Transcripts For CSPAN2 House Hearing On The Flu Vaccine Part 1 20240713

Next, a Public Health official looks at efforts to improve. Vaccine and develop a universal flu vaccine. This house, science, space and Technology Committee hearing is about 2 and half hours. This hearing will come to order and without objection, declare a recess at any time. Good morning and welcome to our witnesses. Todays hearing on science and innovation, the worlds population, killing approximately 300 Million People in the 20th century alone. Smallpox is the only human disease to be eradicated thanks to the development of the vaccine. Another devastating disease, polio, 33 cases reported worldwide in 2018 compared to 350,000 cases in 1988. Every day it save lives especially lives of children and other vulnerable populations. There is no such thing as healthy skepticism when it comes to vaccines. Unfortunately there is a wellfunded Disinformation Campaign targeting the public and weakening Public Health laws. School vaccination requirements have been commonplace in the us for generations and exemptions were granted only for legitimate medical reasons. However in my home state of texas the number of unvaccinated children has spiked since 2003 when the Texas Legislature expanded exemptions to include nonmedical reasons. The number of exemptions rolled from 2000, 2003, 50,000 last year. We see this replayed across the country, innocent children, Health Officials have confirmed 21 measles cases in texas this year and 1261 nationwide. 61 of which led to serious complications. Is the first nurse elected to congress, i have been dedicated to Public Health my entire career. The science committee, health and Human Service agencies, we have long had a role involving Public Health through good science. This morning we will export the signs and Innovation Challenges for Vaccine Development through the lens of influenza. For the healthiest among us, the flu just lay this out for several days with no lasting side effects. However for the very young, the elderly, pregnant women and other vulnerable groups the flu can be deadly. The centers for Disease Control recorded an estimated 48. 8 million illnesses, 79,000 deaths during the 201718 flu season. Approximately 600 of those deaths were children. Influential vaccine production began with collection, analysis of data before the beginning of the flu season. The virus is changed constantly and by the time flu season begins the vaccine may not fully match the circulating viruses. Scientists are working to develop viable and more effective alternatives, eight eggbased vaccines as well as universal vaccine that would not require annual updates, yet another scientific challenge to influenza and many other Infectious Diseases are complete. Disease, incomplete data, antiquated data systems through modernization, data systems and data analytic across the federal and state level, we accelerate vaccine for many diseases, that will help us understand the full cycle from basic research to Vaccine Development for deployment and surveillance. Of the witnesses would also describe the role of federal agencies, state agencies and the private sector including the partnerships among all the stakeholders. I want to extend a warm welcome to all of you and thank the vice chair for his leadership on this issue. I look forward to todays discussion. I might say i have a markup in another committee so i will have to leave before we get through all the deliberations. The chair will recognize mister lucas for an Opening Statement. I would like to thank you for holding this hearing given we are in the middle of flu season. In the United States million individuals are hospitalized for the flu every year including more than 48,000 children. And oklahoma since the 2019 flu season began september 1st, there have been several hospitalizations from the flu but these numbers would be far worse if we did not have vaccines. Vaccination is by far the best flu prevention measure, it is easy to forget 100 years ago the world faced one of the deadliest pandemics in history, the 1980, h1 out and one epidemic known as spanish flu, killed an estimated 50 Million People worldwide including 675,000 people in the United States. The countermeasures of the time were limited, isolation and quarantine. Isolation vaccines did not exist and antibiotics were not fully developed yet. Due to basic research, advancements were made in treatment and prevention of the flu. The development of vaccines played an Important Role in producing and eliminating disease. I can still recall my fathers stories how late summer and fall were a terrifying time as a child because of the threat of polio during those seasons. I did not have to experience this fear because of the first polio vaccine in 1955 and thanks to widespread vaccination polio has been nearly eradicated in the United States, 33 cases reported in 2018. However polio remains a threat in some countries, with the world becoming more connected through modern transportation it only takes one traveler with polio to bring the disease into the United States and as im sure we will hear this morning from our witnesses the best way to keep the United States polio free is to maintain high immunity through vaccination. Considerable advancements have been made in disease surveillance, medical care, medicines, drugs, vaccines and pandemic planning, significant progress has been made, a severe pandemic could be devastating to the global population. If the immune population has grown so has the poultry population to feed them. Increased opportunities for unique viruses from birds, cattle and pigs to infect people. As a member of the House Agriculture Committee i supported the creation of the National Animal vaccination vaccine and veterinarian countermeasures which was included in the last farm bill. This vaccine bank will maintain a sufficient quantity of animal vaccines and other countermeasures to provide Rapid Response to an animal disease outbreak. If an outbreak were to occur and we were not prepared our entire Agricultural Sector would suffer immense losses causing longterm harm to the economic viability of the United States livestock, poultry and swine production not to mention the damage to human health. I look forward hearing from our witnesses about the current state of our stockpile Human Health Vaccines the capacity for Rapid Responses for emergency situations. The influenza vaccine manufacturing infrastructure supporting publicprivate partnerships with domestic vaccine manufacturers for response capacities for events in the United States. The recent executive order to address modernizing flu vaccines. The executive order recognizes influenza as a Public Health and National Security priority with potential to inflict harm on the United States through largescale illness and death. Most important leader establishes a National Passport to explore alternative vaccine production methods and new technologies including a plan to accelerate developers of universal flu vaccine. I look forward to seeing what recommendations come from the passports. I would like to thank chairman johnson for holding this hearing and i would like to thank both witness panels for taking the time to share your expertise, insights, with us this morning and i yield back the balance of my time. If there are members would like to make additional statement your statement will be added to the record. At this time i will introduce witnesses, first witness on the panel, doctor Daniel Jernigan at cdc. He is responsible for oversight and direction, abroad program to improve detection, prevention, treatment and response with seasonal novel and pandemic. And national and global surveillance of influenza and serve as world health organization, collaborating center for the surveillance and control of influenza. Doctor jernigan entered the cdc in 1994 and the captain of the Public Health service and was a recipient of the 2019 service, the next witness on this panel, Anthony Fauci from the National Institutes of Infectious Diseases, a position he has held since 1984 and oversees Extensive Research portfolio, applied research to prevent and treat established Infectious Diseases like hivaids, respiratory diseases, tuberculosis and malaria as well as emerging diseases such as ebola and seek a. He supports research on the transportation, transplantation related illnesses. Asthma and allergies. He is advised 6 president s on hivaids and many other Global Health issues. He was one of the principal architects of the president s emergency plan for aids relief, a program that has saved millions