Hey, everyone, and welcome to the CMSS webinar with our colleagues from the CDC's National Center for Immunization and Respiratory Diseases. We're really pleased today to be joined by two experts from CDC who will really share with us information about preparing your practice and your patients for the fall and winter virus season. We've been really pleased to be joined by Dr. Manisha Patel, who is the Chief Medical Officer in the National Center for Immunization and Respiratory Diseases, and Dr. Sarah Meyer, who is the Chief Medical Officer of the Immunization Services Division in the National Center for Immunization and Respiratory Diseases. We're pleased to be joined today by our specialty societies across CMSS, as well as we've invited some of the health systems who are working with us as part of our CDC cooperative agreement, working with CDC on those working with specialty societies who take care of higher risk patients with chronic illnesses. Just to let you know, we will be open to your questions at any point during the webinar. Feel free to use the Q&A function on the webinar screen. You can also add your comments or questions at any point in the chat. So without further ado, I'm going to turn the virtual podium over to Dr. Patel. Thank you so much. Well, thank you, Dr. Bursa. I really appreciate this opportunity to talk with you all today about how we can prepare our patients for the fall and winter virus season. And what Dr. Meyer and I are hoping to do is share with you some really practical information that you can bring back to your practice this week regarding vaccine recommendations. Select data that you can use when counseling your patients. And then Dr. Meyer will talk through some of those implementation aspects like vaccine access, availability, and insurance coverage. So next slide, please. But before we start, I do think it's worth acknowledging that we are obviously in a very different place than we were pre-pandemic. And while we have collectively lost a lot, we've also gained much in terms of our public health infrastructure. Our surveillance systems are not only more robust and timely, they are better connected to each other, which means that we have more comprehensive data to make proactive decisions instead of reactive ones. We have new and updated tools that are being used more frequently outside of provider offices like vaccinations and pharmacies and rapid antigen tests at home. We have new innovation pipelines like Project NextGen to develop and deploy vaccines and therapeutics even faster. And we have stronger partnerships with many of you leaning heavily into health equity and bringing on nontraditional partners onto your clinical care team. So all patients, regardless of their backgrounds, can be safe and healthy and can thrive. Next slide, please. So with these strong partnerships, we've administered almost 700 million doses of COVID-19 vaccines in the U.S., preventing an estimated 18 million hospitalizations and saving about 3 million lives. This graph shows that the number of COVID-19 hospitalizations has dramatically decreased since the beginning of the pandemic because of better population immunity. But immunity from vaccines or previous infection wanes and viruses do evolve. And even now, we are still seeing more than 15,000 hospitalizations due to COVID-19 every week. Next slide. All this to say is we are not out of the woods yet for COVID-19. In fact, our scenario modeling predicts that even a moderate season of flu, RSV, and COVID-19 co-circulation, which is that top bar, will be worse than a severe flu and RSV season, which is that first gray bar and is also what we saw in 2017. And this can place significant strain on our healthcare systems, especially in communities where healthcare resources may be limited or specialty healthcare systems like pediatric hospitals, of which there just aren't many. So next slide, please. So we need to help our patients prepare. And we have a number of tools we can give them this year. For the first time ever, we have vaccines that are safe and effective against all three of these major respiratory diseases, influenza or flu, COVID-19, and respiratory syncytial virus or RSV. We have widely available treatments for flu and COVID-19, which we know are not being used enough in high-risk patients like those with underlying medical conditions. We have tests patients can use to rapidly diagnose themselves so they can take the necessary steps to protect themselves and their families. And we have a number of everyday actions that people can do, like wearing a well-fitting mask for those who choose to wear a mask and guidance to improve air quality while indoors. Next slide, please. So really the most effective tools we can use are vaccines. And this is especially critical for people who are at highest risk for severe disease. So for COVID-19, everyone six months and older should get one dose of the updated COVID-19 vaccine. Adults 65 and older do not need more than one updated COVID-19 vaccine at this time. We will continue to evaluate that. And children six months through four years and immunocompromised patients may need additional doses depending on their medical history. And then similar to COVID-19, everyone six months and older should get one dose of the 2023 to 2024 seasonal flu vaccine. And the optimal time to get flu vaccine is actually now. And then to provide better protection for adults 65 and older, we recommend they receive high dose recombinant or adjuvanted flu vaccines if they are available. If not, older adults should get standard dose flu vaccine. We now also have immunizations to protect infants against RSV, the leading cause of hospitalization for babies in the U.S. An RSV vaccine is recommended for pregnant people 32 through 36 weeks to protect babies from RSV after they are born. And nircivimab, a monoclonal