers at the level of granularity that you're asking. For now, our recommendation is when it's your turn you should go on to get vaccinated, and that those underlying illnesses are not any reason to hold back from accepting the vaccine.
>> Howard Bauchner: Some of your comments relate to many of the questions that have just arrived, so why don't I read a couple of them. Current understanding on longevity of neutralizing antibody tiders as a function of age, immune status, vaccination, or natural infection. Like how-- so, if I get vaccinated, how long am I good for? That's-- or if I've had disease, how good-- how long am I good for?
>> Nancy Messonnier: Yeah. Those are incredibly important questions that we don't have answers today. When-- in general, for vaccines, we don't have answers on duration of protection at the moment that we first launch a new vaccine. So, it's not surprising that we don't have it. We of course wouldn't want to wait, you know, two years to look at duration of protection before we started vaccinating people. The only way that we're going to get that data is by studying it in real time, looking at studies both of the neutralizing antibody level, but since we don't actually have a pure correlative protection for this vaccine, we're also going to be looking at clinical effectiveness over time. I think we all want to know whether we're going to need booster doses, whether or not this is going to end up like a flu vaccine where we're going to actually have to have annual doses, and I think it's really-- it's just too early to know.
>> Howard Bauchner: A question, you had talked about the safety. You had hinted about the different systems, but someone asked specifically, what systems are in place to monitor long-term safety? I had a conversation with someone who I work with, and really sharp, and he said look, Howard, I really want to wait six months, a year, or two years until there's more safety data. He's young; I think he feels somewhat invulnerable. What are the systems that we actually have for vaccine surveillance safety?
>> Nancy Messonnier: So, one thing that the general public, and maybe even some providers, don't understand is that vaccines are obviously incredibly well studied, up until the point where they're either licensed or authorized. And then we continue to study them. We never actually stop studying the safety of any of the vaccines that are being used routinely in the United States, even vaccines that have been around for 30 years. For this vaccine, we're using all those normal systems, but we're also enhancing them with additional systems to make sure that we have the robust possible ways in which to study vaccines. And so, frankly, the systems are myriad. There are signal detection systems, there are population-based systems. A lot of those are laid out on our website. In the early days of the vaccine program, we're relying specifically on two big systems; one is our vaccine adverse event reporting systems, which is called VAERS, and the other is something that we did specifically for this vaccine, which is called VSAFE, which uses text monitoring to really get proactively active surveillance. If you've gotten vaccinated, I hope that you've enrolled in the system. You would have gotten texts asking how you feel and if you're-- if you weren't feeling well, if your symptoms kept you out of work, for example. And so those are the two systems that we've been relying on on the most early days and active system and VAERS, which is a passive system. As vaccine coverage goes up in the population, you'll see a lot of our other systems really kick in and, you know, again, so far, all signals are good. I feel-- I hope that your colleague looks at the data and is reassured and goes on to get vaccinated. You know, what we're hearing, in general, is that a lot of people are having some short-term side effects after the second dose, and by that I mean specifically sore arm, fatigue, muscle ache, even some people are reporting fevers, especially after that second dose, and it's very short lived, a day or two, and the people that I've talked to say that it's a very easy decision to say that I'm having a day of fatigue and muscle aches is worth it if it means that you're protected against COVID-19.
>> Howard Bauchner: Nancy, I think the U.S., like most countries around the world, have generally pursued immunization of their population. I don't think the U.S. is really very different than most countries around the world. But the emergence of variants from the U.K, Latin America, South Africa, there's more to come, has really, once again, crystalized that we need to sort through a process of trying to vaccinate six and a half or seven billion people. I don't know what role the CDC plays in global vaccination, other than the extraordinary expertise that the CDC's always had. What's your notion? Do you think there's a renewed focus on understanding that there has to be an approach to global vaccination? It's one of the questions.
>> Nancy Messonnier: Yeah, the CDC has an extensive portfolio of global immunization activities, working on Polio and Measles around the world, but also, for example, working on influenza vaccine. So, we actually have an extensive portfolio in that space. I think this year certainly has been a reminder to all of us how interconnected we are and it comes back to what you said, that is control of this pandemic in the United States is going to require control of the pandemic everywhere around the world. So, I'm pleased that CDC is already engaged in conversations with many countries to assist them in standing up their immunization programs. And we're also certainly involved at the World Health Organization in conversations about global immunization.
>> Howard Bauchner: Just returning to some specific vaccines, as everyone knows, Moderna and Pfizer have gone through the EUA, J and J's up for EUA approval. Oxford-AstraZeneca has been around now for a number of months outside the U.S. and people are particularly interested in Novavax. Do you have any sense of the status of AstraZeneca or Novavax coming to the FDA for EUA approval?
>> Nancy Messonnier: I would-- I would never get in front of that timeline. What I would say is that I, like everyone else, am anxious to have additional vaccines for use in the U.S. additional supply. Their clinical trial's ongoing and, you know, we're waiting for the results like everybody else.