of lives throughout the developing world. As our witnesses should know, 5 minutes for your spoken testimony. Your written testimony will be included in the hearing. We begin with questions. Each member will have 5 minutes. We start with doctor lofgren. Jernigan. Thank you, dismissed members of the committee. Im doctor dan jernigan the, from the centers for Disease Control and prevention. I think the committee for the opportunity to discuss the work supporting vaccine innovations to improve prevention of influenza. This is a Significant Health burden in the United States with millions of americans becoming a, hundreds of thousands requiring hospitalization and tens of thousands die income. Influenza viruses are constantly changing requiring us to update the vaccine components every year. These changes can be sudden and significant resulting influence strains that can lead to devastating pandemics. Hospitalization and death can happen in any flu season and each year flu vaccination prevents millions of illnesses, thousands of severe tragic outcomes. This is the way for people to fight the flu. Despite the significant benefits the effectiveness of the flu vaccine at the numbers of americans being vaccinated are not optimal. We are working with nih and other federal and State Government partners to use cuttingedge science to make influenza vaccines better. The probably affected dexa vaccines are the ultimate goal for flu prevention. However, these vaccines are still years away. In the near term, millions of americans making incremental improvements to vaccines that can be produced using already available production platforms and getting more americans each flu season. Cdc has a part of the Vaccine Development administration cycle including continuous virus tracking around the globe. Preparation of vaccine viruses 10 of flu vaccines used in the United States and monitoring vaccine coverage, safety and effectiveness. Cdc has implemented innovations throughout the vaccine lifecycle, cdc is invested in and collaborated with every department on flu surveillance, this is invested in automated realtime reporting of influenza test results for cdc using cloudbased messaging. Cdc transformed flu surveillance by using next generation genomic sequencing to characterize everything received at cdc meaning we can identify and track viruses much more quickly and accurately leading to more candidate vaccine viruses and Early Detection of viruses with pandemic potential. Genomic sequencing equipment which was filled a room now fits in the palm of your hand. We have a mobile mini lab that can be taken on the plane as a carryon, set up almost anywhere in the world including rural resource constraint settings. Cdc has implemented innovations for supporting they were vaccines by developing candidate vaccine viruses and providing genomic sequences used to make recombinant protein vaccine. Both of these new were vaccines have potential to be manufactured more quickly and may be more effective than traditional vaccines. Cdc routinely generates vaccine viruses using a technique called reverse genetics allowing us to build a vaccine in a matter of days or weeks much faster than traditional methods making the us more prepared to respond quickly to a pandemic. Cdc was first to develop a system for the routine monitoring of influenza vaccine effectiveness and the Vaccine Effectiveness Network provides critical information for manufacturers and researchers in developing enhanced vaccines by collecting more specific data how well the vaccine works each season. Recently we have expanded the network and are planning to add new immunity consisting to better evaluate vaccine effectiveness. A component is getting more people vaccinated. Fewer than half of adults in the us receive their influenza vaccines. Despite all of our successes and Global Leadership in detection and prevention there is still more we need to be able to do. Each of the topics i mentioned from working with domestic Public Health partners to developing vaccine candidates and studying vaccine effectiveness will benefit from investment in generating more precise and timely data. I believe we can harness this to make vaccines work better. I want to close by reminding you that you and your families are vaccinated before the holidays when travel begins and thank you for the opportunity to talk about cdc, i look forward to your questions. Thank you. Members of the committee, thank you for the opportunity to testify before you today. Im doctor Anthony Fauci from the institute of Infectious Diseases and i want to talk over the next couple minutes about nih efforts to improve the influence of vaccines and develop the universal flu vaccine. As shown on this slide, although as jernigan mentioned it is important to be vaccinated because even if it is not 100 effective or even 50 effective the benefits to the individual to get vaccinated and to the community is profound. However we can do better because seasonal influenza vaccines are not optimally effective. In addition we know through history pandemics occur but usually too late in our response as we were in the 2009 h1 in one and we spend considerable time chasing after pandemics as we had with the age 5 and one at age 7 and one in which we made significant investments. We needed to do that but those pandemics never occurred. This slide shows the journal of Infectious Diseases containing cases in which my colleagues and i gave the introduction emphasizing the point i made that although influenza vaccines are good and important and should be utilized, we can do better. By doing better we need to improve the seasonal influenza vaccines which would lead to better capability to respond to pandemic influenza which ultimately will get us to the goal that we will speak about in the next minute or two and that is developed of a universal influenza vaccine. In the summer of 2017 we brought a group together to develop a plan we published in 2018 for the Strategic Plan and Research Agenda to mobilize scientists throughout the country and the world to develop universal flu vaccine. Let me explain what we mean by universal flu vaccine, this is a complicated slide but it does make the point. We will not get a universal flu vaccine overnight. I mean it will be a stepwise process in which we go from improvement, broad capability of responding to a particular type of strain versus the ability to respond to all strains. On the lower lefthand part of the slide, divided into two groups of influenza, group 1 and group 2. On the righthand part of the slide the tip of the triangle is what we do today. We make the vaccine for this season that is highly specific to the strains that are circulating this season but those strains change, mutate, drift. What we want to do is go to the next step. Make a vaccine that will cover all the age one in ones in the next step would be to get one that would do all the group 1s and group 2s until ultimately we have a universal vaccine that essentially covers all of these. We will do that with new technologies, we currently have a technique of growing the virus eggs and develop vaccines. Although that is triedandtrue and timehonored it is an efficient and has many areas of going wrong. We are using new platforms as shown here in the slide such as recombinant proteins, viral vectors, nanoparticles and others. This is a blowup of the influenza virus and an important protein. It is important to note the hemoagglutinin has two components, the head and a stem. The head is the part of the response, but it mutates often, changes leading to the ineffectiveness but the dark blue is the stem which doesnt change much at all. The strategy, one of several strategies is to develop a vaccine in which you cut off that head, take the stem and put it on a nano particle which will ultimately serve the vaccine. If i could show you this, this is a 4 million times blowup of what the first universal flu vaccine would look like in these dark blue areas are the stems. We have started a phase i trial as shown here in the spring of this year. It will end at the end of next year and we will do a universal flu vaccine. As the president said in the executive order the purpose of what we are doing is to go ahead and improve little by little until we get vaccines to protect us in the most efficient way possible, thank you. At this point we begin the first round of questions and the chair will recognize herself for five minutes. Doctor Dirksen Senate Office Building 3 there is a Disinformation Campaign of sowing confusion and fear in the public. This campaign carefully targets and praise on