antibody, which is recommended for infants less than eight months born during or entering their first RSV season, which has already started in the U.S. In most instances, patients won't need both to protect those younger infants. Additionally, young children eight through 19 months at higher risk of severe RSV should get a dose of nircivimab in their second RSV season. Now, you may have heard there is a nircivimab shortage. And Dr. Meyer will share some interim guidance on that in her talk. Now, last is RSV vaccines for adults 16 over, which is recommended using shared clinical decision making. Now, what that means is it's a conversation about the benefits and risks of RSV vaccination for your patient. Advanced age, immunocompromising conditions, cardiopulmonary disease, and residents in long-term care facility are just a few of the risk factors for lower respiratory tract RSV. And therefore, these patients may benefit from vaccination. Now, this question is coming up quite a bit. So I did want to mention it here is that we do not currently have a recommendation for adults younger than 60, including patients with immunocompromising conditions for RSV vaccine. But CDC will closely be reviewing those populations and look at those data as they become available. Next slide, please. So we have these tools, but we also know that trust is tremendously important in helping patients understand why these tools are important. And it's really you, the provider, who are your patient's most trusted source of information on vaccines. And we know this from many, many studies that have been conducted. So over these next couple of slides, I want to give you some key data points that might be helpful as you are counseling your patients about the importance of vaccinating against these three respiratory viruses. Next slide. So the first point is that all three of these major respiratory diseases together cause substantial morbidity and mortality in the US, especially in people at high risk, such as older adults, young children, pregnant people, and patients with certain underlying medical conditions. Last year, just these three diseases alone resulted in over 2 million hospitalizations and over 260,000 deaths. Next slide. So why vaccinate against COVID-19? Well, this graph looks at COVID-19 hospitalization rates by age group. And you can see that advanced age, like those over 75 years old in that purple dashed line, had the highest rates of hospitalization this year, followed by infants less than six months who are too young to be vaccinated, and then older adults 65 to 74 years. So when counseling your older patients about COVID-19, it's important we share that vaccination is the best way they can protect themselves against severe COVID-19. Next slide. So even adults younger than 65 years, especially those with medical conditions, are at risk for severe COVID-19 disease. And this graph looks at the proportion of hospitalized patients with various underlying medical conditions. Some conditions like obesity in gray and cardiovascular disease in light blue that are common in the US were also commonly seen in patients hospitalized for COVID-19. So a strong recommendation by you to vaccinate your patients with underlying medical conditions against COVID-19 will play a major role in their health and safety this season. Next slide. You may also get asked by your patients, well, it's really people with medical problems that get very sick with COVID-19, not healthy people. And while that's true, it's not the only truth. In fact, more than half or 53% of kids less than two years who were hospitalized and then admitted to the ICU had no medical underlying medical conditions. So what these slides are showing is that while there are certain groups at higher risk, there's essentially no group that is at zero risk of severe COVID-19. Next slide. Long COVID is a debilitating condition. Many of you may have experience with this with your patients. It can last months or even years and really can greatly impact a person's quality of life. And both children and adults can be impacted by long COVID. But now we have data that shows vaccination can reduce the risk of long COVID by 30 to 40% across all age groups. Next slide. So why vaccinate against flu? And what you see here is that all age groups have some risk of hospitalization from flu. But like COVID-19, we worry most about older adults and young children. So when counseling your patients about flu vaccine, it's really important that they understand they can be hospitalized for flu at any age. But this is an even more important message to get across to people who are at higher risk for severe flu. Next slide. I did want to make a point about vaccine equity. Now this slide is comparing flu vaccine coverage between children living in urban and rural areas with children living in rural areas having flu vaccination coverage rates that are 19% lower than children living in urban areas. And this is a critical issue for our rural and frontier communities, across the board for all vaccines, and given access to healthcare is more limited in those areas, it's even more important we are maximizing preventative care for people living in these communities. Next slide. So, RSV is very common, and most people have very mild symptoms, but it can cause severe disease in older adults, especially in those with advanced age. So, for the providers out there who are taking care of older adults, it's really important to talk with them about RSV vaccination and how RSV vaccination can protect them against RSV hospitalization this year. Next slide. So, most kids are infected by the time they are two years of age with RSV, but it is the leading cause of hospitalization in infants in the United States and can cause severe disease, especially in those youngest infants. And you can see that very clearly here, that