GOOD AFTERNOON AND WELCOME TO THE 2012 JOHN LA MON TANG LECTURE. THIS LECTURE HONORS THE ESTEEMED JOHN LA MON TRAIN. ROSE TO BECOME THE DIRECTOR OF OUR DIVISION OF MICROBIOLOGY AND INFECTIOUS DISEASES AND FINALLY SERVES SO ABLY AS MY DEPUTY DIRECTOR OF 1998 UNTIL HIS UNTIMELY DEATH IN 2004. TODAY WE'RE VERY FORTUNATE TO HAVE JOHN'S WIFE ELAINE HERE WITH US TO HELP US PAY TRIBUTE TO HIS MEMORY, AND I EBS TEND AN ESPECIALLY WARM-UP -- WARM WELCOME TO HER. [APPLAUSE] THOSE OF US WHO KNEW JOHN REMEMBER HIM AS AN EXTRAORDINARILY WONDERFUL HUMAN BEING, AS WELL AS A WISE AND DISTINGUISHED THOUGHT LEADER IN THE FIELD OF INFECTIOUS DISEASES, SOMEONE WHO WAS ALWAYS WAY AHEAD OF HIS TIME. HE WAS BEST KNOWN FOR HIS WORK ON INFLUENZA. JOHN ALSO HELPED LEAD EFFORTS TO DEVELOP VACCINES FOR PERTUSSIS AND CHILDHOOD DIE RE-IA AND PNEUMONIA. HE HAS BEEN SUCH A CLOSE FRIEND, ALLY AND CONSULTANT TO ME, SOMEONE WHO NOT A MAJOR DECISION WAS MADE DURING THE YEARS THAT HE WAS MY DEPUTY THAT DID NOT INVOLVE VERY INTENSIVE CONVERSATIONS WITH JOHN. AND IT WAS FOR THIS REASON AMONG MANY, MANY OTHERS, THAT WE DECIDED THAT WE WOULD HAVE A MEMORIAL LECTURE IN HIS HONOR. AND THUS, IT IS FITTING THAT OUR SPEAKER TODAY, DR. SETH BERKELEY, WILL DISCUSS THE CHALLENGES OF DELIVERING VACCINES FOR THESE AND OTHER DEADLY DISEASES TO CHILDREN IN THE POOREST COUNTRIES IN THE WORLD, SOMETHING THAT WAS NEAR AND DEAR TO JOHN LA MON TAIN'S HEART. SETH IS A CHIEF EXECUTIVE OFFICER OF THE GAMBY ALLIANCE AND ORGANIZATION DEDICATED TO SAVING CHILDREN'S LIVES AND PROMOTING GLOBAL HEALTH BY INCREASING ACCESS TO IMMUNIZATIONS IN DEVELOPING COUNTRIES. SETH EARNED A MEDICAL DEGREE FROM BROWN UNIVERSITY AND COMPLETED HIS RESIDENCY IN INTERNALAL MEDICINE IN BOSTON AND SUBSEQUENTLY HE JOINED THE EPIDEMIO LOGIC INTELLIGENCE SERVICE. IN TONIGHT IN 87, HE BEGAN WORKING FOR THE TASK FORCE FOR CHILD SURVIVAL AT THE CARTER PRESIDENTIAL CENTERS FOR WHICH HE LED AN EPIDEMIO LOGICAL TEAM IN THE UGANDAN MINISTRY OF HEALTH. THE ASSIGNMENT COINCIDE WITH THE MRJS THE -- EMERGENCE WITH THE AIDS PANDEMIC IN UGANDA WHICH IS DO YOU MEANED THROUGH A SURVEY AND DISEASE SURVEILLANCE. THIS PIVOTAL EXPERIENCING LAID THE FOUNDATION FOR SETH'S LATER CAREER. UPON RETURNING TO THE UNITED STATES IN TONIGHT IN 89, HE JOINED THE ROCKEFELLER FOUNDATION TO CREATE AND MANAGE INTERNATIONAL PUBLIC HEALTH PROGRAMS, AND IN NIPTS 93, A GROUP OF HEALTH LEADERS, AIDS ACTIVISTS, VACCINOLOGISTS APPROACHED SETH AT THE FOUNDATION TO ASK FOR HIS HELP IN HOW WE MIGHT ACCELERATE INTERNATIONAL EFFORTS TO DEVELOP AN AIDS VACCINE? IN RESPONSE, HE LAUNCHED THE SERIES OF CONSULTATIONS TO IDENTIFY THE OBSTACLES FACING THE FIELD. THE OUTCOME WAS A PROPOSAL TO CREATE A NONPROFIT PUBLIC PUBLIC-PRIVATE PARTNERSHIP DEDICATED TO DEVELOPING AIDS VACCINES AND THIS LED IN 1996 TO THE CREATION OF THE INTERNATIONAL AIDS VACCINE INITIATIVE FOR WHICH SETH SERVED AS PRESIDENT AND C.E.O. FOR 15 YEARS AND IT WAS IN THIS CAPACITY THAT I GOT TO KNOW HIM SO WELL AND THAT WE BECAME CLOSE FRIENDS. LAST YEAR, SETH LAUNCHED A NEW PHASE OF A CAREER WHEN IN AUGUST HE BECAME THE C.E.O. OF THE GAMBY ALLIANCE. INTERESTINGLY, JOHN LA MON TANGE AND SETH COLLABORATE ON THE PREDECESSOR, AN ORGANIZATION CALLED THE CHILDREN'S VACCINE INITIATIVE. AND I AM SURE IF JOHN WERE HERE TODAY, I AM CERTAIN THAT HE WOULD BE KEEN TO LEARN, AS WE ARE, WHAT PLANS SETH HAS IN STORE FOR GETTING THE MIRACLE OF VACCINES TO THOSE WHO NEED THEM THE MOST. SO PLEASE JOIN ME IN WELCOMING DR. SETH BERKELEY. [APPLAUSE] >> THANK YOU. SO I MUST SAY I AM INCREDIBLY DELIGHTED TO BE TIER AND THANK YOU, TONY, FOR THAT WONDERFUL INTRODUCTION. FORE, YOU GAVE AWAY A LITTLE OF MY PUNCHLINE, GIVEN THE ROLE THAT JOHN PLAYED AND I REALLY WANTED TO START THERE, BECAUSE LIKE MANY IN THIS AUDIENCE, JOHN WAYS FRIENDS, A MENTOR AND IN A RIGOR AND SCIENCE TO THE FIELD OF GLOBAL HEALTH AND BECAME A INITIALLY STARTED OUT WORKING IN THAT INTERESTED AND BECAME AN UNBELIEVEABLE CHAMPION, PERHAPS MORE INSPIDE ON THE GLOBAL HEALTH ISSUES THAN US WORKING IN GLOBAL HEAL OURSELVES. SO WHEN JOHN PASSED WAY TOO EARLY, IT WAS A HUGE LOSS, NOT JUST FOR THIS SCIENCE COMMUNITY BUT FOR THE GLOBAL HEALTH COMMUNITY. SO I AM GOING TO TRY TO TAKE YOU ON RAPID SEQUENCE THROUGH A TALK ABOUT THE AREA, AND IT'S DIFFERENT THAN A LOT OF WHAT YOU TALK ABOUT HERE AT NIH, BECAUSE I AM NOT GOING TO BE TALKING ABOUT BASIC SCIENCE. AS PASSIONATE AS I AM ABOUT THE SCIENCE, THIS IS ABOUT HOW WE TAKE FRUITS THAT HAVE LABOR AND GET IT TO THE PEOPLE WHO NEED IT. SO WE'RE GOING TO START OFF TALKING ABOUT THE GREATEST NEED, THE POWER OF VACCINES, FROM WHY GAMB, I THE IMPORTANCE OF LONG TERM SUSTAINABILITY AND REFLECTIONS ON CHALLENGES AND OPPORTUNITIES GOING FORWARD. SO STARTING OFF ON THE ISSUE OF CHILD MORTALITY, IT'S REALLY A VERY EXCITING TIME IN GLOBAL HEALTH, AND THE GOOD NEWS HAS BEEN THAT THERE HAS BEEN A HUGE REDUCTION IN CHILD DEATHS AROUND THE WORLD. WE'VE SEEN A DECLINE FROM GREATER THAN 12 MILLION DEATHS IN 1990 TO 7.6 MILLION IN 2010. THERE IS AN ACCELERATING RATE OF DECLINE SO WE SAW 1.9 PERCENT A YEAR IN THE DECADE BEFORE 2.5 PERCENT IN THIS LAST DECADE. BUT THE BAD NEWS, OF COURSE, IS THAT 7.6 OR ARE 7.6 TOO MANY. WE ARE STILL SEEING 21,000 CHILDREN DIE EACH DAY AND MANY COUNTRIES ARE NOT ON TRACK TO REACH THE DEVELOPMENT GOAL FOR WHICH IS A CRITICAL TWO THIRDS REDUCTION IN UNDER FIVE MORTALITY RATE BETWEEN TONIGHT IN 90 AND 2015. SO WHERE ARE THOSE DEATHS, AND AS YOU CAN SEE, THE BULK OF THESE ARE OCCURRING IN SUBSAHARAN AFRICA AND SOUTHERN ASIA AND THESE, OF COURSE, ARE AREAS THAT ARE VERY IMPORTANT TO GAMBY AND WE'LL BACK. -- COME BACK. WHAT ARE THESE CHILDREN DYING OF? SHE'S THOES ARE LOOKING AT THE GAMBY-ELIGIBLE COUNTRY AND 73 POOREST COUNTRIES IN THE WORLD WITH A GROSS NATIONAL INCOME OF UNDER $1500 AND