different populations for different relief systems. Innocent children are falling ill with disease as we once thought were eradicated in the us. Young women are being put at increased risk for cancer and these forces are creating a major challenge. How big of a role does social media play in this resurgence and how do we overcome these tactics and what is cdc doing specifically to combat these efforts . We want to do everything we can to get more people vaccinated. We now with influenza that only half of americans actually get vaccines. Another half still need to get vaccinated. One of the reasons they dont get vaccinated is worried about the effectiveness of the vaccine. With regard to our discussion improving the effectiveness of the flu vaccine would get more people to be vaccinated. Your question is around the role of misinformation in social media participating in that. There is a lot of information out there. Parents have lots of places they can get information and a lot of times they dont know which is sciencebased, which is evidencebased etc. At cdc our plan is to strengthen public trust in vaccines by trying to get people to be more confident in vaccines, getting information out there about how effective they are and it comes down to three things, protecting the community, helping to understand the differences in different pockets, different communities. What makes him not have as much confidence as they should and identify Development Materials we could use for those specific communities and Leaders Within those communities. A second thing would be to empower parents, get with young parents when you first have children or pregnant women, get them the right information they can understand better about the benefits of a vaccine and why it is so important to get vaccinated and work so they have tools to talk with those family members as well. Finally, to stop the myths as much as possible. We do that by providing scientific based evidencebased information that is on the website and working to make sure they can be reused on multiple platforms so people can get that sciencebased or evidencebased information. Would you like to comment . To underscore what doctor jernigan said, if you do a survey, what is the most important reason people dont get vaccinated for influenza it is because of the misperception that it doesnt work and i think we need to emphasize that even though it isnt 100 effective even a modestly effective vaccine will prevent you getting infected, will prevent individuals particularly those who are susceptible to complications will prevent them from getting hospitalized and may ultimately save their lives so this perception that the vaccine doesnt work, we need to put that aside because everyone is doctor Dirksen Senate Office Building 8 said, should get vaccinated. Thank you very much. Doctor Dirksen Senate Office Building 3, the state department of health reported influenza has claimed one life, and hospitalize as others. Continuing on the comments you and doctor fauci have made when i look my constituents in the eye to stress the importance of getting vaccinated and to prevent the hospitalization, can you expand on that . You look at neighbors in the eye, it is rural oklahoma and you are talking about things that are to the point. We know the burden of influenza is very high, the illnesses occur because of influenza. There are tens of millions of cases every year, hundreds of thousands of hospitalizations, tens of thousands of deaths that occur every year. We know with the vaccine we have you can prevent thousands of deaths every year, tens of thousands of hospitalizations. It is important to get vaccinated, not just for yourself but it also helps protect the Community Around you. There are a number of benefits the vaccine has. It prevents you from getting sick, from having to be hospitalized, people with underlying chronic diseases, it is like a prevention tool, something you should take every year because it keeps you from having a second heart attack the people with underlying conditions, it helps them as well. It protects pregnant women and babies so those that are born, ineligible for vaccine, getting pregnant mother vaccinated actually helps the baby during that time before they can get vaccinated. Other data shows it is lifesaving in children. You can reduce chance of the by 65 . There are a number of things that are important about it even if it is not 100 effective like doctor fauci mentioned it can reduce the severity of illness if you were to get infected. Doctor fauci, my background is agriculture. We have the Robust National veterinary stockpile which provides farmers and ranchers with countermeasures against damaging animal diseases such as Avian Influenza and swine flu within 24 hours. Could you speak to the current state of the Human Vaccine stockpile management and what we can do to better prepared to address potential pandemic emergencies . I would love to do that except the cdc is the one responsible for the stockpile. I will flip over to you then. Not to keep managing the vaccine. We like what is going on so we can reassure the folks back home we are paying attention, you and your entities are taking care of their best interests. In terms of what we do at cdc we monitor influenza around the globe especially the avian influence and swine flu viruses that are emerging around the globe, we do that through 133 laboratories, detect lows, take that information and use it in the influenza Risk Assessment tool. You can get on your browser and see a graph of where we ranked different potential pandemic viruses in that graph. With that information we work with the rest of the interagency to determine which of those should be made into vaccine candidates, which should be made into vaccines, stockpile which ones should end up in trials and with that we made decisions to put into that stockpile so that the us is prepared. Many of those vaccines, it is in the vaccine stockpile, it may be enough to vaccinate First Responders in a few small risk groups. However these viruses continue to change so it is very important for us to find new vaccine technologies so the stockpile has to keep getting more vaccines put into it but also upstream we have fast technologies and ultimately once there is universal vaccine, to have that available. In my final moments before i yield back i alluded in my Opening Statement my fathers observations prior to the development of polio vaccine 55 how the outbreaks kept getting worse and worse and the sheer terror it brought in the communities in the late Summer Season and early fall. My generation was not alive for that, did not experience that but it was truly terrifying. My first all farm job when i was 14 was going to Little Country cemetery and i had a great aunt who was the family historian and i remember asking her why in one section of the cemetery, why are all these babies buried, all these young women buried . Said look at the tombstones, 19181919, the spanish flu took them all, took them all, and even in rural oklahoma, brought society to a grounding hold for weeks and weeks as it passed through. My generation having not experienced any of that sometimes doesnt understand what the potential downside is and why you and your colleagues worked so hard. Thank you for giving us this opportunity to focus on these issues and with that i yield back. Thank you to the Ranking Member and chairwoman johnson for allowing me to be a doctor today. A couple hearings happening on the hill, this is the most important hearing taking place and that is why all the cameras thinking about it, doctor fauci and doctor jernigan, in my home state, a colleague of mine, we are on the front lines trying to combat the disinformation that is out there and i want to run through a couple quick yes no questions. Is there any Scientific Evidence that vaccines increase the risk of autism . Absolutely not. Doctor Dirksen Senate Office Building 3 . When i was practicing i would talk to some of my patients, they would often come back at me and say i dont want to get the flu vaccine because i had it before and it causes the flu. Is there any evidence the flu vaccine causes the flu . The flu vaccine does not cause the flu. I agree the flu vaccine does not cause the flu. The whole point of science is to pursue the truth and is important for us to dispel these myths. There are legitimate reasons for a if individuals have allergies to eggs etc. To opt out of the vaccine but one of the most important things about why it is important to vaccinate Large Population of folks is a concept of heard immunity and it is important for the