the hospitalization rates in that group of zero to five-month-olds across different calendar years is significantly higher than for other age groups. So, also, important to talk with families about the recommended options to protect infants against RSV this season. And again, given that there is a Nurse of the Mab shortage, it's even more important for those of you who take care of pregnant people to talk about RSV vaccination with your patients. Next slide. There are just so many benefits to vaccinating patients as we head into the belly of the fall and winter respiratory season. And as I mentioned earlier, almost 700 million people have been safely vaccinated against COVID-19 and billions against flu. Side effects are generally mild and serious adverse events are rare. We also know the risk of cardiac complications like myocarditis is actually higher after COVID-19 infection than after COVID-19 vaccination. Next slide. So, in summary, we are in our strongest position yet to protect our patients against flu, COVID-19, and RSV this respiratory season using all the tools that are available to them, immunizations, rapid tests, effective treatments, and other preventive actions. We know immunization against flu, COVID-19, and RSV remains the safest protection. And as trusted sources of vaccine information, you all are critical in getting vaccines into arms. And a reminder, immunity wanes over time and viruses evolve, so these immunizations will be critical tools to fight flu, COVID-19, and RSV this fall and winter virus season. Next slide. So now I'll turn it over to Dr. Meier to talk about how we can, how you all can help get these vaccines into arms. Thank you so much, Dr. Patel, and I just want to say it's really great to be here with you speaking with you today. Before I start, I did want to just really echo something that Dr. Patel said, that, you know, you are the patient's most trusted source of health information, and the specialty, the specialists, you know, specialty providers that your organizations represent take care of some of the highest risk patients, very sick patients, patients with rare diseases, you know, and those patients are going to have a lot of questions, even if the specialists themselves aren't offering vaccines, having, you know, the specialists share information, give their strong recommendation, that's going to be a huge influence on the patient's decision to get vaccinated. So we really appreciate your collaboration in this. Next slide. All right, so I'll start with some of the nuts and bolts, how to order vaccines this season. And just to highlight that for the, you know, the three viral vaccines that Dr. Patel mentioned, COVID, flu, and RSV, these are ordered through routine mechanisms, just like you would for any other vaccine, directed from the manufacturer or wholesaler or distributor. For those providers that participate in the Vaccines for Children or VFC program, it's the exact same process as it is for any other routine vaccine. So we're just highlighting this because this is a little bit different for COVID-19 vaccine this year than it has been in previous years. It was all through a federal distribution program, but we have transitioned now into a commercialized market. So COVID-19 vaccine ordering is the same as what you would do for any other vaccine at this point. Just to be aware that some manufacturers do have varying policies around returns or refunds for expired or unused doses. We know that, you know, a lot of providers have some concerns. Well, what if I don't use all of it? What if it expires before I can use it? So there are, you know, manufacturers do have different, you know, policies around this. So I encourage you to check with those manufacturers about those. And then, as Dr. Patel mentioned, the ability to order nirsevimab doses this season is limited at this time. And that's particularly for the 100 milligram dose, which is used for those infants who are five kilos or older. So those babies who are not in the newborn period, but a little bit older, so that there is some limited availability there. Next slide. So CDC did put out a health advisory on nirsevimab availability last week on the 23rd. This described interim recommendations to provide options for clinicians to protect infants from RSV in the context of limited supply of nirsevimab. So in this guidance, and happy to go through it if there are questions, but in this guidance, there are some considerations of how to prioritize the highest risk infants for the limited doses of nirsevimab. And we also just wanted to highlight that pregnant patients and their providers should take into account the limited availability of nirsevimab during this season when making decisions about maternal RSV immunization. So as Dr. Patel mentioned, to protect the infant, it is recommended that either pregnant women get vaccinated or the infant receives nirsevimab. So we just want to make sure that the pregnant person takes all of this into account when deciding whether to get vaccinated themselves or get their infant immunized. Next slide. One question we get commonly is, can we give all three of these vaccines together? And the short answer is yes. So flu, COVID-19, and RSV vaccines may be co-administered or given at the same visit with each other, but they can also be given at the same time as other routine immunizations that might be recommended. And co-administration might be especially important when the patient has risk factors for severe respiratory illness and when there might not be another opportunity to vaccinate the patient with the recommended vaccines in the near future. We do want patients to be aware that they may experience more side effects like fever and fatigue if multiple vaccines are given together, but these side effects are usually mild to moderate and last only a day or two. If the patient prefers to receive these vaccines during different visits, there is no minimum wait period between these vaccines. Next slide. So just a little bit more about the insurance considerations. We get a lot of questions about this. So this is meant to just provide some very high-level information. If there are really specific insurance companies or types of Medicare and Medicaid plans, we would suggest reaching out to those plans directly. But at a big picture, this is what you can expect for insurance coverage this year. So starting with adult immunizations, so COVID-19, influenza, and then RSV vaccine, whether it be given to the older adult or the pregnant patient, most private insurance plans are required to cover vaccines. But they do have a year to do so after a new recommendation. So for COVID and flu, because the recommendations have been around for years and they've been on the schedule for years now, those should be covered right away. Those should be covered this season. We are aware that there were some delays with some plans, but that those seem to have worked themselves out by now. So it's really just RSV vaccines. They may not be covered under all private plans this season because those companies have a year to do to implement coverage. For Medicare, so COVID-19 and flu vaccines are covered under Medicare Part B, and RSV vaccines are covered under Part D. But with the Inflation Reduction Act provisions, Medicare recipients would be covered for these vaccines without cost sharing. For Medicaid, very similar. They'd be covered without cost sharing. This applies to nearly all full-benefit adult beneficiaries without traditional Medicaid. For pediatric immunization, so COVID-19, influenza, and nirsevimab, it's similar to what I mentioned for adult vaccines. Most private insurance plans are required to cover, but they have one year to do so after the recommendation is made. So for nirsevimab, that means that it may not be covered under all private plans this season. All of these vaccines are covered under the Vaccines for Children's Program, which does provide vaccines to about half of U.S. children. People aged under 19 years of age who meet certain eligibility criteria can get the vaccines at no cost through this program. And like I mentioned, it covers about half of the children. Next slide. I did want to mention CDC's COVID-19 Bridge Access Program because, you know, after the last slide, you may be wondering, well, what about uninsured adults? You know, uninsured children are covered through the Vaccines for Children Program, but what about adults who have absolutely no insurance or whose insurance does not cover all the costs? So we are very fortunate enough to have this year the Bridge Access Program, which provides COVID-19 vaccines for adults without health insurance and whose insurance does not cover all the costs. So it's an adult program. It only covers the COVID-19 vaccine, but these COVID-19 vaccines are available through certain health care providers, some federally supported health centers, and certain retail pharmacy chains participating in the Bridge Access Program. This is a temporary program. It only is going to go through the end of next year, but we are hopeful that this program could help lead us a step closer to a more permanent solution in the Vaccines for Adults Program, which has been proposed in the President's budget but is not yet authorized or funded. But hopefully, we hope that this COVID-19 program is a bridge to more permanent solutions for adult vaccines for uninsured adults. Next slide. I did want to just mention how you can locate vaccines in your community. So for example, if the health care provider is not offering vaccine themselves, this is a great resource to let your patients know about so that they can find vaccines in their communities. So currently, it's a resource for locating influenza and COVID-19 vaccines. It does include availability of COVID-19 vaccines through the Bridge Access Program. So specifically, if you have an un- or underinsured adult patient, it's a great resource to find out where they can get a free COVID-19 vaccine. Next slide. And then finally, just to make people aware that we have recently published a provider toolkit, and it provides a lot of information and resources and links to other materials for protecting your patients from, you know, against the viruses this season, especially through vaccination. Next slide. Thank you both. That was incredibly comprehensive. Invite anybody who'd like to ask a question to put it in the chat. I've already gotten a couple sent to me directly that I'll start with. That is very funny. A couple of times people ask me questions and then the very next slide, Dr. Meyer had she answered it. That was incredibly well-timed. One of the questions was, you talked about the program for being able to locate a free COVID vaccination. What do you do about other vaccination for those who are uninsured if it's not for COVID-19? Yeah. This is a great question and it's challenging. It's why we really do need a more permanent solution in a vaccines for adults program. But through state and local and jurisdiction health departments, they do have a limited number of doses through another program, the 317 program, which provides a limited amount of funding for states and jurisdictions to purchase vaccines for adult populations. Certainly, it doesn't cover all vaccines. There may be just limited numbers. That means that the health department is a good place to check to find out, do they have vaccines available? Which ones? Can a patient access it? I start with the health department. For flu shots, for example, the flu vaccine is comparably much less expensive than some of the other vaccines. There are in some communities more accessibility for something like the flu shot, where if they have a job, their provider might have it, or their health department, or even in some pharmacies, you see things like get your flu shot and get a $10 gift card, and some of those end up being net neutral costs for the patient when you factor all of those things in. There are more limited opportunities, but the health department generally is a good place to start. Great. Yeah, that's a good idea. I did take advantage of my getting food shopping done at the same time as I got. We got four coupons between my husband and I. We're set for the rest of the year at the supermarkets. That was very nice. I was glad you mentioned the thing specifically about people who take care of patients with chronic illnesses. I know it's been a big part of the work that we're doing. You may make the recommendation, but very few of those clinicians are going to have some of these vaccines in their practices. I think it was helpful that you pointed out where they could go. I think that's always one of the biggest challenges, is you may make a recommendation. It's part of what we're trying to work on, is that had you closed the loop, know they went, know they actually were able to find it. I think being able to have the locator information is helpful. One of the biggest issues, it's helpful to see the provider toolkit that we've been working on as part of this corporate agreement with you as well, is do you have any resources as well for clinicians to provide to patients who may be hesitant to take vaccines and resources you might want to share with our societies for CDC? Sarah, go ahead and answer that. Sarah works in the Immunization Services Division, and they do a lot of work on educating providers, but also one of their big things is making sure you all have the information that you need as you're counseling your patients. But before I turn the mic back to her, can I just address one point you made about your viewers and your organizations that are under your umbrella that work with high-risk patients? Certainly, we need vaccines, access, availability, education, all the components around making sure these high-risk patients are protected this season. But I did want to put a plug in because this is something that your providers actually do have, and those are the antivirals. We have sufficient information that we're just not using them enough, we're not using them in a timely way, and so our patients are progressing to more severe disease. I know we didn't talk about that that much in this webinar, but there are a number of resources, the NIH treatment guidelines for COVID-19, as well as the flu guidelines which are posted on the IDSA guidelines. There's a publication on that, happy to send you all those resources as well. But those are really critical, and they will need both vaccines as well as antivirals to make sure they don't progress. I just want to put that. Yeah, that's a great point. IDSA is one of our members, and I think that would be a great resource to make sure we share from IDSA to others because you're right, even if you can't have vaccines, almost all of those specialty practices that take care of high-risk patients routinely give infusions of some sort. Being able to make sure that they add antiviral infusions for these unfortunately vaccine preventable conditions, but when they're there and you're high-risk, you want to make sure we get people treated. Yeah, absolutely. Dr. Meyer, I'll let you answer the rest of that question. Yes. I did want to say, either if we get to it, drop it in the chat here or email you or get the information to you. But we do have a lot of resources on our webpage for vaccine confidence building, including how to have that conversation, motivational interviewing skills, how to address common questions. We do have a lot of those resources which we will get to you. But I did want to just mention, certainly your organizations represent people with common underlying illnesses, obesity, heart disease, but you also represent patients with very rare diseases. We hear a lot from patients over the course of the pandemic, the patients with autoimmune diseases or immunocompromised, or patients who want to be healthy. They're so motivated to be healthy, but they're worried. They're worried, will the vaccine harm me? They need that reassurance from their, certainly their primary care provider would provide that information, their pharmacist, but from you, their specialist who knows their condition so well and has that expertise. I think they need to hear it from you too. They have a lot of the questions around safety. Can I get it? Will it work in me? Will it cause my condition to flare up? Those kinds of questions are what we tend to hear from subspecialty patients and your sharing of information and reassurance and answering your questions, I think would go a long way. Absolutely, and our members include all the primary care groups as well as the specialty groups. So I think the reality for a lot of those patients, they see both of us. I'm a general internist. They'll see me and then they'll go next door and see their oncologist. And so I think the more we can really all reinforce that message and being able to ask their oncologist to get the very detailed information, but for us to just emphasize how high risk they are for any of these vaccine preventable illnesses. I think it's just something so important that we can do to make sure they have what they need, because obviously we're always very worried this time of year for all of our patients and also pregnant patients and older patients. And there's just so many people who take care of people in facilities and nursing homes and rehabilitation centers across our membership. So a lot of patients are in nursing homes and our rehab docs take care of patients in rehabilitation facilities and SNFs. And so there's patients who even go beyond what you think of as