>> Howard Bauchner: Nancy, you've been in this field for decades. You are one of the world's experts. What's been the biggest surprise?
>> Nancy Messonnier: Yeah, you know, in fact, I've been working on COVID-19 since the beginning. You know, it was late December last year when our team got those first reports out of China and really, we've obviously been working on it ever since. In the spring I think I realized that it was likely going to be important to have a vaccine in order to control the pandemic. And although I understood that, perhaps intellectually, the scope and scale of the disruption caused by this pandemic is really something I frankly I don't think any of us fully envisioned. And while I knew it was important to work on a vaccine and how important it was to have it, the need for it now is something that, again, I might have thought, but I didn't fully understand until now we're faced with continuing circulation of disease in the U.S. and the fact that we have a vaccine in hand, that could really help us control it. So, you know, I feel like at this moment in time, we have this great tool but the complication of trying to roll it out through the entire country is quite high and we just need to understand that this is going to challenge us. It's going to be really hard and the only way that we're really going to get where all of us want to go, which is to end this pandemic is for everybody working together, for everybody doing their part really for the whole country coming together around this challenge.
>> Howard Bauchner: When you were in discussions about vaccine development over the last decade and people said that it has to be faster and faster and faster and I've already mentioned Dr. Fauci, Tony had written an article for us talking about how vaccine development had come down from 20 years to 10 years to five years to three years. But even in that viewpoint a few years ago, he never envisioned nine months. Is it the single greatest scientific achievement you could have imagined?
>> Nancy Messonnier: Well, I don't know about that. There are, you know-- there have been amazing scientific achievements, but one thing I think folks may not realize is while it's been really fast, the reason it was able to go so fast is because there has been years of scientific work developing these platforms, the mRNA platform, the adenovirus platform. Those were things that scientists were already working on so that they would be available for exactly situations like this. And so, I don't want folks to think that it came, you know, on January 1st and magically we got a vaccine. That's not true.
>> Howard Bauchner: Right.
>> Nancy Messonnier: You know, we stand on the backs of giants that had been working on this for a really long time and I think it really points out the importance of the scientific process and the investment in exactly these kind of platforms so that we're ready for the next crisis.
>> Howard Bauchner: One or two other questions and then we'll stop. Booster doses for healthcare workers, has that been recommended by the CDC?
>> Nancy Messonnier: So, booster doses would, again, get back to this question of duration of protection, right, and until we know the duration of protection, you know, there's not a recommendation for a booster dose. It's something that we're studying. I understand why healthcare workers would be especially concerned about it.
>> Howard Bauchner: And one of our more curious listeners would like to know which vaccine the Queen of England got. I have no information about that. I don't know if you have any ideas which vaccine she got.
>> Nancy Messonnier: No, but I would suspect she got whatever vaccine was first available, which is frankly what I hope any of us are deciding to do. You know, I get asked all the time, like what vaccine would you get? I'd get whichever one there was in front of me.
>> Howard Bauchner: Last question and then we will stop, Nancy, and before we started the livestream, we talked about it briefly, the issue of equity and vaccine distribution. I feel like it's critical that we talk about that each time I do a livestream. Can you-- can you just reflect on how you see that playing out over the next couple weeks to months?
>> Nancy Messonnier: Equity is a-- has to be a key core principle of this immunization campaign. You know, we know that there are issues of systemic racism that underly the impact of this pandemic, especially in communities of color. I also know that there are issues around trust of vaccines in communities of color. For example, flu vaccine coverage has for years been lower in African American and Hispanic communities compared to white communities. So, we're going into this knowing that there are concerns about hesitancy and access, and we need to make sure that our immunization programs take that into account. Speed is important, but so is equity, and vaccine coverage shouldn't just be considered at a national level; it really has to be considered community by community. Our goal has to be to get vaccine into every corner of every community, but also to make sure that people are prepared to accept it. We had this great event this week, a three-day forum, hosted by CDC, online of course. 13,000 people joined, and part of the goal of that forum was specifically to talk about best practices in communities that had really tackled some of these issues around equity, around access, around hesitancy, and how they've risen to that challenge. There were great stories told. I really think that we can learn a lot by practices being used across the United States, but we need to challenge ourself here. We need to challenge ourself to do better. We need to challenge ourself now to be prepared for when the vaccine is more available. We don't want any community left behind and I think we have to go into this knowing that we need to be prepared to go back to ensure people have the time to get answered their questions. People still trust their own healthcare providers and they trust their own community leaders and we need to arm healthcare providers and community leaders with the answers that they need so that they can talk to their own patients and their own populations.
>> Howard Bauchner: This is Howard Bauchner, Editor and Chief of JAMA. What a privilege to talk with Nancy Messonnier, the Director of the National Center for Immunization and Respiratory Diseases, truly one of the world's experts in this field. Nancy, thanks so much for spending time with me today.
>> Nancy Messonnier: I really enjoyed it despite the technical difficulties. Really great to talk about these important issues.
>> Howard Bauchner: Alright, take care. Stay healthy.
>> Nancy Messonnier: Thank you.