public to understand that particular concept. It is a very important concept, not only for the flu, but our recent unfortunate experience we had particularly in new york city was a classic example of what happens when the umbrella of heard immunity goes below a certain level because you had a community in which the level of vaccination was between 70 80 for measles, you need somewhere between 9193 and more of the community so when someone inevitably comes in from the outside, someone travels and brings back measles, if the community isnt protected by that heard immunity you get the unfortunate situation we saw in the williamsburg section. What our current measles vaccination rates in america . Over 90 . We want to keep that. Measles was a disease that for the most part we eradicated in america and now we are starting to see that with incidents starting to pop up again. Doctor Dirksen Senate Office Building 3, i often Dirksen Senate Office Building 8 jernigan, we dont need vaccines or flu vaccines because we havent had a pandemic like spanish blue for 100 years. Can you talk a little bit about why we have been so lucky . This is a situation where the flu viruses are circulating in animals, can actually mix with those flu viruses in humans and when they do that they share their genes and can create a flu virus that has not been seen before. It can spread quickly through the community and cause severe death and illness and hospitalizations. 1918 was one of the worst, causing 675,000 deaths in the United States. We have three other pandemics in the last hundred years, those were changes in the vaccine that were not as bad. We looked at the 1918 virus and found particular changes in the virus that made it severe. There is nothing preventing it from happening again. For us it is important to maintain vigilance so we can see what is happening, maintain the ability to have Vaccines Available quickly so we can get it and prevent influenza if we were to have another pandemic. In our interconnected world, people across boundaries, having two big oceans dont protect us. You and i had the opportunity to Work Together in west africa. Can you talk a little about the evolution any moment of an vaccine and how it helped us in the 2017 outbreak in western congo and given us ability to better manage . 201416 outbreak in west africa during that period of time, we have a variety of other agencies including the cdc and other International Agencies began the testing of a vaccine that is ultimately made by the company merck. At the time we did phase i studies in the United States, we did it on campus, some in europe and some in west africa. We advanced 2phase 2 in sierra leone, we did one in liberia, and ultimately it was shown in a ring vaccination study in guinea to be effective in preventing infection particularly those who were exposed. That vaccine has been used in the democratic republic of the congo, 245,000 doses have been given in that approach. It is very clear that if in fact we didnt have that vaccine we would be a worse situation than we found ourselves in the democratic republic of the congo. You know from reports coming out of the cdc the number of cases per week and ebola have gone down and down. We are not through with it yet. It is still there but the vaccine has played a role in preventing the explosion we saw in west africa. Doctor fauci, doctor jernigan, thanks for your service to the community, vaccines are safe and effective and save lives. With. Im grateful to the chair for holding this hearing. Flu shots complain Important Role in protecting the public from the flu and reducing its spread. I want to focus my comments on a 90yearold policy which should have ended decades ago. Why do we still have mercury in millions of flu vaccines given to infants, toddlers and pregnant women. In july 1999 the American Academy of pediatrics and vaccine manufacturers issued a joint statement agreeing an aerosol containing vaccines should be removed as soon as possible. And at this point i have a number of documents i would like to include in the record by unanimous consent, a bibliography of studies raising safety concerns about the aerosol which is vaccine mercury and they report the misconceptions about mercury and vaccines, clearing up some misconceptions. Third, 1999 a joint statement of the American Academy of pediatrics and us Public Health service calling for the immediate removal of mercury from all vaccines. In 2004, the institute of medicine recommended removing mercury from all vaccines administered to pregnant women and children. By 2003, mercury was removed from vaccines in the United States yet to year later the cdc recommended the flu vaccine from children 6 months to 36 months of age but refused to state preference for mercury free vaccines. Bus reintroducing mercury to childhood vaccine schedule. In 2006 california passed a law banning victory containing flu vaccines from pregnant women and children under 3. In 2009 much to the credit of chairwoman johnson a bill was introduced for power plants and even more pertinent to vaccinations, mercury is a neurotoxin. Even at low levels mercury can have an Adverse Health effect particularly on women of childbearing age and developing fetuses. Doctor fauci, you work with my predecessor and i viewed your testimony from 2004. They hearing was on removing mercury from flu vaccines. During that hearing cdc director, the fda asked doctor hagan and you stated repeatedly we are removing we are moving rapidly to aerosol free vaccines and also said the better part of valor is if you can move to a vaccine something that is riskfree you should do that. Mercury is in fact a neurotoxin. Babies are at a critical stage of neural development. The one change, flu vaccine became a recommended shot and automatically protected from all liability and accountability by lawsuits. Now they have no incentive to remove mercury. I read over the flu vaccine packages and each one says it has not been tested for safety and pregnant women. Common sense said we should air on the side of safety. Doctor fauci, you testified that 50 years ago. The failure to remove mercury takes a backseat to saving a few bucks with each shot. What steps are being taken by us leader in the Public Health community to move, quote, rapidly to mercury free vaccines quote or is it no longer a priority and when can we expect it to be completed . I dont think i can answer directly the question of when it will be completed, just getting back to the discussions we had years ago in the committee, i said then and i would say again that the optimal situation would be to have aerosol free vaccines mostly as i mentioned at a hearing which you didnt say, mostly for the peace of mind of people, the Scientific Evidence that it is a harmful amount of this material and the vaccine does not indicate that. The issue but i will let jernigan comment on is it is in very few vaccines and only in multidose components and the multidose component the balance of the risk of getting contamination of a bacteria which we now can occur if you dont put Something Like aerosol into the vaccine versus the risk of deleterious effect of the full mercury and not methylmercury balances the favor of making sure you protect from infection the multidose vial. Maybe you could amplify that a bit. It is important to note the cdcs insuring vaccines are safe. Currently this year it is projected to be 169 million doses and we understand only 15 contains multidose vials. Actually there are a vast majority of Vaccines Available are the single dose vials. My time is expired, thank you. Mister posey race a couple issues, maybe just yes no answers, is the flu vaccine safe for pregnant women . Yes. Is the flu vaccine safe for infants and children . Yes. I would like to recognize the gentleman from california. The neighbor from california. I thank the witnesses this morning. How can computational data science partner better with microbiologists to accelerate the research . Computational biology is a discipline that impacts on virtually all the biological issues we do so we do computational biology when we do sequencing of various strains of virus that come in and you make a vaccine in the Opening Statement that he mentioned the fact the capability of the cdc to do math sequencing, any virus including that relies on computational biology to develop a vaccine. Is symmetry better, nanoparticles significant in any way . What it is is the display of multiple components create the ability to engage what we call the b cell repertoire of the indian system so the chances of it hitting the b cells that would be