PNEUMONIA AND DIREIA ARE LARGE CAUSES, MALARIA, OBVIOUSLY, A RANGE OF OTHER DISEASES AND CONDITIONS AND IF WE LOOK AT THE INFECTIOUS DISEASES CAUSES PNEUMONIA AND DIREIA COUNTY FOR 24 AND 18 PERCENT. WE HAVE OTHER VACCINES FOR MEASLES, MENINGITIS, AND OTHER CONDITION THAT'S OBVIOUSLY THE WORLD NEEDS VACCINES FOR. SO LET'S JUMP TO THE POWER OF VACCINES AND I THINK IT'S AN EXTRAORDINARY HISTORY WHICH I AM NOT GOING TO TALK ABOUT IN ANY GREAT DEPTH. BUT WE STARTED A LONG TIME AGO, AND OVER TIME WE'VE SEEN AN ACCELERATION OF DIFFERENT ANTIGENS THAT EXIST FOR INFECTIOUS DISEASES AND THIS IS NOW A COLLAPSE OF THAT TIMELINE AND HERE YOU CAN SEE THE CUMULATIVE NUMBERS OF VACCINES THAT ARE BEING DEVELOPED. OF COURSE, WE HAVE EVEN MORE COMING DOWN THE PIKE. THE CHALLENGE WAS THAT THESE VACCINES WEREN'T GETTING MADE AVAILABLE TO THE PEOPLE WHO NEEDED THEM THE MOST AND THAT REALLY IS THE CHALLENGE IN FRONT OF US. WHAT WHAT WE KNOW IS VACCINES CAN DO EXTRAORDINARY THINGS. THIS IS LOOKING AT THE RESULTS FROM VACCINE OBS A GLOBAL BASIS, AND YOU CAN SEE IN THIS TIME PERIOD, THIS 20-YEAR PERIOD, POPULATION INCREASING 30 PERCENT, AND YOU CAN SEE VERY LARGE REDUCTIONS IN THESE MAJOR INFECTIOUS DISEASES SO WE'RE -- A REALLY EXTRAORDINARY HE CAN'T ON DISEASE BURDEN. ONE OF THE GREAT SUCCESSES IS SMALL POX, WHICH I DON'T NEED TO MOERND THIS AUDIENCE ABOUT. BUT WHAT IS HAPPENING RIGHT NOW IN POLLIO ERAD -- ERADICATION. WHEN THIS WAS STARTED IN TONIGHT IN 99 -- 1988 MORE THAN 350,000 CHILDREN PARALYZED EACH YEAR AND YOU CAN SEE THAT TODAY OMG THREE COUNTRIES ARE STILL ENDEMIC. THE REALLY EXTRAORDINARY CHANGE WAS INDIA WHICH THREE YEARS AGO HAD THE LARGEST NUMBER OF CASES IN THE WORLD AND NOW HAS BEEN POLIO-FREE FOR ABOUT A YEAR AND A HALF. SO WE'RE SEEING THE POWER OF VACCINES AND WHAT IT'S ACTUALLY DOING AND OBVIOUSLY, IT'S CRITICAL THAT THIS EFFORT GET COMPLETED. WE'VE ALSO SEEN DRAMATIC EFFECTS ONMACYLES AND HERE IS LOOKING AT WORLDWIDE MEASLES CASES AND COVERAGE RATES AND A DRAMATIC CHANGE SINCE AN ACCELERATION OF MEASLES VACCINE USE AROUND THE WORLD. BUT WHAT YOU CAN SEE IN THIS, LOOKING AT THE AFRICAN REGION IS A RESURGENT AND A FOURFOLD INCREASE SINCE 2008. AND WHAT'S INTERESTING, THIS IS LOOKING AT A WORLDWIDE MAP AND YOU WILL SEE ON THE LOWER LEFT A COUNTRY YOU'D EXPECT ME TO SHOW. SO THE DEMOCRATIC REPUBLIC OF THE CONGO, VERY, VERY LARGE OUTBREAK. 133,818 CASES AND SURVEILLANCE IS NOT SO GOOD THERE SO I SUSPECT A MUCH LARGER NUMBER OF CASES. BUT JUST AS IMPORTANT, FLASHING ON THE UPPER RIGHT IS HERE IS FRANCE WITH CLOSE TO 16,000 CASES AND THESE CASES OBVIOUSLY HAVE BEEN IMPORTED FROM DIFFERENT PLACES. I KNOW IT WAS A BIG OUTBREAK HERE IN THE U.S. AND ARIZONA THAT WAS TRANSMITTED ABOUT A SWISS VISITOR. WE DON'T THINK OF SWISS VISITORS AS BEING PEOPLE TO TRANSMIT INFECTIOUS DISEASES BUT IT REMINDS US THE INTERCONNECTEDNESS OF THE WORLD AND WHY WE HAVE TO PAY ATTENTION TO POPULATIONS ANYWHERE IN THE WORLD. SO THIS IS A HUGE PROBLEM, NOW BEING DERIV IN THE DEVELOPING WORLD BUT NOT D BY NOT USING THE VACCINE BUT IN THE DEVELOPED WORLD BY THEVE VACCINE DENIALISTS. AND HOW DO WE FIGHT THE INTERNET IN ESSENCE AND THE MISINFORMATION THAT'S SPREADING BECAUSE IT'S ONE THING TO HAVE SOMETHING IN A NEWSPAPER WHERE YOU CAN RECALL IT BUT IT'S VERY HARD TO DO THAT ON THE INTERNET AND WE'RE BEGINNING TO SEE THIS MISINFORMATION SPREAD INTO THE DEVELOPING WORLD AS WELL. FROM THE WEST AND THAT'S A HUGE PROBLEM. LOOKING OPT GROUND AT OTHER DISEASES, HERE IS A GRAPH LOOKING AT AN ACT OF SURVEILLANCE SYSTEM IN UGANDA AFTER INFLUENZA-TYPE B VACCINE INTRODUCTION AND YOU CAN SEE THE DRAMATIC EFFECT THAT'S OCCURRING IN THAT COMMUNE. AND HERE IS A SLIDE FROM MEXICO LOOKING AT A ROTOVIRUS DIREIA AND WHAT'S INTERESTING HERE IS NOT ONLY THE RUCTION IN THE AGE GROUP THAT WAS RECEIVING THE VACCINE AND UNDER ONE YEAR, BUT YOU CAN ALSO SEE THE RUCTION OCCURRING IN OLDER AGED CHILDREN AND THERE WAS A LITTLE BIT OF A SURPRISING EFFECT BECAUSE ALTHOUGH WE EXPECTED IMMUNITY, WE DIDN'T EXPECT IT TO LEAD INTO OLDER AGE GROUPS. THIS IS SOMETHING IMPORTANT TO LOOK FOR AS THEY UNDER THE EPIDEMIOLOGY OF THESE DISEASES IN THE DEVELOPING WORLD. AN AMAZING STORY IS WHAT'S HAPPENED WITH THE MENINGITIS BELT. MANY OF YOU STUDENTS OF INFECTIOUS DISEASE KNOW ABOUT THE MENINGITIS BELT IN AFRICA, UNSPLAPD EPIDEMICS, THAT KIND OF RUN THROUGH THE CONT NEPT, CREATE NOT OM HUGE MORTALITY BUT AMAZING MORBIDITY AND BASIC PARALYSIS, AS MANY, MANY PEOPLE ARE SICK DURING THIS PERIOD. A CANDIDATE VACCINE WAS MADE. THE TECHNOLOGY FOR THESE VACCINES IS RELATIVELY OLD BUT A VACCINE WAS MADE SPECIFICALLY FOR THE DEVELOPING WORLD A PRODUCT PROFILE OF UNDER 50 CENTS A DOSE. IT WAS ROLLED OUT AND THIS IS LOOKING AT MENINGITIS CASES IN BER KINO FOSSA AND YOU CAN SEE IN THE BLUE COLUMN GOING FROM 156 DOCUMENTED CASES DOWN TO ZEROEST LOWEST EVER GIANT. LITTLE DISTURBING IS THE NEXT COLUMN OVER, WHERE YOU ARE SEEING W 135 CASES AND ONE OF THE QUESTIONS IS WHAT DO WE HAVE TO DO ABOUT IS THERE GOING TO BE REPLACEMENT IN THESE AREAS IN THE MENINGITIS BELT, IT WAS CHARACTERISTICALLY A THAT WAS THE PROBLEM. BUT IT MAY BE THAT THERE WILL BE REPLACEMENT AND THESE ARE SOME OF THE RESEARCH AGENDAS THAT ARE REQUIRED LOOKING IN THE FUTURE. NOW, TRYING TO MAKE THE CASE FOR VACCINES AND I THINK I'VE SHOWN YOU THE POWER ON DISEASES, BUT THE U.S. HAS TRIED VERY HARD TO MAKE AN ECONOMIC CASE. IT'S SHOWN THAT YOU SAVE IN HEALTH COSTS SIX BILLION, LESS OUT-OF-POCKET EXPENSES, LESS TIME CARING FOR SICK CHILDREN AND A RUCTION OF $REDUCTION IN $1 BILLION OF PRODUCTIVITY LOSS, LONGER LIFETIME PRODUCTISTS AND TRADE IN TOURISM BENEFITS OF INFECTIOUS DISEASE OUTBREAKS. INTERESTINGLY IN THE DEVELOPING WORLD, WE ALSO HAVE BENEFITS BUT THEY'RE NOT AS WELL DOCUMENT SOD I AM SHOWING YOU SOME REAL DATA BUT IT'S VERY THIN AND