being sort of chronically ill, but they're all very high risk. And so kind of getting that message out to all of them about what they could do, especially with this wide array of vaccines now available as well. So any other sort of electronic tools that you have available, any apps or things like that, that we could try to push out to our members? I do have to say every single time my residents try to give pneumococcus these days, we still go to the same little sheet on the wall of our clinic because it's pretty complex. Any newer resources you want to share that might be helpful? Sarah, you want to? Yeah, one thing I will point out is, we do have some new schedules resources just for the immunization schedule as a whole. We're trying to get those out in a more timely way. So instead of just the immunization schedule being updated once a year, we're getting those out, anytime there's an updated recommendation. So just to make your providers aware of that, so that if they have questions about RSV or flu or COVID, those are on the schedule, but when there's updates, you don't have to wait a whole year to get that information. Yeah, absolutely. So those are available on our website. We are also, and Mo can speak to this as well, pushing out some more dashboards so that your providers can go online and get updated data on cases and infection rates and hospitalizations, but also vaccine coverage and things like that. So there's some data dashboards for all three of the viruses, the fall and winter viruses in one place, which is often a good resource for people to be able to access quickly. Now I would just tag on, I really love this idea of an app or something that we can actually have, providers are so busy now, busier than they've ever been. And so really trying to make it as easy as possible. I have to come back to you, and since it's a smaller group, I can share this now, is that I do believe that there is a pneumococcal app that folks are working on within the Division of Bacterial Diseases. We can get back to you on that. But I think you're seeded a thought for us about sort of next gen in terms of how we can help providers get vaccines into arms. And some of that is having it right in your hand, in your phone. So I appreciate that suggestion. Yeah, I mean, many years ago when I was at AHRQ, we did that for the preventive services guidelines. It was just so easy to put age and gender and high risk. And it looks like Amy has put something in here already for us, for our pneumococcal vaccinations. So thank you, Amy. It looks like we already do, we do have a question in the chat as well. It looks like it's from one of our occupational health clinics, which is part of one of our ACOM, one of our specialty clinics, which is if you have, we have employees being treated for breast cancer as part of their occupational health clinics. Is COVID recommended for them and should, or should they wait until their treatments are finished? So we're talking about COVID-19 vaccines for patients that are treated? Yeah. So, you know, we always say talk to your doctor because there's a lot of nuances around how that patient might be doing, especially with the immunocompromised patients. And so there's no specific restriction while they're undergoing treatment for them to get vaccinated, but certainly for certain types of conditions, like if they're going into transplant phase, there are some timing issues to consider. And if, especially if they're on a certain mab, like rituximab or any of these sort of, the ones that sort of wipe out your B cells, you know, those kinds of things that we need to consider the timing for. And the other thing I'll just add is certainly for immunocompromised patients, we do actually have language in our guidance that sort of gives providers flexibility to give additional doses of the updated COVID-19 vaccine. So there are two parts to the immunocompromised patients. One is that they do, we want them to complete an initial series. And so they would need to look back at their history. But the other part is right now that they could also get additional doses of COVID-19 vaccine, the updated one, if the provider chooses that's necessary. So there's some flexibilities for patients that have immunocompromising conditions. You're right, it is so specific these days, depending on what agent you're on, where you are in the course of your treatment, that I think being able to go back to your treating clinician is always good advice. It's certainly my approach, even as general internist, because it just, even these days, it's hard to know which agent they're on and the complexities of it these days has gotten so difficult. Let's see if we have any other questions in the chat. I don't see any other questions. Let's see, I don't think I have any other questions, but this was just incredibly comprehensive. I think those slides are absolutely wonderful. We look forward to pushing them out with the recording to all of our members and make sure everybody has it in their hands. We'll also push it out to all the health systems we're working with as part of our Specialty Societies Advancing Immunization. And I think with that, we could give you guys back some time in your day. Thank you so much for joining us. This was absolutely wonderful, really gave us some insights, particularly to some of the newer vaccines. I think there've been lots of sort of questions about RSV that I think you've certainly answered my questions and we'll be delighted to share this with everybody. So thank you so much for joining us and we look forward to, we're happy to share any additional questions that we hear back with you. So thank you again. Thank you for being such a great partners. Oh, my pleasure. We look forward to working with you. Absolutely. Thanks again. Take care. Bye.

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