responsible to give you the kind of antibody response you want is highly immunogenic approach and nano particle approaches to any vaccine are the wave of the future and that is what we are trying to do to get away from the situation of having to grow a complete virus and use it as the vaccine the way we are doing in bags. We use Recombinant Dna Technology and show the immune system, only that part of the virus you want to respond to and avoid all the other distracting immune responses. That is why the Scientific Community is so excited about new technologies. Doctor jernigan, if we find ourselves in a pandemic, how quickly with existing technology can vaccines catch up with the outbreak . An example in 2017, the identification of a very bad age 7 and 9 influenza virus that began to circulate among poultry in china, almost 2000 human cases. We were able to receive the vaccine the virus sequence directly to china. And use reverse genetics to build the vaccine virus. Conditions at cdc and be able to hand the vaccine virus to the manufacturers. We can do that in a matter of days to weeks. However, once we hand it to the manufacturers they are bound by of the existing Manufacturing Capabilities that they have. 18 of all manufacturing is nonagbased manufacturing, the rest is eggbased manufacturing which takes at least 6 months so giving things to be quicker would be an important National Security thing for us to be able to respond more quickly. Can you address the autoimmune reaction to influenza vaccines . Forgive my pronunciation such as green beret syndrome . Do that if you like. There has been a rare association of reactivity between some of the antigenic components of vaccine and certain tissues in the body. There was again, this is not been clearly proven yet but in one of the vaccines that were available for the h1 in one flew of 2009, there was the suggestion that one of the peptides which is part of a protein that was associated with the vaccine induced a response the cross reacted with a substance called hypo treatment which is one of the neuropeptides involved in narcolepsy. The autoimmune phenomenon, discussed, but not definitively proven. When you expose the body to a protein it recognizes it as something similar to what is in your body and makes an autoimmune response. My son had a scary reaction to an injection, can you speak to that . It was a seizure that was pretty scary, not dangerous but scared the hell out of us. Certainly. Unknown reaction. I dont know the particulars but it is possible. Is a dangerous . Know, for the most part it isnt something that has a lasting impact. Thank you. I will yield back. Thank you mr. Chairman. We appreciate the witnesses we appreciate the witnesses being here and sharing your expertise. So my first question, dr. Jernigan, deals with in your testimony you mentioned the development of a mobile minilab cloudbased platform that can be set in a remote resource meant of settings to process test virus specimens and to send that genomic data up to the club for further analysis and action. Could you elaborate on how this cloudbased platform would allow Public Health officials to address outbreaks both quicker and more effectively in largely a rural area like my fourth Congressional District inng indiana . So yes, referring to the use of these micro technologies like this one here which actually is a sequencer. You take the specimen, prepare it in some little boxes that we take that fit into a carryon on a plane picky repair them and simply injected in. Theres a way you canp do whats called barcoding of the specimen to do multiple specimens at one time. With that you get a sequence and the sequence tells you the genes of the influence of viruses. This is something with demonstrated in different settings. We did take it to iowa swine fair where we swabbed a number of the a show pigs and able to quickly determine if they had influenza, the swine influenza circulating among thatza group. That data plugs into a laptop through the usb port and then on the laptop it runs a lot of information and prepares the signal that get set up to the cloud would have a process called irma. Irma is a tool, pipeline tool that takes the data and uses Machine Learning and Artificial Intelligence to try to determine which of the flu viruses are actually in the sequences. That information gets pulled down by our staff at cdc where they can then if needed generate a vaccine virus. This allows us to take the tool to the place where the problem is occurring rather than having to try to figure out how to get viruses to the cdc. Take that one step farther, you can region lies wherever of you collected your data and you can develop a vaccine specific for those areas . It possible. The manufacturing process would let you probably not be able to get but yes, you can tailor what you know about in certain reasons. I think dr. Watkins will probably get intoha some of the data issues in the subsequent testimony. So you mention pigs and have a background in agriculture, so when you were swabbing those pigs, any thoughts on the african swine fever . African swine fever something thats different from the swine influenza. Im not an expert in the swine fever but certainly the same kinds of the celts could be used anywhere in the world to do that kind of detection. Thank you. Dr. Fauci, do you have any thoughts in that area . The point dr. Jernigan made essentially, in some aspects im glad you brought that up because we constantly get people confused between african swine fever and influenza that its in pigs that could be combined with an influenza to give us a pandemic. T it has absolutely nothing to do with that but sometimes people get confused on the word african swine fever which is really completely unrelated toch influenza. And i appreciate that. That was part of the reason i mentioned that. So i yield back. Thank you. But you recognize mr. Foster. Thank you, madam thank you, i think you are witnesses. Back to the nano particle, dr. Fauci can you say about the nature of the nano particle and how you bond the stem sections to the nanoparticles . Its very interesting. Its the beauty of nature. Its a self assembling particle, protein from a bacteria and what it does is when you combine the genes of both, when they express themselves they spread themselves as a nanoparticles which symmetrically has the they just fit properly. They just fit. I hate to use this with its almost like a miracle of the Natural Selection of the nano particle is a larger protein folded in the geometry. Exactly what. The stem section is how to preserve but not absolutely preserved. Right. Are you then going to need several versions of this or other dozens of versions or just in terms of the stem prebuilt . We dont know but we became that we will not need very much because even though its not completely preserved we dont believe that mutations that occur in the stem have a functional relevance in making it different from one to the other. Everything was done so far where weve looked at the stem and we just recently completed a series of experiments where you made antibody against multiple components of the stem, and then use the antibodies to screen the entire group of the group one which contains ten of those, and just neutralize every one of them. So we think im not 100 100 , that if i we get a series of antibodies against multiple components of the stem, we could probably knock out an entire group, and there are two major groups. I think we would need at least two bute dont think we will nd ten. Fascinating. You mentioned, this is in phase one Clinical Trials at niaid research center. Is a proven effective in animals . Yes. Since allll the way through safety and effectiveness in animals and is that safety what we showed in animals is that when youci check it into te animal you got a complete array of antibodies against the whole panel of the flu. You dont count them with every single one that you know you have a protected level of antibody. I study. Changing the subject of a lipid. Dr. Jernigan, could you say a little bit about the unique challenge of achieving high rates of immunization in african populations, where they very often have a lot of reticence to connect to anything official because of the demonization of immigrant communities . Relative to my earlier comment about ways to protect the community as a form of increasing vaccine conference, certainly there are communities that dont value themu vaccine d so i think the better way to get those groups to identify what are the factors that are deemed not to get vaccinated. In case of immigrant communities, falling to 