THIS IS AN AREA THAT WE'D LOVE TO SEE MORE RESEARCH IN. ONE IS THE ISSUE THAT HEALTHY CHILDREN DO BETTER AT SCHOOL. THEY HAVE BETTER ATTENDANCE AND HIGHER TEST SCORES. ONE STUDY SHOWED A FULLY IMMUNIZED CHILD AT+++ UNIVERSAL CHILDHOOD IMMUNIZATION. AND IN 1990, WHEN THERE WAS A DECLARATION OF UNIVERSAL CHILDHOOD IMMUNIZATION THAT WAS 80 PERCENT COVERAGE. IT WAS PROBABLY 75-ISH, THE WORLD TOOK ITS EYE OFF THAT PRIZE AND WE SAW COVERAGE RATES DROP. BUT AT THAT TIME A NEW INITIATIVE WAS LAUNCHED AND JOHN WAS VERY INVOLVED WITH THIS, THE CHILDREN'S VACCINE FIBRILATEIVE AND THIS WAS TO TRY TO NOT ONLY ENHANCE IMMUNIZATION BUT TO HAVE A RESEARCH AGENDA TO TRY TO MAKE VACCINES THAT WERE MORE TEMPERATURE-STABLE, THAT WERE EASIER TO USE AND APPROPRIATE FOR THE DEVELOPING WORLD, INEXPENSIVE. AND THAT ORGANIZATION FELL APART NOT BECAUSE OF THE VISION BUT BECAUSE I WOULD SAY PETTY POLITICS AND JEALOUSIES AND OTHER ISSUES. AND SO IN 2000, ANOTHER ATTEMPT WAS MADE. THE GAMBY ALLIANCE WAS LAUNCHED. AND I WAS INVOLVED WITH THAT. AND AS WAS JOHN. AND YOU'VE ALREADY HEARD A LITTLE BIT ABOUT WHAT THE MISSION IS. FOUR MAJOR STRATEGIES TO ACCELERATE THE UPTAKE AND USE OF UNDERUSED AND NEW VACCINES, TO CONTRIBUTE TO STRENGTHENING THE CAPACITY OF INTEGRATED HEALTH SYSTEMS TO DELIVER IMMUNIZATION TO, INCREASE THE PREDICTABILITY OF GLOBAL FINANCING AND IMPROVE THE SUSTAINABILITY OF NATIONAL FINANCING FOR IMMUNIZATION, AND FAMILY TO, SHAPE VACCINE MARKETS AND I'LL TALK ABOUT THESE FOUR GOALS. SO FIRST OF ALL, IT'S AN INTERESTING ORGANIZATIONAL MODEL. IT'S ACTUALLY A PARTNERSHIP, WORKING WITH THE MAJOR GROUPS THAT WORK IN IMMUNIZATION. SO GAMBY DOESN'T HAVE PEOPLE ON THE GROUND ITSELF. IT DOESN'T DUPLICATE WHAT OTHERS ARE DOING. IT TRIES TO WORK WITH THEM AND BRING THEM IN. AS YOU CAN IMAGINE, THIS CREATES SOME CHALLENGES IN TERMS OF ABILITY TO WORK TOGETHER AND ALIGNMENT OF MISSION. BUT WHAT IT MEANS IS THAT YOU CAN BE VERY EFFICIENT USING ALL OF THE SLEPTS SERVICES THAT ARE OUT THERE. SLEPTS. WE HAVE AN UNUSUAL GOVERNANCE STRUCTURE IF THAT SITTING AROUND THE BOARD OF GAMBY IS ALL OF THESE CRITICAL REPRESENTATIVE GROUPS. WHO, THE WORLD BANK, UNICEF, VACCINE INDUSTRY, BOTH FROM THE NORTH AND THE SOUTH, CIVIL SOCIETY, A RANGE OF INDEPENDENT INDIVIDUALS, RESEARCH AND TECHNICAL INSTITUTES, DONOR GOVERNMENTS, THE GATES FOUNDATION, ET CETERA. SO THIS SERVES A COUPLE OF FUNCTIONS. BUT THE MAIN FUNCTION DOES IS IT ALIGNS ALL OF THESE PARTNERS ON THE GOALS AND TRIES TO DRIVE THEM FORWARD, WHICH IS QUITE HELPFUL IN TERMS OF WORKING TOGETHER. GARVEE HAS IMMUNIZED OVER 325 MILLION CHILDREN WITH NEW VACCINES, CONTRIBUTING TO PREVENTING OVER 5.5 MILLION FUTURE DEATHS. AND OVER 7 OCOUNTRIES AND HELPED SHAPE THE VACCINE MARKETS AND YOU CAN SEE HERE THE DRIBS OF THE -- DISTRIBUTION OF THE DISEASES AFFECTED BY GARVEE. WE WILL OBVIOUSLY, SEE A SHIFT IN WHERE THE DISEASES ARE PREVENTED. AND THIS COMPLICATED SLIDE LOOKS AT WHERE GARVEE IS WORKING. YOU CAN SEE THE GEOGRAPHIC DISTRIBUTION OF THE 73 COUNTRIES AND THE DIFFERENT COLORS REFER TO THE DIFFERENT VACCINES THAT ARE BEING ROLLED OUT ACROSS THESE COUNTRIES. SO CURRENTLY, GAMBY SUPPORTS THE VACCINE, WHICH IS A HEPATITIS B. THE ROTAVIRUS, HUMAN PAPILLOMA VIRUS, RUBELA, YELLOW FEVER AND STOCKPILES FOR YELLOW FEVER AND MENINGITIS. WE'RE LOOKING RIGHT NOW AT ROLLING OUT JAPANESE ENCEPHALITIS AND ARE WAITING FOR A PREQUALIFICATION OF THE VACCINE, AS WELL AS WHEN A TIZED VACCINE IS AVAILABLE. WE'RE WATCHING WHAT HAPPENS WITH THE MALARIA TRIALS AND DENGI AND I'LL TALK ABOUT IPV IS A POTENTIALLY IMPORTANT AGENT IN THE FUTURE. SO IN A SENSE THE VACCINE, WHICH WAS A NOVEL CONCEPT FOR GARVY, WAS TO ROLL THEM OUT, IS PRETTY MUCH COMPLETE. WE'VE GONIT OUT TO MOVIE OF THE COUNTRIES. THE ROLLOUTS HAVE ACTUALLY OCCURRED. IF YOU LOOK AT THE DISEASE BURDEN LOOKING AT INCIDENTS IN CHILDREN UNDER FIB, YOU CAN SEE WHERE THE HIGH INCIDENCE IS AND OVERLYING LIST IN STRIPES IS THE GAMBY GAMBY-ELIGIBLE COUNTRIES. AND HERE IN COLORS THE COUNTRIES WHERE PNEUMOCOCK PNEUMOCOCKOVACCINE HAS BEEN INTERVIEWED AND THERE ARE 12 MORE COUNTRIES THAT WILL RECEIVE THIS. IT'S INTERESTING BECAUSE ONE OF THE CHALLENGES IS HOW QUICK CAN WE GET THESE OUT? AND THE PC V 13 WAS ROMD OUT IN THE DEVELOPING WORLD ABOUT A YEAR AFTER IT WAS INTRODUCED IN THE WEST AND I'LL COME BACK TO THAT LATER AND WHY THAT'S SO IMPORTANT. HERE IS ROTAVIRUS VACCINE. SIMILAR GRAPH. WE FORECAST 22 MORE COUNTRIES OTHER THAN THE ONES THAT ARE IN COLOR HERE TO TRY TO ROLL THOSE OUT. INTERESTINGLY, FOR THE FIRST TIME AND THIS WAS JUST A COUPLE OF WEEKS AGO, WE HAD A DID YOUAL ROLLOUT OF THE VACCINE IN GHANA. THIS WAS REALLY EXCITING. IT WAS YOU CAN IMAGINE, COMPLICATED IN HAVING PEOPLE TREASON TO DO BOTH IN ORAL VACCINE, WORRYING ABOUT COLD CHAIN FOR BOGE BUT A LOT OF EFFICIENCY IN DOING IT AND THE BEGANIANS WERE INCREDIBLY EXCITED ABOUT THIS. IF YOU LOOK AT THE TRADITIONAL TRAJECTORY. AND HERE IS EPTITIS B AND YOU CAN SEE THE INTRODUCTION IN THE UNITED STATES IN 1981. YOU CAN SEE A 12-YEAR LAG BEFORE IT FIRST APPEARED IN THE LOW-INCOME COUNTRIES. YOU CAN THEN SEE THAT BEFORE GAMBY WAS LAUNCHED, THERE WAS ANOTHER LAG THAT OCCURRED. YOU CAN SEE THE UPTICK, AS GAMBY MOVED INTO THE SPACE, A 50 PERCENT SIX-YEAR DELAY IN ITS REDUCTION TO 50 PERCENT OF THE COUNTRIES AND LOW-INCOME COUNTRIES EXCEEDED THE PERCENTAGE OF COUNTRIES GETTING HEPATITIS B EVEN OVER THE HIGH-INCOME COUNTRIES. SO THIS IS THE GOAL WE'RE TRYING TO DO IS TO GET RID OF THIS DELAY THAT IS THERE AND TRY TO GET IT OUT WHERE IT NEEDS TO BE RIGHT AWAY. AND YOU CAN SEE FROM AN EQUITY POINT OF VIEW WHAT'S HAPPENED HERE. YOU CAN SEE OVER HERE IN 2000, HIGH-INCOME COUNTRIES UP TO 2010. YOU CAN SEE A RISE IN COVERAGE, AND YOU CAN SEE THIS DRAMATIC INCREASE IN LOW-INCOME COUNTRIES ULTIMATELY EXCEEDING AND HERE IS THE SAME THING FOR HEPATITIS -- INFLUENZA TYPE B. VERY EXCITING. OBVIOUSLY, IBSHOWN YOU HIGH--INCOME AND LOW-INCOME. THE MIDDLE-INCOME COUNTRIES ARE BEGINNING TO BE AN ISSUE AS WE MOVE TO MORE EXPENSIVE VACCINES AND HOW WE'RE GETTING THEM ROLLED OUT THERE IS A CHALLENGE I THINK WE'RE GOING TO HAVE TO DEAL WITH IN THE FUTURE. IT'S GETTING OUT TO THE PEOPLE WHO NEED THEM THE MOST AND WHAT YOU CAN SEE HERE IS DIFFERENCE IN INDIA BETWEEN URBAN. ON AVERAGE 57 PERCENT RURAL. 36 PERCENT AND YOU CAN SEE IN RICH-TO-POOR AN OBVIOUS CHANGE HERE ACROSS THE DIFFERENT STRATA. SO ONE OF THE CHALLENGES IS HOW DO WE MAKE SURE THERE IS EQUITY IN THE DISTRIBUTION OF THESE VACCINES? ONE OF THE CHALLENGES IN DOING THIS -- AND THIS IS RELEVANT TO ALL WE DO IN GLOBAL HEALTH IS THE RAIN FROM STRUCTURE IN THE COUNTRIES. WE INVEST IN ABOUT 15 TO 25 PERCENT OF OUR INCOME INTO TRYING TO BUILD HEAL SYSTEMS FOR DELIVERY+++ THE CONCEPT BEHIND RAMSEY PRICING IS HOW YOU MOST EFFICIENTLY MAKE THINGS AVAILABLE. AND SO IT USED THAN THAT MANY OF THE COMPANIES LOOKED AT THIS MODEL OF TRYING TO PROVIDE VACCINES IN HIGH-INCOME COUNTRIES, VERY HIGH PRICES, VERY LARGE PROFIT. BUT IT TURNS OUT IF YOUR GOAL IS TO TRY TO MAXIMIZE YOUR PROFIT AS WELL AS MAXIMIZE THE AVAILABILITY, WHAT YOU'D RATHER DO IS HAVE ALSO SERVE MIDDLE-INCOME AND LOWER-INCOME BECAUSE ALTHOUGH YOU MAKE LESS PROFIT PER DOSE IN THESE AREAS, THE TOTAL PROFIT UNDER THE SURF IS -- CURVING IS LARGER. SO COMPANIES WOULD WANT TO DO THIS. AND THE CHALLENGE FOR US IS TOTO TRY TO MOVE TOWARDS RAMSEY PRICING. IF YOU START INCREASING THE VOLUMES, YOU DRIVE THE COST OF GOODS DOWN, WHICH MEANS THAT YOU ARE ACTUALLY GOING TO MAKE MORE MONEY IN YOUR PRIMARY MARKETS AS WELL. FROM AN INDUSTRIAL SECTOR, IT IS GOOD TO DO THIS. THE CHALLENGE IS HAVING THE POLITICAL WILL, WHICH RELATES TO NOT THE SOUTH. IT RELATES TO THE NORTH. HOW DO WE TELL LEGISLATEORS IN THE NORTH THAT WE'RE GOING TO PAY HUNDREDS AND HUNDREDS OF DOLLARS FOR VACCINES THAT ARE MUCH MORE EXPENSIVE. ONE OF THE BREAKTHROUGHS IS BUILDING A MARKET THAT IS LARGE ENOUGH FOR COMPANIES TO SERVICE AND YOU CAN SEE COMFORT DRAMATIC PRICE REDUCTION THAT'S HAVE OCCURRED. YOU SEE A 97 PERCENT PRICE REDUCTION FROM THE PRICES THAT ARE AVAILABLE IN THE U.S. PUBLIC MARKET. THIS IS GOING TO BE CRITICAL BECAUSE IF WE WERE PAYING THIS PRICE USING DONOR RESOURCES, THIS WOULD BE IMPOSSIBLE TO SUSTAIN OVER TIME. SO ONE OF THE THINGS WE DO IS TRY TO STRENGTHEN THE MARKET AND SHAPE IT. AND IN DOING THAT, WE'RE NOT JUST INTERESTED IN PRICE. I WANT TO EMPHASIZE THAT AND THE PRICE REDUCTIONS WON'T CONTINUE TOE CURE AS DRAMATICALLY. WHAT WE NEED IS A STABLE AND SECURE VACCINE MARKET. WE TO MAKE SURE THAT THERE IS ENOUGH MONEY OF COMPANIES INVESTED IN VACCINES TO MAKE SURE THEY HAVE THE QUALITY THAT'S NEEDED AND THAT'S CRITICAL FOR HAVING THE WORLD BE CONFIDENT ON VACCINES. OVER THE SHORT TERM WE'VE SEEN DRAMATIC PRICE REDUCTIONS. WE'VE ALSO SEEN NEW ENTRANTS AND THIS IS IMPORTANT BY BRINGING MANUFACTURERS IN, WE INCREASE SECURITY BECAUSE IF ONE MANUFACTURER HAS A PROBLEM AND THAT COULD BE IN THE NORTH OR SOUTH, THERE ARE OTHER SUPPLIERS TO STEP IN. FAMILY OVER THE LONG TERM AND THIS IS OF COURSE WHERE NIH HAS A CRITICAL ROLE TO PLAY, IS INCREM IN VATION AND SKMU AFFORDABLE PRODUCTS THAT CAN MAKE A DIFFERENCE, INCLUDING IMPROVEMENTS IN DELIVERIES AND PLATFORMS, ET CETERA. SO ALL OF THESE ARE ISSUES WE'RE PAYING ATTENTION TO IN OUR MARKET SHAPING. AND IT'S INTERESTING BECAUSE HISTORICALLY VACCINES INITIALLY WERE AN INTERESTING THING AND THEN THEY BECAME COMMODIZED BECAUSE THEY WERE PURCHASED BY GOVERNMENTS AND WERE QUITE INEXPENSIVE AND SO THERE WAS A HUGE INVESTMENT OF COMPANIES AND VACCINES. WE WEPT FROM HAVING A LARGE NUMBER OF VACCINE COMPANIES TO VERY FEW AND THEN IT BEGAN TO CHANGE, CONFINED OF IN THE 90S WITH BOTH ENGAGEMENT ON THE GLOBAL SCENE, HEPATITIS B FIRST, BUT THE REALLY BIG CHANGE WAS PREV NAR, THE FIRST VACCINE THAT BECAME A BILLION-DOLLAR VACCINE. THAT VACCINE TODAY HAS A MARKET OF MORE THAN $3 P BILLION A YEAR. ALSO THE GATES FOUNDATION AND GAMBY, ALL OF THIS HAS NOW MADE AN ATTRACTABLE INVESTMENT FOR VACCINE COMPANIES, WHICH IS CRITICAL FOR INNOVATION. AND SO WE THINK IT'S A VERY GOOD TIME FOR VACCINE COMPANIES. HOWEVER, WE ALSO WANT TO SEE THE MERGING MARKETS ENGAGED. AND MOST OF OUR SUPPLY WAS COMING FROM INDUSTRIALIZED COUNTRIES. TODAY, THE LARGEST NUMBER OF SUPPLIERS ARE COMING FROM THE DEVELOPING WORLD. ALTHOUGH WE HAVE HAD SOME QUAMAT PROBLEMS IN SOME OF THE DEVELOPING WORLD PROBABLY BECAUSE THE PRICE HAS BEEN DRIVEN DOWN TOO MUCH. WE ASK ALL OF OUR COUNTRIES TO COFINANCE THEIR VACCINES. SO THIS IS NOT A HANDOUT. EVERY COUNTRY PAYS, AND YOU CAN SEE OVER TIME WE'VE HAD A GROWTH IN THE NUMBER OF COUNTRIES THAT ARE COFINANCING AND THE AMOUNT OF MONEY THAT THEY'VE PUT ON THE TABLE. THIS IS WHAT THE MODEL LOOKS LIKE AND THE VERY POOREST COUNTRIES THEY PAY A VERY SMALL AMOUNT, 20 CENTS A DOSE. AS YOU GET INTO INTERIMMEDIATE COMPANIES, THEY PAY A HIGHER PERCENTAGE AS THEY GRADUATE, THEY TAKE ON THE FULL COST OF VACCINES. THIS IS LOOKING AT NUMOCOCCAL AND IF YOU LOOK AT THIS FROM A STATISTICAL POINT OF VIEW, IF YOU ASKED THE LOW-INCOME COUNTRIES TO TAKE ON THIS, IT WOULD BE AN KPEMING BURDEN. 6.3 PERCENT OF THEIR NATIONAL HEALTH EXPENDITURES. BUT AS COUNTRIES GET HEALTHIER AND CLOSE TO GRADUATION, WHICH IS $1500 GROSS NATIONAL INCOME, THEY'D HAVE TO SPEND .6 PERCENT OF THEIR HEALTH BUDGET ON VACCINES, WHICH IS A FIGURE THAT ANY COUNTRY SHOULD BE INVESTING. THE QUESTION IS NOT CAN COUNTRIES AFFORD IT. THE QUESTION IS DO COUNTRIES PRIORITIZE THE SOCIAL SECTOR AND PRIORITIZE VACCINES? SO WE HAVE AN ACTIVE PROGRAM TO REACH OUT TO MINISTRIES OF FIN TO TRY TO GET THEM TO HAVE LINE ITEMS IN THEIR BUDGET AND TO PAY AN EVERINCREASING AMOUNT OF THE COST FOR THESE VACCINES . LET ME LAST MOVE ON TO SOME OF THE CHALLENGES AND OPPORTUNITIES THAT ARE IN FRONTS OF US. SO IF WE LOOK NOW AT THE ENTIRE WORLD -- AND THIS IS LOOKING AT SURVIVING NEWBORNS IN 2010, YOU CAN SEE WE'RE DOING PRETTY WELL ON DPT. HEPATITIS B IS BETTER. BUT YOU CAN SEE THE TWO NEW VACCINES THAT GAMBY IS FOCUSING ON STILL ARE REALLY VERY LOW IN COVERAGE AND THIS IS WHERE THE REAL PUSH HAS TO BE, GIVE FACT THAT THESE ARE THE LARGEST KILLERS IN THE DEVELOPING WORLD. SO FOR GARVY, THE MAIN FOCUS IS TO TRY TO GET THE VACCINES OUT OVER THE NEXT FEW YEARS. THE POLIO ERADICATION EFFORT TRADITIONALLY HAS NOT BEEN WORKING THAT CLOSELY WITH GARVY. I THINK TLAS SHAME. ONE OF THE THINGS THAT'S BEING TOSSED AROUND NOW IS THE IDEA THAT INSTEAD OF FOLLOWING A TRADITIONAL PATHWAY FOR DEALING WITH THE ERADICATION AND THEN ELIMINATION OF VACCINE DERIVED POLIO VIRUS, WHAT WE SHOULD BE DOING IS A PARALLEL APPROACH WHERE WE NOT ONLY WORK ON ONE SIDE TRYING TO FINISH THE ERADICATION BUT TRY TO ELIMINATE THE VACCINE-INDUCED POLIO. AND IF THAT'S TO BE DONE, WE HAVE TO SHIFT PROBABLY AWAY FROM OPV 2, GOING TO A POLIO VACCINE AND INTRODUCE IPV. SO GARRY IS WAITING TO SEE THE SAGE DISCUSSIONS AT WHO. BUT GARVY IS LOOKING AT HOW WE COULD SEEDO THIS EITHER AS A STAND-ALONE VACCINE. SO THIS WILL BE AN IMPORTANT FUTURE DIRECTION. ONE OF THE INTERESTING THINGS IS THAT THERE WAS A SUMMIT IN LAST SEPTEMBER IN NEW YORK. THE NON-COMMUNICABLE DISEASE SUMMIT AND I ASKED IF THIS WAS REALLY A MISGNOMEOR BECAUSE WHAT WE ALREADY KNOW IS NOT INSIGNIFICANT PERCENT OF THE GLOBAL CANCER BURDEN IS CAUSED BY KNOWN INFECTIOUS AGENTS AND WE ALREADY HAVE VACCINES AT LEAST AGAINST TWO OF THEM, EPTITIS B AND HIGH PRESSUREV. I'VE SHOWN A GRAPH THAT SHOWS GARVY HAS MOVED VACCINES OUT AND AVERTED 3.7 MILLION FUTURE DEATHS AND WE KNOW THAT HIGH PRESSUREV VACCINES CAN -- HPV VACCINES CAN CAUSE DEATH IN WOMEN IN THE DEVELOPING WORLD. HERE IS A LOOK AT CANCER CAUSED BY INFECTIOUS DISEASES AND I SUSPECT THIS LIST WOULD BE MUCH LONGER AND A LARGER PERCENTAGE OF CAUSES CAUD BY INFECTIONS. THIS IS AN AREA THAT WE CAN MAKE A DIFFERENCE ACROSS THE WORLD. AND ONE OF THE INTERESTING DEBATES ON THIS IS HOW DO WE DO THIS? DO WE HAVE TO DO IT WITH SCREENING BECAUSE MANY OF  THESE COUNTRIES DON'T HAVE CANCER SCREENING BUT THIS IS AN OPPORTUNITY TO GET VACCINES OUT WHICH ARE SIMPLE TO PREVENT THE DISEASE. OBVIOUSLY IN AN IDEAALE WORLD WE HAVE TO BE ABLE TO DIAGNOSE AND TREAT AS WELL. BUT IF WE CAN'T DO THAT, WE STILL SHOULD PREVENT. THIS IS LOOKING AT THE DEVELOPING WORLD AND YOU CAN SEE THAT IN THE LESS DEVELOPED REGIONS, YOU ARE SEEING A HIGHER BURDEN OF THESE THAN IN THE MORE DEVELOPED REGIONS. WHAT WE KNOW IS THAT YOU CAN HAVE A DRAMATIC EFFECT, AND ONE OF THE THINGS THAT WAS A GREAT SUCCESS STORY FOR GARVY WAS IN CHINA WAS ENGAGING WITH THE CHINESE GOVERNMENT IN THE WEST OF CHINA AND GETTING HEPATITIS B IN THEIR VACCINE REGIME AND WITH THAT WE WERE ABLE TO SEE THEM GO FROM VERY HIGH LEVELS OF HEPATITIS B KRARJ -- CARRIAGE TO LOW LEVELS AND THEY ROLLED IT OUT ACROSS THE COUNTRY AND AT THE END OBVIOUSLY MILLIONS AND MILLIONS OF LIVES ALREADY SAVED. SO WE KNOW WE CAN DO THIS. THE CHALLENGE IS PUSHING FORWARD. AND IF YOU LOOK AT THE GLOBAL BURDEN OF CERVICAL CANCER, THE ESTIMATE IS THAT THERE WERE 530,000 NEW CASES IN 2008. 27 5,000 DEATHS, MOST OF WHICH 88 PERCENT IN THE DEVELOPING WORLD AND YOU CAN SEE A LIST HERE OF INCIDENCE MAP OF THE DISEASE AND ON TOP OF THAT ARE THE GARVY GARVY-ELIGIBLE COUNTRIES. AND IF I GO BACK TO THE PREVIOUS ONE, YOU CAN SEE WHERE THE GARVY COUNTRIES ARE. THIS IS A MAP OF VACCINE INTRODUCTION WORLDWIDE AND YOU CAN SEE THEY'RE ALMOST COMPLETE OPPOSITE HERE OF THE VACCINE ISN'T GETTING TO WHERE IT'S NEEDED, WHERE THE HIGHEST BURDEN OF DISEASE IS. AND SO THIS IS THE GARVY COUNTRIES THAT ARE LISTED THERE AND YOU CAN SEE THAT THAT'S A TERRA INCOG NITA. FOR US IT'S AN IMPORTANT ISSUE. IF WE LOOK AT THE INCIDENCE OF DISEASE IN HIGH--INCOME COUNTRIES IT'S LOWER THAN IN HIGH--INCOME COUNTRIES BUT THE MORTALITY IS HIGHER SO THEY HAVE A DOUBLE WHAMY OF MORE INCIDENCE OF DISEASE BUT A HIGHER MOR TAL RATE. SO THIS IS A HUGE PRIORITY FOR US, AND SURPRISINGLY, THIS HAS BEEN SOMEWHAT CONTROVERSIAL IN TERMS OF ROLLING IT OUT, BUT I THINK IT'S SOMETHING THAT THE BOARD VERY MUCH WANTS TO SEE AS A PRIORITY. NOW, FROM A PUBLIC HEALTH POINT OF VIEW, IT HAS A REALLY INTERESTING POSSIBILITY, WHICH IS WE ARE ENTERING HERE IN GIRLS AND SO ALONE THIS IS COST-EFFECTIVE AS THE PRICE WE HAVE. IF WE WERE TO COME COUPLE THIS WITH -- COUPLE THIS WITH FAMILY PLANNING, SAFE MOTHERED INFORMATION, CHILD NUTRITION, ISSUES ON SEXUAL AND REPRODUCTIVE HEALTH, A RANGE OF POTENTIAL INPUTS, IT BECOMES EVEN MORE EFFECTIVE BUT WE HAVE TO BRIDGE ACROSS DIFFERENT SECTORS ACROSS THE HEALTH SECTOR, CANCER, REPRODUCTIVE HEALTH, H.I.V. PREVENTION, ET CETERA, ET CETERA. SO THIS IS SOMETHING WE'RE WORKING ON NOW. RUBELA IS ALSO A CHALLENGE. 112,000 CASES STILL OCCURRING, 90 IT IF GARVY GARVY-ELIGIBLE COUNTRIES AND SO OUR PLAN IS TO TRY TO INTRODUCE A RUBELA VACCINE, ALONG WITH MEASLES AND THIS GIVES YOU THE IDEA OF THE MLESSES AND MILLIONS OF DOSES WE'RE PLANNING ON DOING WITH AN INTRODUCTION IN 49 COUNTRIES. AND THE WAY THIS IS GOING TO BE DONE IS CAMPAIGNS RUNNING ACROSS THE ENTIRE YOUNG POPULATION UP TO AGE 15 TO TRY TO REDUCE THE INCIDENCE OF RUBELA, NOT JUST TO GET TO WOMEN BEFORE THEY'RE PREGNANT. IT REQUIRES VERY HIGH COVERAGE RATES, OBVIOUSLY TO MAKE SURE THAT YOU DON'T HAVE A REINFECTION THAT OCCURS IN WOMEN BEFORE PREGNANCY AND SO COUNTRIES HAVE TO HAVE A SUSTAINED OF MEASLES VACCINE OF GREATER THAN 8LE0 PERCENT IN ORDER TO BE ELIGIBLE TO DO THIS. OBVIOUSLY, THERE IS UNFINISHED BUSINESS. I'VE ALREADY SHOWN YOU THERE IS COVERAGE THAT IS NOT AS HIGH AS IT NEEDS TO BE. THE NEW VACCINES IN TRYING TO ROLL OUT AND OF COURSE FOR ME AND TONY HAS ALREADY MENTIONED MY PAST INTEREST IN H.I.V. VACCINES. CLEARLY WE STILL NEED VACCINES FOR TB AND H.I.V. WHICH ONCE WE HAVE THEM, WILL FALL INTO HOW YOU GET THESE VACCINES OUT TO THE PEOPLE WHO NEED THEM? AND THE SYSTEMS NOW ARE IN PLACE TO BE ABLE TO DO THAT. INTERESTINGLY, HPV BECOMES THE MODEL BECAUSE IT WILL ALLOW TO US KIND OF GET TO PEOPLE RIGHT BEFORE THE BEGINNING OF THEIR SEXUAL ACTIVITY AND THEREFORE WOULD BE THE RIGHT WAY TO START OFF. OBVIOUSLY, WE'D EVENTUALLY LIKE TO IMMUNIZE AS A CHILDHOOD VACCINE BUT THAT'S GOING TO BE A WHILE FROM NOW. IN TERMS OF RESEARCH, GARVY IS NOT A RESEARCH AGENCY BUT WE DO DO APPLIED RESEARCH AND SO THESE ARE SOME OF THE TOPICS WE'RE WORKING ON. WE'RE OFTEN DOCK REAL-WORLD EFFECTIVENESS DOING STUDIES. WEIBE DONE EPIDEM LOGIC STUDIES. A LITTLE BIT ON THE HEALTH ECONOMICS I SHOWED YOU AND THE IMPORTANCE OF TRYING TO BE ABLE TO MAKE THE CASE FOR IMMUNIZATION AND WHY IT'S AN IMPORTANT INVESTMENT. AND THEN ISSUES ON IMPLEMENTATION. VACCINE ROLLOUT AND SYSTEM-WIDE IMPLICATIONS. BUT WE RELY ON AGENCIES LIKE NIH TO HELP US WITH PLATFORMS AND NEW VACCINES, AS WELL AS NEW TOOLS. HERE IS AN EXAMPLE OF ONE OF THE PROBLEMS THAT I HAVE. THIS IS LOOKING AT ETHIOPIA. THIS IS A COVERAGE COUNTRY ESTIMATE THAT IS AFFIRMED BY WHO, SO THE ESTIMATE HERE IN 2010 WAS 8LE6 PERCENT COVERAGE RATE BY WHO AND UNICEF. YOU CAN SEE HERE IS AN ESTIMATE FROM CHRIS MURRAY'S GROUP AT THE INSTITUTE FOR HEALTH, METRICS AND EVALUATION AND THE DEMOGRAPHIC HEALTH SURVEY SUPPORTED BY THE U.S. IN 2010, A VERY THOROUGH SURVEY IN THAT COUNTRY SHOWED A COVERAGE RATE OF 36.5 PERCENT. THIS IS NOT A CONFIDENCE INTERVAL PROBLEM HERE. QUESTION IS WHAT IS TRUTH? WHAT WE'D LIKE TO HAVE IS THE ABILITY TO GO IN AND FIGURE OUT WHAT IS TRUTH. SO TO DO THAT, WE NEED BETTER DATA. WE NEED TIMELY DATA FROM THE DEVELOPING WORLD. WE NEED TO DEAL WITH THIS UNSERPENT AND BETTER SURVEY METHODOLOGY. ONE AREA I'M VERY INTERESTED IN IS BIOMARKERS. COULD WE GO IN AND LOOK AT A COUPLE OF HUNDRED KIDS WHO WERE IN THE SKBAE ASK THE QUESTION -- SURVEY AND ASK THEM WERE THEY AX NATED OR NOT -- VACCINATE ORDER NOT? WE HAVE TO TAKE ADVANTAGE OF IT TOOLS AND METHODS, REALTIME DATA, NEW WAYS TO DIAGNOSE DISEASES. THESE ARE ALL AREAS THAT I KNOW NIH ARE WORKING ON AND HAS DIRECT APKABLET TO OUR PUBLIC HEALTH GOALS IN THE DEVELOPING WORLD. FINALLY, BRUCE IS SITTING IN THE AUDIENCE AND SMILING. HERE IS AN INTERESTING EXAMPLE. SO THE U.N. IS CONSIDERING RIGHT NOW A BAN ON MERCURY FOR OBVIOUS REASONS IN MANY INDUSTRIES. THIS IS AN IMPORTANT TISSUE RIGHT -- ISSUE. BUT MERCURY IS USED IN PRESERVING VACCINES. THE WHO AND SAGE HAS RECOMMENDED THAT VACCINES BE EXEMPT. WE KNOW THAT THIS IS A SAFE PRESERVATIVE AND ESSENTIAL AND IF THIS BAN WERE TO OCCUR, WOULD REALLY AFFECT OUR VACCINE MARK. IT'S NOT JUST WELL, WE COULD GO GO TO SINGLE DOSE. MARKET. IT'S A COLD CHAIN ISSUE. WE WOULDN'T BE ABLE TO MANAGE SINGLE DOSE FOR THE ENTIRE WORLD EITHER IN COLD CHAIN OR IN TRANSPORT. ONE. QUESTIONS IS WHO IS GOING TO INVEST IN TRYING TO CREATE NEW PRESERVE TIBS THAT DON'T HAVE MERCURY BUT THAT COULD BE USED AND THERE IS NOT AS MUCH INTEREST IN THE VACCINE INDUSTRY IN DOING THIS BECAUSE THEY WORRY ABOUT JEOPARDIZING THEIR VACCINES FROM REGULATORY AUTHORITIES AND OF COURSE, THE MARKET IN THE WEST HAS GONE TO SINGLE DOSE FOR CONVENIENCE OF PROVIDERS, ET CETERA. SO THIS IS AN EXAMPLE OF A PUBLIC HEALTH RESEARCH THAT NEEDS ATTENTION. SO LASTLY, LET ME JUST SAY THAT WHEN I GAME TO GARVY, THE WORLD WAS VERY MUCH DIVIDED. GARVY WAS SEEN AS NEW VACCINES AND A POLIO ERADICATION EFFORT AND REGIONAL VACCINES AND WHAT WE'RE GOING TO TRY TO DO IS COME TOGETHER, HOW IS IT WE CAN HAVE SYNERGIES AND WORK TOGETHER BECAUSE WHEN YOU ARE DOING THE POLIO ERADICATION EFFORT AND HAVING PROBLEMS IN PAKISTAN, THAT'S SAME PLACE HAVING PROBLEMS WITH MEASLES AND HAVING PROBLEMS WITH NEW VACCINES AS WELL AS EXISTING ONES. HOW DO WE WORK TOGETHER? AND THIS IS AN IMPORTANT PART OF WHAT I'M HOPING WILL OCCUR IN THE FUTURE. SO WITH THAT, I'LL STOP AND I'M HAPPY TO ANSWER ANY QUESTIONS. [APPLAUSE] THANK YOU VERY MUCH. >> SETH, THAT WAS REALLY TERRIFIC. QUESTIONS OR COMMENTS? JIM? >> WITH HPV, YOU'RE GOING TO HAVE TO GET WOMEN AND -- [INAUDIBLE] >> THAT IS AN SLEPT QUESTION. AND SO FIRST OF ALL, THE TRUE ANSWER IS WE DON'T YET KNOW. BUT THE WAY WE'RE DEALING WITH IT IS BEFORE A COUNTRY CAN APPLY FOR A ROLLOUT NATIONWIDE, THEY HAVE TO PROVE THAT THEY KNOW HOW TO DELIVER THE VACCINE. SO THERE ARE A FEW COUNTRIES THAT HAVE DONE SOME PILOT STUDIES AND IN THOSE CASES THEY CAN APPLY WITH THE DATA THIS THEY HAVE TO SHOW THAT THEY KNOW WHAT THEY'RE DOING. FOR OTHER COUNTRIES THEY HAVE TO DO A PILOT AND IN THAT PILOT, WHICH WE WILL FUND BOTH THE VACCINE AND THE PILOT, THEY WILL HAVE AN OPPORTUNITIES IN ONE DISTRICT THAT HAS BOGE RURAL AND URBAN POPULATIONS TO SHOW THAT THEY CAN GET AT LEAST 50 PERCENT OF THE POPULATION IMMUNIZED. THEY HAVE REACH THEM AND WHAT IS THE BEST MECHANISM IN THAT COUNTRY? IS IT THROUGH SCHOOLS WITH SPLEMS? IS IT USING SOME TYPE OF CAMPAIGN APPROACH OR OTHER APPROACHES THAT SHOULD BE DONE? SO EACH COUNTRY IS OUT AND WITH THAT PILOT THEN ASSUMING IT'S SUCCESSFUL, THEN WE WOULD APPROVE THE NATIONWIDE ROLLOUT. >> I WAS VERY STRUCK BY THE EXTRAORDINARY DICHOTOMY BETWEEN THE SLIDE WHERE YOU SHOWED THE GLOBAL VACCINE PERCENTAGE. HEPATITIS B WAS WAY OVER, AND HPV WAS HERE. EVEN IF YOU FACTOR IN THE ISSUE OF GETTING ADD LESSENT WOMEN, YOU STILL SHOULD HAVE MORE HPV JUST ON THE BASIS OF HOW GOOD HEPATITIS B IS BECAUSE YOU HAD TO HAVE GOTTEN PEOPLE TO GET HEPATITIS B. WHY DON'T WE GET HPV TO EVERYBODY AND YOUNGSTERS THE WAY THEY TRY TO DO IN THE UNITED STATES, BOTH MALE AND FEMALE TO GET AWAY FROM THE VACCINATION OF A WOMAN FOR SEXUALLY TRANSMITTED DISEASE OR DOES MICHELLE BACHMANN HAVE INFLUENCE IN AFRICA? [LAUGHTER] >> NOW THAT I'VE BEEN ASKED POLITICALLY INCORRECT. MICHELLE BACHMANN APPLIED AND GOT SWISS CITIZENSHIP LAST WEEK. AND THEN A DAY LATER THEY REVERSED IT BECAUSE THEY SAID WELL, IF YOU'RE SWISS, YOU CLEARLY CAN'T BE A GOOD AMERICAN POLITICIAN. ANYWAY, THAT'S JUST AN ASIDE. THAT'S A TRUE STORY. I'M NOT MAKING THAT UP. THE INTERESTING QUESTION IS HEPATITIS B IS VERY INEXPENSEIB AND HAS BEEN AROUND FOR A LONG TIME. I WAS IN THE ORIGINAL TRIAL OF PHYSICIANS AND MEN WHO HAVE SEX WITH MEN. I WAS IN THE TRIAL. AND SO I REMEMBER IN THOSE DAYS VERY EXPENSIVE AND THE TIME YOU REMEMBER WHEN WE LATER ON CAME FROM POOLED SERUM AND PEOPLE WERE WORRIED ABOUT THIS WAS PRE-H.I.V. AND WHATEVER THE AGENT WAS IN THERE AND I REMEMBER HAVING A LITTLE BIT OF THAT FEAR. WE HAVE SEEN AN AMAZING PRODUCTION OF THIS VACCINE. SO NOW THE VACCINE HAS COST TENS A CENTS OF DOSE. WITH HPV, WE'VE NOW GOT IT DOWN TO $5 A DOSE FOR THE DEVELOPING WORLD. BUT AT THAT COST IT IS STILL A VERY EXPENSIVE VACCINE AND TRYING TO DO WHAT YOU SAY WOULD BE SOMETHING IN THE FUTURE WHEN THE PRICE COMES DOWN. WE BELIEVE IT'S LIKELY TO BE EFFECTIVE AS A TWO-DOSE VACCINE AND THAT'S SOMETHING THOSE STUDIES ARE UNDER WAY. AND WE'D LOB TO LOOK AT INTERESTING DOSING SCHEDULES. IF WE COULD, FOR EXAMPLE, GIVE IT ANNUALLY INSTEAD OF IN A TIGHTER SCHEDULE, THEN YOU WOULD BE ABLE TO COME ONCE A YEAR, LET'S SAY TO SCHOOLS TO DO THIS. MY GUESS IS THAT'S NOT GOING TO WORK BUT THESE ARE ALL THINGS THAT HAVE TO BE ANSWERED BY DATA. I SUSPECT MAYBE TO YEARS FROM NOW 20 YEARS FROM NOW WE'LL HAVE THAT SAME TYPE OF COVERAGE BUT IT'S GOING TO BE A WHILE. >> BRUCE -- [INAUDIBLE] >> PRIOR TO WHEN I START THE WORKING WITH OTHERS, THERE WAS TWO GROUPS IN THE WORLD. THERE WAS KIND OF THE UNITED STATES, EUROPE, JAPAN, AND THERE WAS R AND REST OF WORLD. AND COMPANIES WEREN'T INTERESTED IN THAT. THEY MIGHT GIB VACCINE AWAY. HUMANITARIAN REASONS BUT IT WASN'T AN IMPORTANT MARKET, WHICH CHANGED A NUMBER OF THINGS. ONE IS THERE WAS INITIALLY AN ASSUMPTION THAT YOU COULD CHARGE ANYTHING YOU WANT IN THE U.S. AND NO ONE WOULD EVER WORRY ABOUT COST AND IN THE DEVELOPING WORLD THERE WERE -- YOU COULDN'T BE COUNT IN THOSE MARKETS. PEOPLE MIGHT NOT BE ABLE TO PAY. AND SO THERE WAS A MOVEMENT GOING TOWARDS THE WESTERN MARKETS. WHAT'S CHANGED NOW IS ONE, PEOPLE ARE -- AND NOW IN THE SOUTH YOU'VE GOT INCREASED GROWTH RATES AND THAT'S WHERE THE MONEY IS NOW. YOU'VE GOT INCREASED MIDDLE CLASS POPULATIONS AS WELL AND COMPANIES WANT TO BE ENGAGED THERE. THERE NOW IS HUGE INTEREST BUT WHAT GARVY DID IS WE CREATE AID VERY LARGE MARKET THAT WAS RELIABLE FOR THESE VERY POOR COUNTRIES AND SO THAT WAS A HUGE HE CAN'T BECAUSE WE CAN TELL A MANUFACTURER WE'LL BUY THESE NUMBER OF TENS OF MILLIONS OF DOSES AND WE'LL DO OVER THE NK FIVE YEARS AND GIVE PROJECTIONS SO THAT ALLOWS THEM TO NOTIFY THAT THEIR SHAREHOLDERS BASED ON RAMSEY PRICING THAT THEY CAN STILL MAKE MONEY AND DRIVE THEIR COST DOWN. AS YOU POINT OUT, THOUGH, THE CHALLENGE IS WHAT ABOUT NEW VACCINES? ONE OF THE INNOVATIONS IN FINANCING, WHICH IS AN IMPORTANT PART OF GARVY, WAS TO CREATE A COMMITMENT AROUND THE VACCINE. HOW DO YOU CREATE A VACCINE THAT HAS THE STRAINS FOR THE DEVELOPING WORLD IF IT AND GIVE THE INCENTIVE TO THE COMPANY? SO THAT WAS AN APPROACH WHERE WE SET UP A $1.35 BILLION POT FOR WHICH OF EVERY DOSE OF VACCINE WE'D PAY AN ADDITIONAL $3.50 AND BE ABLE TO USE TO AMOR TIES IT AND THAT ALLOWED THE COMPANIES TO FOCUS ON THE VACCINES WE NEEDED. WE'RE HAVING DISCUSSIONS ABOUT VACCINES THAT DOESN'T EXIST YET FOR THE POTENTIAL OF IPV. THOSE ARE SOME OF THE EFFECTS THAT ARE OCCURRING IN TERMS OF BEING ABLE TO FOCUS ON FUTURE MARKETS. >> ONE OTHER QUESTION? >> SURE. >> YOU SAID INDIA DID A GOOD JOB OF BOUCHBSING BACK FROM THE -- BOUNCING BAB FROM THE POLIO ISSUE AND YOU SHOWED -- RED STANDING OUT AS A BAD JOB. WHAT'S GOING ON WITH INDIA WHERE THEY CAN BE SO SUCCESSFUL WITH ONE AND SUCH A FAILURE WITH THE OTHER? >> INDIA IS FILLED WITH COMPLICATIONS AND PARADOXES. I THINK THE MOST INTERESTING THING IN INDIA IS WHEN THEY FOCUS ON DOING SOMETHING, THEY DO IT. IF YOU TALK TO BILL FAGEY WHO WAS RESPONSIBLE FOR SMALL POX ERADICATION IN INDIA. IF WE DIDN'T CALL THEM OFF, THEY'D BE GOING AROUND AND ERADICATING IN THE COMMUNITY. STILL FIGHTING THE WAR 50 YEARS LATER. SO I THINK INDIA IS -- WAS OVERWHELMED BY THE TASK OF TRYING TO PROVIDE HEALTHCARE FOR THE ENTIRE POPULATION. AND IT HAS BEEN WORKING TIME PROVE IT AND HEALTHCARE HAS BEEN GETTING BETTER THERE. ON IMMUNIZATION THE STATES THAT YOU'D EXPECT PERFORMED REALLY WELL. SO THEY HAVE VERY HIGH COVERAGE RATES IN EDUCATION, IN HEALTHCARE AS WELL. SOME OF THE POOREST STATES DON'T. WHAT'S HAPPENED NOW IS THAT INDIA HAS BEEN EMBOLDENED BY THE SUCCESS THEY HAD IN POLIO. NOW THEY HAD VACCINE OPPOSITION, WHICH IS ONE OF THE THINGS THAT HELD THEM BACK FROM ROLLING IT OUT BUT THEY HAVE THE COURAGE NOW TO STEP UP TO THE PLATE AND SEEN THAT THE ROLLOUTS ARE GOING WELL AND SO THEY'RE REALLY EXCITED AND NOW THEY WAB TO -- WANT TO MOVE ON AND SO THE GOVERNMENT'S ENGAGED AND WHEN THAT HAPPENS AND OUR ROLL IS CATALYTIC. WE PROVIDE SMALL AMOUNT OF FUNDING TO GET THE DISTRICTS DOING. ONCE THEY DECIDE TO DO IT, THEY'LL JUST DO IT. I THINK WE'LL SEE INDIA BEING A GREAT SUCCESS STORY IN IMMUNIZATION. >> [INAUDIBLE] >> WELL, FIRST OF ALL, WE WILL SEE A SHIFT. RIGHT NOW INDIA, FOR EXAMPLE, IS MAKING THEIR OWN VACCINE. THOSE WILL CHANGE. PARAMETERS. CHINA, WHICH UP UNTIL NOW, HAS NOT BEEN AN EXPORTER OF VACCINES AND HAS NOT HAD A REGULARSTRY SYSTEM NOW HAS ONE AND WE EXPECT THE FIRST PREQUALIFIED VACCINE SO THE MARKET WILL CHANGE. THE OTHER INTERESTING THING, THOUGH, IS UNLIKE, FOR EXAMPLE, H.I.V., WHERE FOR EVERY PERSON ON TREATMENT THERE IS TWO NEW INFECTIONS STILL. WE HAVE A CAP IF OUR BIRTH COHORT AND WITH COUNTRIES GRADUATING, WE'RE GOING TO SEE LESS AND LESS CHILDREN IN THAT BIRTH COHORT. SO I WOULD SAY WE'RE KIND OF AT ABOUT THE PEAK NOW AND I SAY ABOUT IF A MALARIA VACCINE APPEARS AND IT'S MORE EXPENSIVE, THAT MAY DRIVE US UP A LITTLE BIT. AND OVER TIME THE CURVE WILL COME DOWN, GIVEEN THE CHANGE IN PRICES. WHAT WE NEED IS EXTERNAL RESOURCES BUT COUNTRIES WILL TAKE ON A BIGGER SHARE OF IT. PRICES WILL CHANGE AND OVER THE LONG TIME THE REQUIREMENT FOR EXTERNAL RESOURCES WILL GO DOWN. SO I THINK IT'S A SUSTAINABLE STRATEGY. ANOTHER ISSUE IS, OF COURSE, IT'S THE MOST COST-EFFECTIVE OF ALL INTERVENTIONS. IN A WORLD THAT IS SPENDING A LOT ON GLOBAL HEALTH, THIS IS ONE THAT I THINK MEASURES UP PRETTY WELL IN TERMS OF RESOURCE MOBILIZATION. >> YOUNG LADY IN THE BACK? >> [INAUDIBLE] >> SO THANK YOU FOR THOSE. COULDN'T HEAR THE QUESTION. WHAT TYPE OF IN AVAILABLE APPROACHES? IT'S DIFFERENT IN DIFFERENT COUNTRIES. FOR EXAMPLE, IN AFGHANISTAN, THE GOVERNMENT HAS ASKED THAT NGOS DO THE IMPLEMENTATION. SO THE GOVERNMENT REQUESTS THE MONEY BUT THEY PUT IT THROUGH THE NGO SECTOR WHO CAN REACH OUT TO AREAS THAT PERHAPS THE GOVERNMENT ISN'T DOING SO WELL. PAKISTAN HAS A SOMEWHAT DIFFERENT PROBLEM. THEY HAVE RECENTLY DECENTRALIZED. WE CONSIDER DECENTRALIZATION A GOOD THING FROM A MANAGEMENT POINT OF VIEW BUT THEY JUST GOT RID OF THEIR FEDERAL HEALTH MINISTRY. THE OM COUNTRY IN THE WORLD THAT DOESN'T HAVE A HEALTH MINISTRY AND THIS C3=z A PROBLEM AND YOU'D HAVE TO WORK IN EACH STATE SEPARATELY AND UNDERSTAND THAT THEY HAVE THEIR OWN VACCINATION SCHEDULES, ET CETERA. WE'VE BEEN ABLE TO HAVE THE GOVERNMENT UNDERSTAND PERHAPS THAT THIS IS NOT THE BEST IDEA AND SO THERE IS NOW AN IMMUNIZATION FOCAL POINT THAT IS STILL DOING SOME OF THE WORK. BUT IT IS AN ISSUE. SO WE'RE ABOUT TO ROLL OUT SOME VACCINES IN PAKISTAN AND WHAT WE DECIDED TO DO WAS TO REALLY OUT INITIALLY IN THE PUN JAB, WHICH IS MORE THAN 50 PERCENT OF THE POPULATION AND IS RELATIVELY STABLE AND RELATIVELY HIGH-PERFORMER. WITH THAT RESULT THEN WE WILL GO NATIONAL AND IN TERMS OF THE SECURITY AREAS AND HIGH-RISK, YOU HAVE TO RELY ON GOVERNMENT RELIGIOUS INSTITUTIONS, NGOS AND TRIES OTHERS TO TRY TO GET IT OUT THERE. THE ULTIMATE CHALLENGE HAS TO BE GETTING INTO THOSE AREAS PARTICULARLY BECAUSE FOR POLIO ERADICATION, THOSE ARE AREAS THAT ARE ABSOLUTELY CRITICAL. AND IT DID NOT HELP THAT THERE WAS THIS CAMPAIGN AND WHAT SHE WAS REFERRING TO AS THE FACT THAT THERE WAS A CAMPAIGN TO TRY TO GET TO BIM'S FAMILY BY -- BIN LADEN'S FAMILY BY A DOCTOR GOING AROUND SUPPOSEDLY GIVING HEPATITIS B IMMUNIZATIONS TO GET BIOLOGICAL SAMPLES THAT COULD BE VALIDATED AS BEING THE BIN LADEN FAMILY. SO FAR WE HAVEN'T SEEN AN EFFECTIVE AD THAT I KNOW OF BUT WHO KNOWS WHAT'S GOING TO HAPPEN AND I HOPE THAT THAT WILL NEVER HAPPEN AGAIN BECAUSE WE'VE WORKED SO HARD TO BUILD THE TRUST OF THE POPULATION IN IMMUNIZATION AND ONCE YOU LOSE IT, IT'S VERY HARD TO GET IT BACK. SO HOPEFULLY, THAT WON'T HAPPEN AGAIN. >> BONNIE? >> [INAUDIBLE] >> COLD CHAIN CONTINUES TO BE A HUGE ISSUE AND THERE IS IMPROVEMENT IN TECHNOLOGIES SO WE ARE SEEING SOLAR-POWERED FRIDGES AND MORE EFFICIENT MATERIALS. A LOT OF THE OLD-FASHIONED KEROSENE-TYPE SYSTEMS THAT WERE GOOD TO WORK IN VERY, VERY RURAL AREAS BUT WEREN'T VERY RELIABLE ARE BEING REPLACED NOW. IT SILL ACE PROBLEM AND IDEALLY SOMEDAY WE'D LIKE TO NOT HAVE A COLD CHAIN. AND WE NOW KNOW THAT THERE ARE A LOT OF THESE VACCINES THAT ACTUALLY ARE STABLE AT ROOM TEMPERATURE FIRE WHILE AND THERE IS SOME DISCUSSION ABOUT PERHAPS WE WANT TO SEGREGATE AND ALLOW SOME VACCINES TO NOT BE KEPT AS RIGOROUSLY IN THE COLD CHAIN. THE DANGER IS YOU END UP WITH CONFUSION AND YOU END UP HAVING THE VACCINES THAT ARE QUITE SENSITIVE BE DESTROYED. SO PEOPLE ARE AGONIZING ABOUT THAT. NOW THE BIGGEST PROBLEM ISN'T SO MUCH KEEPING VACCINES COLD. IT'S FREEZING VACCINES. AND SO THERE IS A TIGHT LIMIT BETWEEN TWO AND EIGHT DEGREES FOR MOST OF THE VACCINES AND TRYING TO AS I SAID, BOTH GET BETTER PRODUCTS BUT ALSO COLD CHAIN SYSTEMS THAT ARE MORE STABLE IS REALLY IMPORTANT. AND FOR US IT'S A HUGE PROBLEM BECAUSE WITH ALL THESE HUGE VACCINES, YOU CAN SEE THE VOLUME OF COLD CHAIN HAS GONE UP DRAMATICALLY. >> [INAUDIBLE] >> ARE YOU TALKING ABOUT THE ERADICATION SIDE NOW OR ARE YOU TALKING ABOUT -- >> [INAUDIBLE] >> SO THERE IS A COUPLE OF PROBLEMS. INITIALLY THEY WERE HAVING PROBLEMS WITH GETTING STRONG IMMUNE RESPONSES TO SOME OF THE STRAINS, WHICH IS WHY THEY SHIFTED IT A 13 AND WOTWO-HAS BEEN ERADICATED FOR A WHILE. THEY HAD BETTER IMMUNE RESPONSE WAS A ONE THREE. IN COUNTRIES NOW THAT HAVE ELIMINATED POLIO AS WE'RE CONTINUING TO WORK WITH OTHER COUNTRIES, THEY'RE BEGINNING TO HAVE VACCINE-INDUCE VACCINE-INDUCED POLIO AND WHEN YOU HAVE THOUSANDS OF CASES YOU DON'T NOTICE A COUPLE OF VACCINE-INDUCED CASES BUT ALL OF A SUDDEN YOU'VE NOW GOT MOVIE OF THE CASES INDUCED AND IT'S A PROBLEM. THE THIRD ISSUE AND THIS IS THAT IT'S A GREAT BOOSTER AND GIFRSSES YOU HIGHER IMMUNE RESPONSES SO THE IDEA WOULD BE HOW DO WE NOW AS PART OF FINISHING THE ERADICATION, SHIFT OVER AND USE THOSE BUT ALSO AT THE SAME TIME TRY TO ELIMINATE SOME OF THESE VACCINE INDUCED POLIO STRAINS? AGAIN, THIS WAS INITIALLY ARGUED AT SAGE A COUPLE OF MONTHS AGO. SAGE DIDN'T BUY IT AND CEPT THEM BACK TO GET MORE DATA SO WE PRESUMED THAT IT WILL BE APPROVED BUT WE DON'T KNOW THAT AND PART OF THAT IS THE QUESTIONS ON EPIDEMIOLOGY AND HOW IT WILL WORK GOING FORWARD. >> OKAY. WHY DON'T WE END THE FORMAL PART OF IT? I USUALLY SAY GO UPSTAIRS AND GATHER FOR COFFEE BUT THANKS TO GSA THERE IS NO MORE COFFEE. SO IF YOU WANT TO COME DOWN AND CHAT WITH SETH. HE CAN'T STAY TOO MUCH LONGER BECAUSE HE HAS TO CATCH A PLANE BUT WHY DON'T WE JUST END RIGHT NOW? THANK YOU. [APPLAUSE]