2016 election i talked toun principls in minority communities in my district who were turning kids away from school because they were not being immunized because they were terrified that ice is going to come get them if they got the kids immunized. These are kids that are u. S. Citizens but that someone in the family might be undocumented. Is that something come to monitor the rates of nonimmunization in different populations . D. C. And effect . I dont know if we have that information. We do look at Immunization Coverage and look at it by race and ethnicity, but in terms of specifics rent immigrant communities i dont know that we have that information. If you could do little get back to his i would appreciate it. Finally, you had mentioned that it was the Meat Industry in various forms was a major player in spreading and gimmicks and having the fibrocystic in in a world where you had artificial vegetable based meat which is one a lot of people dream about, is it something the way you would be less prone to pandemics . Influenza viruses are in reservoirs, so she was w on of those reservoirs and theres human specific influences that circulate among humans. Thepe biggest reservoir is among birds and the biggest reservoir among birds is migratory waterfowl. The ducks and geese so migratory. Thats not something anyone would want. That would be very difficult to try to get rid of. With each of them and youll. Was absolutely. I would yield my 2 seconds. Wonderful. One of the great challenges those of any agriculture industry do with our migratory birds and animals move around from canada to central and south america. They are the thing that we must fight about because in their lower flights thehe deposit lite presence as a go a long which then are subject to consumption of the forms of livestock. Thats an issue that causes as great angst, not maybe thats just the best place to leave it. [laughing] recognize mr. Gonzalez. Thank you. Thank you for calling this hearing and thank you to our panel for allll your work. I am a somewhat new father, a 19 month old son, and obviously the flu with respect to our children is something that is near and dear told my heart and many heas in this room and across the country. According to a wall street journal article cdc estimated over 27,000 children ages four and general hospitalized with the virus and 118 died in 20172018 flu season. Clearly these are troubling for any parent, i think the uncertainty may be more than anything else. While immunization levels in the u. S. Are relatively high, gaps still exist and providers can do more to increase utilization rates among the patients and their colleagues. According to the cdc fewer than 70 of Healthcare Providers received thehe influenza vaccine each year. How does the cdc engage with Healthcare Providers to promote vaccination . Certainly through a number of different studies, cdc has identified one way to get patients vaccinated is too make sure that the Healthcare Providers are promoting the vaccine as well. If you look at the coverage among Healthcare Providers, it falls into different categories. The more you are at an academic hospital, the more likely are to be back cited as a Healthcare Provider the more training to have as physicians have up to 90 . The farther you get away from a hospital, the lower the training, like an aide at a longterm care facility. Those of the ones that are not being vaccine donated being vaccinated. Great. Additionally, in the last decade its predicted fewer than 50 of americans actually get the shot. What research has been done or are you all doing just to get a sense of why folks are not actually getting vaccinated . There are periodically focus Group Testing that gets done for different groups to try to find out what the reasons are. The main reason that weve identified in the lastad few yes is the effectiveness of the vaccine. People dont think its as effective as it should be and thats keeping them from getting the vaccine. Weul know now theres more placs to get vaccine than ever, so access is one of those things that may have been a problem but were getting over it now. And niaid develop vaccines and highlight its Research Strategy towardsto this goal and first digit plan influenza vaccine. In your testimony you highlight one of the main challenges facing the goal of producing universal vaccines is improving vaccine production strategies. Could you tell us about plan to address this challenge and keep working towards a universal vaccine . Thank you for the question, mr. Gonzalez. That was the point im trying to make that we really need to switch into different what i call vaccine platforms. In other words, not to require to having to decide on a strain in february and then take six and a half to seven months to get it grown and processed to be able to put h in a vaccine, whee as if you the kind of platforms such as a nano particle which is one of several platforms, so as part of our Strategic Plan that i articulated in the document that you mentioned, is to try and develop an perfect various platforms so that we can get away from the burden of having to grow the virus. Thank you. I will yield my remaining v tim. Let me recognize ms. Stevens. Thank you so much for this insightful panel, and thank you, doctor baer, a sulfur for bring us all here together. We heard all of it today that despite strong effort efforts h the public and private sector that a universal flu vaccine remains elusive. What scientific advances do you see on the horizon to improve the flu vaccine . I believe the scientific advances will be what i was showing on one of those slides of ultimately being able to develop a vaccine that would induce a t response that would have broader coverage. I was jut actually speaking to a scientist who made a breakthrough discovery and in 2009 to develop the anti body from a person who was infected with flu and it found a then he found out that not only did it neutralize the virus that the person was infected with, it neutralized all of the viruses in that particular group which is the grip one, ten ten virus. That was a scientific breakthrough that allowed us to go to next up in a universal flu vaccine. Its breakthroughshs like that that a i predict over the nexto years or make it easier and easier to get to the ultimate goal of universal flu vaccine. Dr. Jernigan come together to think . In terms of nearterm kinds of things, what weve been looking at, the main problem is one of the virus components. We can only put four different components in and one of them called h3n2. H3n2. Thats a problem child of vaccine. So that when we know when you put into eggs to manufacture which is 85 of all manufacturing, the inset changing the influenza virus so that it no longer looks as much like the circulating viruses that are infecting people. The use of the eggbased manufacturing introducing some changes that may be have an effect on the effectiveness of the vaccine itself. Moving to sell based vaccine, moving to recumbent vaccines may be quicker and may make the vaccine to be looking more like the h3n2 viruses that are circulating. Can the federal government played a role particularly in terms of the tools that are being developed to monitor the effectiveness and safety of our vaccines . Absolutely. At cdc whether Vaccine Effectiveness Network that we manage. Weve been able to expand some but i thinknk expanding that muh greater would allow us to be able to get information about how to vaccine is working better or worse in certain age groups, certain parts of the country, certain types of individuals. It would give us a lot more information to know how to make the current vaccines better. In your testimony, dr. Watkins, you mentioned that Public Health Data Infrastructure is a little outdated and it hinders our ability to prevent outbreaks before they occur. It hinders our ability to respond rapidly when they do occur, and it also hinders our overall ability aroundin surveillance o data. Could you just speak a little bit about hotel is a little bit about that Tasha Watkins is nearterm sorry. Im so eager for watkins and youre both looking at me like watkins is in here. But, but what if you could talk about Data Infrastructure and we will also pay note to watkins when they arrive. I think over time weve seen this been an improvement in the use of data at healthcare facilities, through Electronic Health records et cetera but the Public Health establishment has to receive information from multiple different sources. Right now theres not a standardized for a common way that that information can come in. Plus, its hard for a state Health Department to be able to quickly get the information they need to know is this a case of whatever particular reportable disease, do i need to intervee quickly, has this person been vaccinated . From it flu perspective we currently get realtime information about influenza like illness from a number of different sources, but only about half of that is realtime. The others doctors lef forms and things. If we were able to get realtime information from all of those providers regularly we would be able to know exactly whats happening with the flu at a much more local level, more precise data, more actionable data for decisionmaking. Thank you, dr. Jernigan. Or and yes, it is the racer information and data. Thank you, mr. Chairman. I yield back. Let me recognize doctor babbitt. Thank you, chairman. Appreciate you. And appreciate you gentlemen for being the expert testimony. Just wanted to ask you, dr. Jernigan, first what are some of the emerging technologies and practices being developed to identify different pathogens, targets and modernize the delivery of vaccines . And pardon if you only answered questions like this but i have a markup on a different floor in the same building so i i just e in. Im a dentist and one of my call extended as if it were vaccines to eliminate cavities one of my colleagues and if i be against us. Yes, of course, but we encourage hollowing and things like that, okay . With regard to the diagnostics, im not going to address the cavity issue, inch of the diagnostics the cdc maintains the International Reagent Resource which is an online storefront that all of the Public Health departments in the train and 140 laboratory around the globe were able to go on an order standard with agents of cdc make so we know the globe is doing the same kind of testing for influenza we can use that information quickly. That uses a process called pcr or preliminary Chain Reaction which is as common way, we are updating that but whats really been game change is the ability of genomics sequencing. Cdc has established three national influences influence of Preference Centers and theea United States with it you all of that Genomic Testing so we can pick up emerging antibiotic resistance, viruses that might be pandemic, fibers that is emerging, those kinds of things so weg can act more quickly. Thank you very much. Thats very fascinating. And what are the main scientific and technological hurdles that stand in the way of the development of a universal influenza vaccine . I call the tail end of the question that have similar one like that, and how are you working to overcome these, dr. Jernigan . Certainly i will let dr. Fauci to all the various different hurdles that are out there. For us the influence of virus is able to activate human immunity for ever, and so you get influenza every year, so the task at hand is a very difficult when in that the virus itself, the body itself is not able to of longlasting immunity. We are trying to find something that the body itself is not very good at. Dr. Fauci, if you go ahead and elaborate on that as well. Well, theres one hurdle that i think is really a series hurdle, even ifhi we get a universal vaccine that would induce a response against the wide array of influences, that is a phenomenon actually very interesting called imprinting, and what it is is that your body tends to make y a response agait the first influenza or the first antigen that it was exposed to when you were a youngster. So that even later on in life whenwa you get exposed to that organism, that microorganism again, from an evolutionaryy standpoint that was a good thing because that means your immune system is primed so that if you see that microbe again you make a really good response. Thats great for Something Like measles or mumps or rubella which doesnt change. It stays the same. With influenza it works against you so that what you will do is if the first i am an h1n1 person in the sense that i was born at a time when h1n1 was around. Mywh immune system is primed to make response against h1n1. If i get expose to an h3n2 or even get faxing with that, even though i will make a reasonable response, my body will revert to wanted to make response to h1n1. It refers to sometimes as original antigen its so the real problem is how to get around that so that you can vaccinate somebody and overcome that tendency to make a response against something that you were originally exposed to . Thats going to be an important obstacle. That was the question i was saving for you, mostly you answered it because this is why measles, mumps and rubella vaccines have a 97 effectiveness, where influenza is only, what is it, 10 . No. That was a very bad year. 60 . 4060 . Thats the biggest hurdle we have. Exactly. You hit the nail on the head exactly. Thank you, very much and ani yield back. Let me recognizenk mr. Caste. Thank you, mr. Chair. Thank you both so much. I am totally intrigued by this universal vaccine idea and i want to start if you just qme as a biology nerd. I want tos follow on the question, so the fact that the stem has been so preserved, how confident are you that thats because theres something fundamentally that the bug just cant change that protein versus the fact that statistically the antigens were on the service and so as we start developing antibodieses to go up to the st, are you confident the stem to t are evolving into something . It could evolve under immunological pressure, but from the standpoint of conserved components can we call them parts of proteins, when something is concerned about evolution, its usually because its critical for that particular thing to survive, whether its a species, an animal or protein so that must be something about that stem thats absolutely critical to the function of the virus. Going to change but we have to be careful and not make an assumption that will be wrong. Is the animal stuff of duration to give you confidence. To be honest, no. We havent done it for a decade and we show over a period of time we keep vaccinating an animal making it responsive and then years later we havent proven that yet. So what if anything can we do to accelerate these universal vaccines quick. Thankfully we have very good support from congress to do the work we are doing in fact there will ask appropriation to set aside to stimulate the research in that area so we are very appreciative to congress what you are already doing. I will take a chance that we share a sense of humor what you call alternative medicine when it works quicks . Medicine. We are add moment of rise of Climate Science denial and Anti Vaccine Movement in the rise of people who think of the stars are when they were born has an impact on their future. As you think about Public Health one of the concerns Anti Vaccine Movement consciously choosing not to do the medicine another separate of those that choose to take bogus medicine which of those baby and praising this wrong but are there comparable concerns are we doing enough to combat both quick. I think they are comparable there are danger in both you brought up two very important points there is an obvious concern of people who are anti science and there is a danger to have deleterious effects assuming the efficacy to do that. Several years ago we established the institute for complementary medicine to look at some of these things that people are convinced works whether they do or do not so we are doing something about putting scientific rigor to these potentially bogus but on the anti science and the only thing we can do is continue at the cdc and nih to get out the message and the evidencebased proof of what works theres nothing like evidence to convince someone it works you have to come in with evidence over and over. Are we doing enough to keep bogus science offtheshelf . I see flu medicine and theres homeopathy editor of the average person knows the difference so should we be doing more quick. As a society we could be im not sure that we could or the cdc could do but clearly there is stuff out there that doesnt do anything except potentially harm people. We recognize mister murphy. Professionally gentleman i have followed both of your careers with fantastic landmark discoveries with hiv now it is manageable. As the last one to speak i have to figure out what people have already asked. So pointing out the anti Scientific Movement i think thats a major problem people are now starting back on the flat earth agenda. Going back to the Anti Vaccine Movement could you speak to that what it has done for populations at risk and where do you see that going in the future . It is a major issue. Certainly there are pockets where individuals are talking with one another and schools that hear from each other so those pockets can lead to children not being vaccinated. Its important to recognize they get their information in multiple ways so for how of us we get the evidence based information for what the needs are so those specific groups it will be very difficult i would like to revisit you both i dont think people really understood the gravity what would have happened if that had gotten into any place. Does it mutate at the level the other ones do so explain the infection rate versus hiv i think that could be helpful. With ebola unlike influenza that mutates it is pretty stable there is always mutations they have not proven to be functionally relevant so those in the strain of west africa there are different tapes ebola zaire and ebola sudan the one we are dealing with right now really hasnt been a problem to be functionally relevant so you can measure but it doesnt change anything about it so the question you ask the relationship with the vaccine that any change of the virus has no change so it looks pretty good so as i mentioned earlier in the testimony the 250,000 vaccinations now the second part is the issue of how it is transmitted in the untreated on vaccinated arena like the drc the mortality that is 60 or 70 percent and is transmitted only by direct contact with the contaminated bodily fluid. That was important so if they get a fever they are not pleading or vomiting it is non contagious not a concern of people so if you get Something Like influenza and it is transmitted by the respiratory route and there is a window youre not very sick and you could shed the virus before you get sick so there is a substantial difference in transmission its tough to get infected unless you have direct contact with a really sick person you get the flu on the elevator next to you. Thank you mister chairman i will yield back. Thank you i like to add one more document. Clearly it indicates while these are safe for most people there are some for whom its not safe with a billion dollars that they did not mention 46 percent were for the influence based vaccination for quite it want to ruin the love but i should not be cavalier for those for whom it is an appropriate and we do try to identify what might not be appropriate to receive though shots. Thank you for reminding us we could get the flu in the elevator which we ride in all the time in this building. And thank you to the witnesses for being here today. Reflective of what happened last century it was antics on astounding success essentially we eliminated polio and diphtheria largely defeated those the who estimates that vaccines have prevented at least 10 Million Deaths between 2010 and 2015. In the hearing today we are acknowledging there is a great deal of work to do especially with influenza one of the most pervasive Infectious Diseases globally so we are still struggling to effectively predict those epidemics because of the rapidly changing nature but there is this exciting cuttingedge research to develop these new approaches thank you for bringing your model and your lab. Im glad thats why we are having this hearing today. Some research is happening at the university in portland and to work on a novel method of longterm vaccination with target pathogens in the cmv virus trigger a response by the t cells i dont understand what that means im hoping you can explain it but teethree are you familiar with this approach and can you explain how that differs from what you described in your testimony or more traditional antibodies are the method in search of a breakthrough quick. The person you are referring to is doctor lewis ticker and he has established a vaccine platform which uses a virus that is highly mutagenic it is called a vector platform so thats it we have experience with inserting into the virus the gene of a particular protein. He is done with tuberculosi tuberculosis, hiv and other pathogens. So what happens if he wanted to make a vaccine which he is trying to do against hiv, he takes the gene in the outer protein of the hiv and sticks it into the virus and injects it into an animal that is not a benign virus. But it is very effective. So it pumps out the protein which is the hiv protein. So at the university with Gene Therapy Institute so asking doctor jernigan we have over 25 over models that use and they have to tell us if the flu will peak the speaker when it will start its way not what it is doing now but what will it do it could be an Outpatient Clinic and then to have more beds of the icu. So data from within 100 countries to determine which virus are recommended in inclusion to see that that is usable what can be done to improve the International Disease to be better prepared it is a very good view of influenza. But there are blank spots on the globe and the more to get improved surveillance and more timely information that helps the rest of us to show up and make better vaccines. My time is expired i yield back. Thank you for joining us here today. In october the cdc released maternal vaccination i was surprised pregnant women receive the flu and whooping cough vaccine women with the flu are twice as likely to be hospitalized if pregnant and 70 percent of whooping coughs death are in children younger than two months of age. The flu vaccination during c reduces admission of babies by 60 percent whooping cough by 91 percent to help we can agree they are a critical part of prenatal care for expectant mothers. And understand that doctor jernigan and you said in your testimony half will get their flu shot because i have the perception that it is not effective i know we have talked about misperceptions and false information but how can we more effectively communicate the benefits. Regard to pregnant women it is a real Success Story you have seen it rise to that level and clearly we need to do more with the other vaccines if you look at who was vaccinated you can see its among the old and the very young. But those that are late in their teens thats when we have to start increasing the vaccination so thats where we really start to use social media. And getting the use to getting a vaccine every year. Plus its a group of people that dont avail themselves to preventative healthcare so that group is a challenge for one we need to work on. Im glad you brought up social media and how that can impact lives in a good way or bad way and one of the issues with social Media Information spreads so quickly with its viral nature allows people to miss communicate without sources that point out if something is false or is true to withstand peerreviewed. It is something we have seen across committees and other context and how lives are at stake in the American Academy of pediatrics with major social media platforms with google and interest to highlight from spread across their site and i understand you have already given your testimony about the misinformation and how it spreads. But do you think these platforms are doing enough . I think people access information in multiple ways so to make sure we get our information is scientific and evidencebased format that is reusable is important. I agree we can do more and do better but the platforms that we have now for the message has a positive effect but clearly it is a challenge that will not go away. We have to keep on is not a problem that we can solve. We have to do it over and over again. Thank you so much i yield back. Enclosing if you questions that have come up repeatedly folks will say its almost the end of november ive made it this far is that correct. Our recommendation is that we recommend you get your vaccine if possible by the end of october but as long as it is circulating we recommend you get a vaccine so it is not too late. The goal to get people vaccinated prior to the season start because there is two weeks of time prior to allow their immune systems to build up that clearly we recommend you continue to get vaccinated now. Most of america is watching this hearing right now. Not the other one. [laughter] it is not too late. Another question that comes up occasionally vaccine versus flu shot any recommendations quick. We do not have a preference for one over another there are parental preferences like the nasal vaccine there is no preference for one over the other. Once again thank you for your service to this country into medicine and for those watching at home flu shots are safe vaccines are safe and vaccines are effective and save lives. Now well will allow the second panel to be thank you. [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations]