IT'S A TERRIFIC HONOR TO BE ABLE TO INTRODUCE 2 OF NIAIDs MOST BRILLIANT STARTS D R. VERONIQUE NUSSENBLATT AND DR. ELODI GHEDIN WHO WILL TALK ABOUT WHAT, ELSE? SO I WILL GIVE A BRIEF INTRODUCTION AND ELODIIS OUR CHIEF OF CONSULTATION SERVICES SO YOU SLEEP APNEA AND OBESITYY HER ALL OVER AND OUR PROGRAM DIRECTOR FOR TRAINING AND INFECTIOUS DISEASE, SHE GREW UP IN THE REGION, WENT TO UNIVERSITY OF MARYLAND AND JOHNS LOP KINS WHERE SHE GOT HER MHS IN EPIDEMIOLOGY AND INFECTIOUS DISEASE, YOU SEE THE LINK HERE AND THEN HER M. D. AT MARYLAND, HER RESIDENCY ON THE ESTEEMED [INDISCERNIBLE] SERVICE, I HAVE A STAKE HERE AND THEN DID INFECTIOUS DISEASE TRAINING AT JOHNS HOPKINS FOLLOWED BY FURTHER TRAINING IN EPIDEMIOLOGY AND PUBLIC HEALTH. A SHORT STINT IN [INDISCERNIBLE] BEFORE COMING BACK TO HOPKINS WHERE SHE WAS RUNNING PART OF THE PROGRAM OUT AT THE BAYVIEW MEDICAL CENTER AND THEN WE WERE FANTASTICALLY LUCKY TO GET HER TO COME BACK HERE AND TO RUN OUR TRAINING PROGRAM. AND SHE IS A 2021 NIH RECIPIENT OF THE COVID-19 AWARD FOR THE OUTBREAK RESPONSE TEAM. FOLLOWING HER WILL BE DR. ELODIE GHEDIN, YOU YOU MIGHT BE SAYING WAIT A MINUTE COVID-19'S A FASCINATING PROGRAM BUT IT'S NOT TYPICALLY CONSIDERED A PARASITIC DISEASE. THIS WAS AN ERROR, I DON'T KNOW HOW THIS HAPPENED HERE BUT THE FACT IS THAT MICROBIAL GENOMICS IS ALWAYS IMPORTANT. SO ELODIE COMES TO US FROM CANADA. YOU WOULDN'T KNOW IT LOOKING OUTSIDE RIGHT NOW BUT GOT HER B. S. AT Mc GILL AND HER MASTERS AT UNIVERSITY OF QUEBEC AND Ph.D. AT Mc GILL. SHE DID HER POST DOC HERE AT THE LPD DISP WENT FROM LEER TO THE INSTITUTE FOR IME NATIONAL LIBRARY OF MEDICINIC RESEARCH TIGER IN THE YEAR OF ROCKVILLE AND THEN WENT TO PITTSBURGH WHERE SHE ROSE THROUGH THE RANKS TO AN ASSOCIATE PROFESSOR WITH TENURE BEFORE DECAMPING TO NEW YORK WHERE SHE WAS THE-- WE WERE FORTUNATE TO THIS AND SHE'S ALSO THE RECIPIENT TO THE FOUNDATION FELLOWSHIP. SO WITH THAT I WILL STOP AND TURN IT OVER TO DRS. NUSSENBLATT AND GHEDIN. >> THANK YOU SO MUCH FOR JUST A KIND INTRODUCTION. AND ON BEHALF OF BOTH OF US AS WELL, THANK THE COVID-19 SIG LECTURE COMMITTEE FOR THE INVITATION TO SPEAK TODAY ABOUT A TOPIC THAT'S OF GREAT INTEREST TO BOTH OF US WHICH IS WHETHER THE INABILITY OF SOME IMMUNE O COMPROMISED INDIVIDUALS TO EFFECTIVELY CONTROL AND CLEAR SARS-COV-2 AFTER INFECTION COULD BE CONTRIBUTING TO A POTENTIAL VARIANT EMERGENCE. SO THIS ILLUSTRATION SHOWS US THE TIMELINE OF THE INNATE AND THE ADAPTIVE IMMUNE RESPONSES DURING SARS-COV-2 INFECTION, SO WE SEE THE INNATE RESPONSE PRETTY IMMEDIATELY SIMULATING INTERFERON TO COMBAT THE VIRUS AND AS THE VIRAL LOAD INCREASES, WE THEN SEE THE ADAPTIVE IMMUNE RESPONSE WITH THE B-CELL AND T-CELL PROLIFERATION, ANTIBODY PRODUCTION LEADING TO DECREASE IN VIRAL LOAD, RESOLUTION OF SYMPTOMS AND ULTIMATELY, THE CLEARANCE OF THE VIRUS. NEXT SLIDE, PLEASE. SO IN THIS ILLUSTRATION THAT YOU SEE ON THE RIGHT, WE ARE SHOWING WHAT WE OFTEN SEE IN MANY IMMUNE O COMPROMISED HOSTS WHICH IS THAT YOU STILL SEE THIS INNATE RESPONSE BUT YOU DON'T HAVE THAT ROBUST ADAPTIVE IMMUNE RESPONSE LEADING TO PROLONGED VIRAL PROLIFERATION, PROLONGED INFECTION AND IN COMBINATION WITH INFLAMMATION FROM THE INNATE IMMUNE SYSTEM, WE ALSO SEE PROLONGED SYMPTOMS AS WELL. NEXT SLIDE, PLEASE. SO WHY DOES THAT MATTER, WELL IN THE UNITED STATES ALONE, WE HAVE APPROXIMATELY 7 MILLION INDIVIDUALS WITH SOME TYPE OF IMMUNE O COMPROMISE, AND WHILE ALL OF THE CONDITIONS YOU SEE ON THIS SLIDE TODAY ARE ASSOCIATED TO SOME DEGREE WITH PROLONGED INFECTION WITH SARS-COV-2, THE PATIENTS IN WHICH WE REALLY SEE THE VERY PROLONGED REPRUITT DESSENT TYPES OF INFECTIONS ARE THOSE WHO HAVE SEVERE B-CELL DEPLETION, USUALLY WITH SOME T-CELL COMPROMISE AS WELL. SO THAT CAN BE BECAUSE OF UNDERLYING HEMEAT O LOGIC MALIGNANCIES OR FROM LYMPHO-DEPLETION, SO TODAY WE WILL FOCUS ON DURATION OF INFECTION, IT'S IMPORTANT TO POINT OUT THAT THE ISSUES WE ARE GOING TO BRING UP TODAY AND THE CONCERNS ABOUT VIRAL EVOLUTION CAN BE APPLIED TO ANY INDIVIDUAL WITH IMPAIRED IMMUNITY. NEXT SLIDE, PLEASE. SO WHILE THIS COMES WITH MEDICAL CONCERNS, IT ALSO BRINGS PUBLIC HEALTH CONCERNS. BECAUSE IT RAISES THE QUESTION COULD PATIENTS WITH IMMUNE O SUPPRESSION WHO HAVE PERSISTENT OR PROLONGED INFECTION BE SERVING A RESERVOIR FOR MULTIMUTATIONAL VIRUSES THAT MAY BE ACCUMULATING MORE MUTATIONS AT A FREQUENCY THAT'S HIGHER THAN EXPECTED AND COULD THOSE BE SPILLING OUT INTO THE COMMUNITY. WE KNOW THAT SOME VARIANTS OF CONCERN HAVE THESE MUTATIONAL LEAKS SO THESE SUGGEST AN EXTENDED OF PERIOD OF HOST WITHIN WHICH EVOLUTION HAS OCCURRED. NEXT SLIDE, PLEASE. SO THIS TABLE HERE SHOW US US STUDIES THAT HAVE BEEN PUBLISHED OF PATIENTS WITH--WHO ARE IMMUNE O SUPPRESSED WITH A LONG DURATION OF LONG DURATION OF ACTIVE SARS-COV-2 INFECTION AND YOU CAN SEE THAT MOST OF THEM WHAT THEY HAVE IN COMMON IS SEVERE B-CELL IMPAIRMENT EITHER FROM A MEDICATION LIKE RETUXIMAB, OR A SETTING THR THERAPY FOR A HEMEAT O LOGIC MALIGNANCY, ALTHOUGH WE ARE SEEING REPORTS NOW COME NOTHING THE LITERATURE OF PATIENTS WITH UNCONTROLLED HIV FOR EXAMPLE, HAVING PROLONGED INFECTION AS WELL. SOMETIMES THEY'RE IN THE HOSPITAL THE ENTIRE TIME, SOMETIMES THEY GET BETTER WITH THE THERAPIES WE GIVE THEM ONLY TO REPRUITT DESAND REPRESENT. SO SOME OF THESE REQUIRE SOME KIND OF FREQUENT INTERVENTION TO GET THEM BETTER. AND SO YOU CAN IMAGINE THAT AN INFECTION THAT GOES ON FOR THAT LONG GIVES THE VIRUS AMPLE OPPORTUNITY TO MUTATE AND IN FACT, ALL OF THESE CASES REPORT MUTATIONS IN THE RECEPTOR BINDING DOMAIN, THE PRIME TARGET OF THE PROTECTIVE ANTIBODY RESPONSE AND IMPORTANT FOR VIRAL ENTRY. IN ADDITION MANY PATIENTS ARE ALSO TREATED WITH CONVALESCENT PLASMA OR ANTIBODIES AND CONVALESCENT PLASMA IS RECOMMENDEDDER ON USED ROUTINELY IN NONIMMUNE O SUPPRESSED PATIENTS. BUT, WE DO HAVE EVIDENCE THAT IN PATIENTS WHO ARE IMMUNE O SUPPRESSED SPECIFICALLY THOSE WITH HEMEAT O LOGIC MALIGNANCIES CONVALESCENT PLASMA CAN LEAD TO BETTER OUTCOMES AND SO EVENT THOUGH IT'S NOT USED ROUTINELY IN THE COMMUNITY, MANY CENTERS ARE STILL USING THESE TO TREAT THESE VERY DIFFICULT CASES. NEXT SLIDE, PLEASE. SO THIS FIGURE SHOWS US SEQUENCE POLYMORPHISMS OVER TIME IN A PATIENT WITH A VERY PROLONGED INFECTION OF 152 DAYS. SO THIS IS A PEASHT WHO'S HAD A SEVERE ANTILIPID PHOSPHO-INFECTION, THIS PATIENT REQUIRED MANY ROUNDS OF REMDESIVIR AND EVENTUALLY AROUND DAY 140 WAS GIVEN MONOCLONAL ANTIBODY AS WELL TO HELP HIM TRY TO CLEAR THE VIRUS AND WHAT YOU CAN SEE IS THAT AT THE LAST TIME POINT AT DAY 152 WE SEE THE EMERNLG ENSEL OF MUTATIONS THAT YOU CAN SEE HERE IN RED THAT HAVE BEEN REPORT INDEED A VARIANCE OF CONCERN PREVIOUSLY. NEXT SLIDE, PLEASE. THIS FIGURE ALSO SHOWS US MUTATIONS THAT OCCUR IN THE VIRUS IN A PATIENT INFECTED OVER TIME. THIS PATIENT HAD SARS-COV-2 INFECTION FOR OVER A YEAR. THIS WAS A PATIENT WHO HAD UNDERGONE HEMATOPOIETIC STEM CELL TRANSPLANTATION 6 MONTHS PRIOR TO INFECTION AND HE RECEIVED RETUX MAB AT THE SAME TIME FOR ACTIVATION SO THIS PATIENT PROLONGED COURSE RECEIVED CONVALESCENT PLASMA MULTIPLE TIMES THROUGHOUT HIS INFECTION WITH THE SECOND 1 OCCURRING HERE AROUND DAY 200 AND THEN BECAUSE HE DIDN'T IMPROVE, HE WAS ALSO GIVEN MONOCLONAL ANTIBODY AT THE END OF HIS INFECTION. AND WHAT YOU ARE SUPPOSED TO BE SEEING ON THE SLIDE, I'M NOT SURE IF YOU CAN SEE IT, I'M NOT SEEING IT ON MINE BUT WHAT YOU SLEEP APNEA AND OBESITYY IN THE--WITH THE BLUE LINE HERE IS THAT THE EMERGENCE OF A MUTATION AGAIN THAT'S BEEN ASSOCIATE WIDE VARIANTS OF CONCERN IN THE PAST AND BY THE END OF HIS INFECTION, A HUNDRED PERCENT OF HIS VIRAL MUTATION SAW THIS HAPPEN. SO AGAIN SEEING THIS HAPPEN OVER A LONG PERIOD OF TIME IN A PATIENT WITH INFECTION. NEXT SLIDE, PLEASE. SO WHAT I WOULD LIKE TO SHARE WITH YOU NOW IS A CASE THAT I CAN AND ALLISON RODER, A COMPUTATION BIOLOGIST IN ELODIE'S LAB PUBLISH INDEED THE JOURNAL OF INFECTIOUS DISEASES AND THIS IS THE CASE OF A NEARLY YEAR LONG COVID-19 INFECTION IN A PATIENT WHO WAS TREATED HERE AT THE NIH CLINICAL CENTER. AND IN WHOM WE ALSO FOUND IN-HOST EVOLUTION OF SARS-COV-2. NEXT SLIDE, PLEASE. SO THIS IS A 48 YEAR-OLD WOMAN WITH A HISTORY OF DIFFUSE LARGE B-CELL EMILY POEM FOAMA AND SHE WAS--B-CELL LYMPHOMA AND SHE WAS TREATED WITH THE CAR-T CELL THERAPY AND AS A RESULT SHE HAD ONGOING DISPLACIA, CD4 T-CELL LYMPHPENIA AND INCREASED RESPIRATORY INFECTIONS BECAUSE OF THAT. THIS WAS 1 OF THE FIRST PATIENTS THAT ADMITTED HERE AT THE CLINICAL CENTER WITH COVID-19. SHE WAS 1 OF OUR FIRST PATIENTS THAT WE TOOK CARE OF AND SHE REPRESENTED TO UTION ON APRIL 27th, 2020 WITH AN 11 DAY HISTORY OF FEVER, HEADACHE, CONGESTION, COUGH AND RIGHT AWAY, SARS-KICKOFF 2 WAS SUSPECTED. HOWEVER, SHE TESTED NEGATIVE ON NAIS O-PHARYNGIAL SWAB PRIOR TO ADMISSION AND THEN TWICE AFTER ADMISSION. ON ADMISSION SHE REQUIRED SUPPLEMENTAL OXYGEN AND DESPITE TREATMENT WITH BROAD SPECTRUM ANTIBIOTICS, HER SYMPTOMS CONTINUED TO WORSEN AND SHE WIRED MORE OXYGEN. SO ON MAY FIRST A BRANCHIAL LAVAGE WAS PERFORMED MEANING DEEP LUNG SPECIMENS WERE OBTAINED. AND AGAIN THIS WAS WAY AT THE BEGINNING OF THE PANDEMIC AND WE DID NOT HAVE REMDESIVIR AVAILABLE TO US TO TREAT HER. WE ALSO DID NOT HAVE ROBUST CLINICAL TRIAL DATA SURROUNDING THE USE OF CORTICOSTEROIDS FOR ACUTE COVID-19 INFECTIONS SO NEITHER OF THOSE AGENTS WERE ADMINISTEREDDA THE TIME. SO SHE WAS HOSPITALIZED HERE FOR 1 MONTH ANDURE DIDDING THAT MONTH WE OBTAINED ORAL SWAP SWABS TO TEST FOR SARS-COV-2, YOU CAN SEE WITH VIRAL LOADS HERE WITH THE PURPLE CIRCLE, SHE WAS POSITIVE THE ENTIRE TIME. SO AFTER A MONTH, BECAUSE WE RECOGNIZE THAT JUST LIKE WITH OTHER INFECT YOWZ DECEASES, THAT AS AN IMMUNE O COMPROMISED PATIENT, SHE MAY NOT RECOVER AS QUICKLY AS RECALLINGS. WE SENT HER HOME WITH A PLAN FOR HER TO CONVALESCE AT HOME AND TO GET BETTER. NEXT SLIDE, PLEASE. SO FROM THE PERIOD OF TIME WHEN SHE WENT HOME UNTIL DECEMBER 2020, SO FOR SEVERAL MONTHS SHE CONTINUED TO HAVE WAXING AND WANING SYMPTOMS. SHE HAD A PERSISTENT COUGH, STILL SHORT OF BREATH BUT SHE WOULD TELL US THIS WOULD GET MUCH, MUCH, BETTER ONLY TO GET WORSE A FEW WEEKS LATER. SHE ALSO HAD WAXING AND--SHE HAD INTERMITTENT LOW GRADE FEVERS AS WELL. SO ALL OF THOSE SYMPTOMS WERE STILL PRESENT BUT WAXING AND WANING AND SHE ALSO HAD A PERSISTENT OXYGEN REQUIREMENT SO CLEARLY SOMETHING WAS GOING ON IN HER LUNGS. DURING THAT PERIOD OF TIME, WE ALSO OBTAINED NAIS O PHARYNGIAL SWABS THAT WERE EITHER NEGATIVE PC Rs FOR SARS-COV-2 OR HAD VERY LOW VIRAL LOADS. AND SO AT THAT POINT BECAUSE OF HER OVERALL MILD SYMPTOMATOLOGY AND LOW VIRAL LOADS, THESE POSITIVE PC Rs WERE THOUGHT TO BE MOST LIKELY DUE TO SHUTTING OF NONVIABLE VIRAL PARTICLES WHICH WAS ALREADY RECOGNIZED TO HAPPEN IN BOTH IMMUNE O COMPROMISED AND NONIMMUNE O COMPROMISED INDIVIDUALS. NEXT SLIDE, PLEASE. SO WHAT YOU CAN SEE HERE ARE THE PATIENT CT SCANS. SO, ON YOUR LEFT THIS IS THE CT SCAN FROM APRIL 2020 SO THIS IS WHEN SHE RESENTED TO US. SO IMAGINE THE PATIENT IS LYING ON A TABLE WITH HER HEAD BEHIND THIS IMAGE, SHE'S LYING ON HER BACK WITH THE HEAD BEHIND THIS IMAGE AND WE ARE STANDING AT HER FEET AND THIS IS A CROSS SECTION OF HER CHEST. SO IN THE MIDDLE IS HER HEART AND ON BOTH SIDES ARE HER LUNGS AND WHAT THE BLUE ARROWS ARE SHOWING YOU ARE THESE KIND OF ROUND IRREGULAR KIND OF WHAT WE WOULD CALL FLUFFY INFILTRATES THAT REPRESENT COVID-19 PNEUMONIA. ON THE RIGHT IS HER CT SCAN FROM DECEMBER 2020. AND I'M NOT SHOWING YOU THE SAME CUT IN HER CHEST BUT YOU CAN PROBABLY APPRECIATE THAT THE INFILTRATE NOW THAT'S IN THE CIRCLE LOOKING DIFFERENT THAN THE 1 FROM 2020. SO THESE CHANGES HERE ARE CONSIST WENT SOMETHING CALLED ORGANIZING PNEUMONIA, AND ORGANIZING PNEUMONIA IS AN INTERSTITIAL LUNG DISEASE THAT ESSENTIALLY REPRESENTS THE LUNG TRYING TO HEAL ITSELF, SO IT'S AN IMMUNE DRIVEN PROCESS AND WE SEE THIS IN DIFFERENT CLINICAL SCENARIOS, INCLUDING AFTER SARS-COV-2 INFECTION. AND THIS TYPE OF--SO ORGANIZING PNEUMONIA IS TREATED WITH STEROIDS. SO THIS WAS BROUGHT UP AS PERHAPS A CAUSE OF OUR PATIENTS ONGOING SYMPTOMS. NOW BEFORE TREATING HER WITH STEROIDS, WE DID WANT TO MAKE SURE THAT SHE ESPECIALLY AS AN IMMUNE O COMPROMISE TD HOST DID NOT HAVE ANY OTHER INFECTIONS WE HAD TO WORRY ABOUT BEFORE GIVING HER STEROIDS. NOW THE PATIENT DECLINED ANOTHER BRANCHIAL ALVEOLAR LAVAGE BUT WE WERE ABLE TO GET INDUCED SPUTUM AND THAT WAS NEGATIVE FOR BACTERIAL OR FUNGAL PATHOGENS. NEXT SLIDE, PLEASE. SO THE DECISION WAS MADE TO TREAT WITH PREDNISONE, BECAUSE WE THOUGHT WE WOULD IMPROVE HER SYMPTOMS AND GET BETTER AND SO ON DECEMBER DAY 242 PREDNISONE WAS STARTED AND THAT WAS WITH A MILD IMPROVEMENT IN SYMPTOMS, VERY MILD IMPROVEMENT IN HER CT SCAN. NEXT SLIDE, PLEASE. BUT ON DAY 284, WE WERE TIPPED OFF THAT SOMETHING WAS NOT RIGHT BECAUSE WE OBTAINED ANOTHER NASO-PHARYNGIAL SWAB AND THAT 1 HAD A VIRAL LOAD THAT WAS MUCH HIGHER THAN THE 1S SHE HAD PREVIOUSLY AND THAT TIPPED US OFF THAT SOMETHING WAS NOT RIGHT ESPECIALLY IN THE SETTING OF HAVING STARTED THE STEROIDS. SO THEN WE STARTED ASKING OURSELVES THE QUESTION:--AND SHE REQUIRED A LOT MORE OXYGEN SO WE BROUGHT HER INTO THE HOSPITAL. WE TREATED HER WITH CONVALESCENT PLASMA, THIS TIME WE DID GIVE HER REMDESIVIR FOR 10 DAYS, AND WE STARTED WEANING HER STEROIDS. AND HER SYMPTOMS GOT BETTER, SO HER COUGH GOT BETTER HER SHORTNESS OF BREATH GOT BETTER AND ABOUT 3 WEEKS LATER, ON DAY 334 SHE CLEARED THE VIRUS. AND AND IN ADDITION, YOU KNOW WE SAW THAT HER INFLAMMATORY MARKERS HAD GOTTEN BETTER AND THAT HER CT SCAN WAS IMPROVING. SO THANKFULLY A HAPPY ENDING HERE. NEXT SLIDE PLEASE. BUT AGAIN, THIS CASE REALLY BROUGHT UP A LOT OF QUESTIONS IN OUR MINDS ABOUT, YOU KNOW WHAT HAD GONE ON THIS ENTIRE TIME IS QUITE A LEARNING CASE AND YOU KNOW THE MAIN QUESTION THAT WE REALLY HAD WAS HAD WE RECRUDESCED, THIS UNDER LYING YEAR LONG SARS-COV-2 INFECTION OR MAYBE THAL PATIENT BEEN EXPOSED TO COVID-19, AND COULD SHE BEEN EXPOSED ABOUT, SHE LIVE INDEED A MULTIGENERATIONAL HOUSE, AND WOE SOPHISTICATEDY WE APPROACHED HER AND WE TOOK VIRAL ISOLATES FROM THE BEGINNING OF THE INFECTION AND THE END OF HER INFECTION AND THEY WERE SEQUENCED AND WITH THAT I WILL PASS THE MIC TO ELODIE. >> THANK YOU, VERONIQUE. SO THAT WAS THE MAIN QUESTION SHE HAD WHEN THIS CASE HAPPENED. WAS IT THE SAME VIRUS OR WAS IT A REINFECTION? AND SO WHAT YOU SEE HERE IS A PHILOGENETIC TREE, A CIRCULAR N TREE AND WE SEQUENCED THE WHOLE GENOME FROM THESE SAMPLES FROM EARLY MAY AND THEN FROM MARCH 2021 AND WHAT WE SAW WAS THAT ACTUALLY ALL THE SAMPLES CLUSTERED TOGETHER IN THE TREE SHOWING THAT THEY'RE ALL RELATED IN SOME WAY. WHAT YOU SEE HERE, THIS VERY LONG BRANCH INDICATES THAT THE VIRUS HAS EVOLVED OVER THAT PERIOD OF TIME, BUT IT'S STILL ALL--THEY ALL BELONG TOGETHER. THIS LINEAGE WAS BASICALLY AN OLD LINEAGE WE SAW CIRCULATING IN 2020 BUT THAT WAS NO LONGER CIRCULATING IN 2021. SO THAT FURTHER JUSTIFIED AGAIN THAT THIS WAS ONCE INFECTION THAT WAS JUST A LONG, LONG INFECTION. THE BUT WHAT WAS MORE INTERESTING WHEN YOU LOOK AT THE VIRUS AND THE VIRUS GENOME INFORMATION IS REALLY WHERE THE VIRUS EVOLVES AND HOW IT EVOLVES. SO THIS IS A REPRESENTATION ESCHEMA OF THE DIFFERENT GENES OF THE WHOLE GENOME OF SARS-COV-2. THE SPIKE IS RIGHT HERE. AND BELOW IS JUST A BLOCK WITH LITTLE COLORED BOXES THAT INDICATE POSITIONS ALONG THE GENOME WHERE YOU DO SEE A MUTATION OCCURRING OVER TIME. SO EACH ROW REPRESENTS A DIFFERENT SAMPLE. AND EACH OF THESE SAMPLES ARE COMPARED TO THE FIRST 1 TAKEN IN MAY FIRST 2020. THAT WAS THE BALL SAMPLE THAT VERONIQUE MENTIONED. YOU CAN CAN SEE ACCUMULATIONS OCCURRING OVER TIME. NOW IF THIS WAS JUST A VIRUS CIRCULATING IN THE POPULATION, YOU WOULD EXPECT TO SEE MUTATIONS OVER THIS 335 DAYS AND YOU WOULD EXPECT AN EVOLUTIONARY RATE OF ABOUT, YOU KNOW 1 MUTATION OCCURRING EVERY 2 WEEKS WHICH IS A LITTLE WHAT WE WERE SEEING IN THIS PATIENT BUT THESE MUTATIONS WERE ACCUMULATING WITHIN THE HOST BUT WE DID SEE A LITTLE BIT MORE THAN WE WOULD HAVE EXPECTED SIMPLY WITH THE EVOLUTIONARY RATE. WHAT'S MORE INTERESTING IS WHEN YOU FOCUS SPECIFICALLY ON THE TYPES OF MUTATIONS YOU IDENTIFY AND SO FOR EXAMPLE, IF YOU LOOK AT THE SPIKE IN ANOTHER REGION OF THE GENOME, WE SAW 2 DELETIONS. NOW 1 OF THESE DELETIONS IS WELL REPORTED AND I'LL GO INTO THAT IN A MINUTE AND IT'S IN THE SPIKE PROTEIN BUT ANOTHER 1 THAT IS QUITE INTERESTING AND THERE HAVE BEEN OTHER STUDIES PUT IN IMMUNE O COMPETENT MUTATIONS WHERE YOU SEE DELETION OF PORTIONS OF CERTAIN GENES, 67 B AND ORF8, IN OUR CASE WE SAW FULL DELETION OF THESE 2 GENES AND DELETION IS PARTICULARLY INTERESTING BEFORE AND IMMUNE O COMPROMISED PATIENTS, THESE KINDS OF DELETIONS AND I WILL--DESPITE THIS IN THE REGION AND DESPITE THE TERMINAL DOMAIN THAT BINDS TO THE RECEPTOR,--TRY TO CONTROL THE VIRUS, SO WE OBSERVE THIS DELETION IN THE GENOME. WHAT WAS MORE INTERESTING IS ACTUALLY THE DYNAMICS OF THIS MUTATION SO WE ONLY OBSERVE THIS DELETION WITHIN THE 2 LAST SAMPLES THIS NUCLEOTIDES GENOME RECEIVE THE DELETION AND REPRESENTED HERE BASICALLY A CLIFF SO WHAT I NOTED HERE IS ACTUALLY THE READ COVERAGE, AND IF YOU DON'T KNOW WHAT READ COVERAGE IS, THIS IS WHAT IT MEANS SO WHEN YOU SAMPLE SOMEBODY, THEY DON'T JUST HAVE 1 VIRUS, THEY HAVE A POPULATION OF VIRUSES AND EACH OF THESE VIRUSES HAVE A GENOME. SO WHEN WE BASICALLY BREAK UP THESE GENOMES, SO THAT WE CAN DECODE THEM AND SEQUENCE THEM, WE HAVE THE SEQUENCE READS THAT WE THEN READ BACK. SO WHEN YOU HEAR A GENOMICS PERSON TALKING ABOUT HIGH COVERAGE OR LOW COVERAGE, THIS IS WHAT WE MEAN, IT MEANS A REGION OF THE GENOME THAT IS VERY WELL REPRESENTED BY A LOT OF SEQUENCE READS OR A REGION THAT IS UNDERREPRESENTED BY SEQUENCE READS, BUT THEN WE GENERATE WHAT'S CALLED A CONE CENSUS SEQUENCE, SO GOING OVER THE WHOLE GENOME, AND EVERY POSITION, WE TAKE WHAT SEEMS TO BE THE MOST DOMINANT NUCLEOTIDE AND YOU GENERATE THIS VIRUS GENOME, SO WHEN YOU'RE HEAR ABOUT VIRUS GENOMES THAT ARE BEING DECODED AND RIGHT NOW IF PUBLIC DATABASES CLOSE TO 9 MILLION SARS-COV-2 VIRUS GENOMES, IT'S ALWAYS TALKING ABOUT A CONSENSUS SEQUENCE BUT THERE'S INFORMATION IN THESE UNDERLYING READS. SO IF WE GO BACK TO OUR REGION OF THE VIRUS AND HOW IT MUTATED OVER TIME, WE SEE THAT THAT ORF7 B OR 8 REGION HAS A FEW VIRUSES STILL IN THE POPULATION OF VIRUSES THAT HAVE THAT REGION THAT IS INTACT AND THAT'S WHY YOU SEE 24 X OR 24 READS THAT WILL COVER THAT REGION, BUT VERY QUICKLY WITHIN 1 DAY, THIS PATIENT LOST ALL THE REGIONS SO 7 B AND ORF8 ARE COMPLETELY DELETED IN THAT GENOME. NOW THAT DELETION IS PRETTY LARGE, CLOSE TO 500 NUCLEOTIDES AND IT'S IN FACT THE LARGEST REGION THAT HAS BEEN REPORTED TO DATE. NOW WHAT DOES ORF8 OR 7 B DO? SO ORF8 EXPRESSION IS THOUGHT TO NOT BE ESSENTIAL FOR REPLICATIONS AND SAME THING FOR ORF 7 B BUT THEY ARE THOUGHT TO BE INVOLVED IN IMMUNE RESPONSE SO IT COULD BE THAT IN PATIENT, THERE IS NO USE FOR THIS VIRUS TO CARRY THESE GENES BECAUSE THE IMMUNE RESPONSE IS PRETTY LOW. NOW THERE HAVE BEEN OTHER STUDIES SHOWING OTHER LARGE DELETIONS IN THAT REGION SUCH AS THIS 382 NUCLEOTIDE DELETION AND THEY FOUND THAT IT DID CORRELATE WITH MILDER DISEASE IN 1 STUDY LOWER INCIDENCE OF HYPOXIA. SO THESE ARE DIFFERENT STUDIES AND DIFFERENT PARTS OF THE WORLD WHERE THEY HAVE OBSERVED DELETIONS IN THAT REGION. SO IT SEEMS THAT THE ORF 8 REGION IS A PRETTY MALLEABLE REGION OF THE GENOME, SO THERE'S A LOT OF DIVERSITY IN THAT REGION. SO THIS TAKES ME TO THE DIVERSITY OF THE POPULATION THAT EXISTS IN A PATIENT BE IT AN IMMUNE O COMPETENT PATIENT OR IMMUNE O COMPROMISED PATIENT SO IF YOU GO BACK TO MY SCHEMA OF LOOKING AT THE SEQUENCE READS, THE OTHER INFORMATION WE CAN CAPTURE IS YOU SEE AN ORANGE HERE, WHAT WOULD BE MUTATIONS. BUT THEY'RE NOT IN THE MAJORITY OF THE SEQUENCE READS, MEANING THAT SOME OF THE VIRUSES WITHIN THE POPULATION, WITHIN THAT PATIENT OR CARRYING DIFFERENT MUTATIONS BUT THEY'VE ACCUMULATED AT ENOUGH HIGH LEVEL THAT WE CAN CAPTURE THEM AS PRETTY IMPORTANT MINOR VARIANTS. SO FROM THIS SEQUENCE DATA, YOU CAN ACTUALLY PULL OUT THE CONSENSUS SEQUENCE BUT ALSO SOME INFORMATION OF MINOR VARIANTS. SO ON THE LEFT HERE, HOW YOU CAN SHOW THIS ALSO, SO IN THIS PATIENT, WE HAVE THE DIFFERENT COLLECTION DATES, WE HAVE DIFFERENT GENES AND THESE ARE IMMUNE O ACID ACID POSITIONS WHERE THE--SO THERE IS CHATTER IN THE VIRAL POPULATION THAT CAN LEAD TO NEW VIRUS GENOMES THAT HAVE NEW MUTATIONS INSERT REGIONS OF THE GENOME. NOW I'M MENTIONING THIS BECAUSE IF YOU GO BACK TO SOME OF THESE IMMUNO COMPROMISED PATIENTS AND SOME OF THESE STUDIES, THERE'S 1 STUDY BY HENSLY WHERE THEY'VE LOOKED OVER TIME AT DIFFERENT MINOR VARIANTS AND YOU CAN SEE HOW THERE ARE DELETIONS THAT CAN OCCUR, THAT CAN APPEAR IN SOME OF THESE MINOR VARIANTS AND POSITIONS ALSO IN THE RECEPTOR BINDING DOMAIN THAT SEEM TO OCCUR ALSO OVER TIME AND THAT YOU CAN CAPTURE IN THE MINOR VARIANTS. NOW ANYTHING THAT CIRCULATING IN THE WORLD THAT BECOMES YOU KNOW A VIRUS THAT'S CIRCULATING GLOBALLY, YOU CAN SEE EVOLUTION HAPPENING BETWEEN HOSTS SO AS WE TRANSMIT VIRUSES, THEY CAN ADAPT DIFFERENTLY IN DIFFERENT HOSTS BUT EVOLUTION ALSO HAPPENS OF COURSE WITHIN THE HOST AND THAT'S THE INFORMATION WE'RE TRYING TO CAPTURE ESPECIALLY IN THE CONTEXT OF IDENTIFYING POTENTIALLY EMERGING VARIANTS AND VARIANTS OF CONCERN. AND SO, WHEN YOU LOOK AT THIS POPULATION AND EMERGENCE OF A NEW VARIANTS. SO THERE'S THIS 1 STUDY THAT POST DOC IN MY LAB [INDISCERNIBLE] IS DOING WHERE SHE'S TRYING TO LEVERAGE VERY LARGE DATA SETS OF NEXT GENERATION SEQUENCING DATA TO BE ABLE TO ANSWER SOME OF THESE QUESTIONS ON WHAT IS THE DIVERSITY WITHIN A HOST. SO ACTUALLY SASHA IS GIVING A TALK AT THE LPD SEMINARS AT 1:00 O'CLOCK WHERE SHE WILL GO IN DETAIL SO I WON'T BE SHOWING TO SHOWING--TOO MUCH ABOUT HER STUDY BUT I WANT TO MAKE A POINT IN THE CONTEXT OF WHAT WE'RE TALKING ABOUT WITH EVOLUTION WITH AN IMMUNO COMPETENT AND IMMUNO COMPROMISED PATIENTS. SO THERE HAVE BEEN A FEW STUDIES LOOKING AT MINOR VALID AND RELIABLE YABT AND COUNTING MINOR VARIANTS WITHIN INDIVIDUALS. AND THIS IS JUST A REPRESENTATION OF 2 OF THESE STUDIES. NOW MINOR VARIANTS HAPPEN, BUT THEY'RE NOT PRESENT AT A HUGE NUMBER SO IT'S NOT AS IF YOU HAVE A LOT OF DIVERSITY OCCURRING WITHIN THIS VIRUS POPULATION BECAUSE ALTHOUGH THE VIRUS MAKES MISTAKES, EVERY TIME IT REPLICATES, A LOT OF THESE MISTAKES WILL JUST BE PUDGIERED AND YOU WILL GET REALLY JUST VIRUSES THAT ARE COMPETENT AND THAT CAN REPLICATE. SO WHAT YOU'RE SEEING IN THE MINOR VARIANTS ARE VIRUSES THAT HAVE MUTATIONS OR THESE DELETIONS OR MISTAKES BUT THAT ARE ABLE TO REPLICATE. SO IN GENERAL, IF YOU LOOK AT THE NUMBER OF SPECIMENS SO THIS IS A STUDY WHERE THEY HAD YOU KNOW ABOUT A HUNDRED SPECIMENS HERE, THEY HAD MANY MORE AND YOU LOOK AT THE NUMBER OF MINOR VARIANTS PER SAMPLE, THE NUMBER SEEMS TO BE AROUND 2-3, SO IN GENERAL THERE ARE VERY FEW MINOR VARIANTS IN A POPULATION OF VIRUSES BUT YOU DO HAVE EXCEPTIONINGS WHERE THERE ARE SOME SAMPLES THAT HAVE A LOT OF MINOR VARIANTS SO WE'RE TRYING TO UNDERSTAND WHAT LEADS TO THIS. ARE THESE PATIENTS DO THEY HAVE SOMETHING DIFFERENT ABOUT THEIR IMMUNE SYSTEM, IS THERE SOMETHING THAT WE CAN CAPTURE IN THIS DIVERSITY IN THEIR VIRUS POPULATION. SO WITH SASHA HAS BEEN DOING IS SHE'S BEEN GETTING ALL THE RAW DATA FROM A STUDY THAT IS GOING ON IN HOUSTON METHODIST AND LED BY JIM MUSSER WHERE THEY'VE BEEN SEQUENCING OR SEQUENCING FOR EVERY SINGLE PATIENT THAT TESTS POSITIVE FOR SARS-COV-2 AS PART OF THE HOUSTON METHOD SESSION. SO WE OBLIGATIONS STAINED ABOUT 40 NOVA SEEK RUNS, IT'S A SEQUENCING TRIEWMENT THAT PROVIDES A VERY LARGE MEMBER OF SAMPLES AND VERY HIGH DEPTH OF COVERAGE. AND WE'VE LOOKED AT ABOUT 21,000 WHOLE GENOMES THAT WERE SEQUENCED BETWEEN DECEMBER 2020 AND JULY 2021 TO LOOK AT MINOR VARIANTS AND SEE IF WE CAN CAPTURE SOME OF THIS INFORMATION NOW I'M CUTTING OUT A LOT OF STEPS BUT 1 THING THAT SASHA OBSERVED IS THAT IF YOU LOOK AT THE NUMBER OF SAMPLES WITH--ARE THERE MUSEUM TAIPGZ AFFAIRS TEAM LEADER HOT SPOTS IN THE GENOME WHERE WE WOULD SEE CERTAIN VARIANTS EMERGING. I'VE HIGHLIGHTED THE SPIKED PROTEIN HERE IN RED TO SHOW YOU THAT IT'S NOT NECESSARILY IN THE SPIKE WHERE YOU WOULD HAVE THE MOST MINOR VARIANTS THAT WOULD BE OBSERVED. WE ACTUALLY SEE THEM A LOT IN THE NUCLEOCAP SID PROTEIN AND ALSO IN ORF 8. IN ORF 8 AS YOU HEARD EARLIER, SEEMS TO BE PRETTY MALLEABLE REGION OF THE GENOME. SO YOU SEE DELETIONS, BUT YOU ALSO SEE A FEW MUTATIONS. SO, WHAT YOU SEE IN SOME OF THESE GENES IS THAT YOU HAVE YOU TEND TO SEE MANY SAMPLES THAT HAVE MULTIPLE VARIANTS SO FOR EXAMPLE, YOU SEE HERE THAT YOU CAN COULD GO CAP SID THAT YOU CAN HAVE DIFFERENT NUCLEOTIDES THAT OCCUR IN THAT SAME POSITION. SO AGAIN IT'S THIS CHATTER. THERE ARE SPOTS OR REGIONS IN THE GENOME WHERE YOU HAVE A LOT OF DIVERSITY, A LOT OF FLEXIBILITY AND CHATTER. AND IF I TAKE THE EXAMPLE HERE FROM THE SPIKE, THERE'S ACTUALLY AN IMPORTANT POSITION WHICH IS THE FEWER AND CLEAVAGE SITE AND WE SEE THIS IS A SITE THAT HAS A LOT OF MUTATIONS OFTEN IN THESE SAMPLES. SO, LET'S GO BACK TO OUR IDEA OF VARIANTS OF CONCERN. SO IF YOU LOOK GLOBALLY AT SOMETHING LIKE ALFOBBS THAT'S THE B117 AND THE DELTA WE'RE MORE FAMILIAR WITH, THE 681 POSITION TENDS TO TWITCH BETWEEN THIS H AND THE R AND WE SEE SUBSTITUTIONS IN THIS MINORITY FRACTION OF THE GENOME. SO THE REASON I MENTION THIS IS THAT VARIANTS OF CONCERN DO TEND TO MERGE WITH A LARGE NUMBER OF NEW MUTATIONS AND CAN WE CAPTURE THESE MUTATIONS IN THE SEQUENCE DATA IN THE MINOR VARIANT DATA? NOW, HAVING A LOT OF DIVERSITY WITHIN AN INDIVIDUAL ACCOUNTED FACILITATE EMERGES ENSEL OF DIFFERENT VERSIONS OF THE VIRUS, INCLUDING AND SHE'S ACTUALLY DETERMINED THAT THERE IS AN ASSOCIATION BETWEEN HIGH VARIANT NUMBERS AND DISEASE ASSOCIATION VARIABILITY. AND 1 QUESTION WE HAVE IS WHETHER DIVERSE IS SEEN IN IMMUNO SUPPRESSED PATIENTS AND SO THIS IS THE TYPE OF ANALYSIS THAT IS ONGOING RIGHT NOW, WHERE WE WOULD NEED TO LOOK AT LARGER POPULATIONS OF IMMUNO SUPPRESSED INDIVIDUALS TO ANSWER THAT QUESTION. BECAUSE IF WE GO TO OMICRON AND WE KNOW THAT OMICRON HAS SEEMED TO ACCUMULATE A LOT OF MUTATIONS OVER OVER ITS GENOME AND HERE'S A REPRESENTATION OF A PHILOGENETIC TREE THAT WAS MADE BY NEXT STRAIN AND HERE CAN YOU SEE OMICRON HAS THIS VERY LONG BRANCH LENGTH AND THAT INDICATES THAT GENETICALLY IT'S QUITE DIFFERENT FROM THE REST OF THESE VARIANTS OF CONCERN AND IN FACT IF THERE'S THIS NICE PAPER THAT IS A PERSPECTIVE TYPE PAPER IN NATURE THAT WAS PUBLISHED I THINK IN THE LAST WEEK OR EARLIER THIS WEEK WHERE THEY SHOW HERE OVER TIME THE NUMBER OF MUTATIONS IN THE SPIKE PROTEIN FOR OMICRON, COMPARED TO OTHER VARIANTS OF CONCERN, CAN YOU SEE THAT OMIKRON HAS MANY MORE BUT ALSO IT SEEMS THAT IT'S CLOSEST KNOWN ANCESTOR PROBABLY DATES BACK PRETTY FAR BACK. NOW THIS PARTICULAR PIECE IS ABOUT WHAT WOULD BE THE SOURCE OF OMICRON, IS IT FROM AN ANIMAL RESERVOIR WHERE THIS IVLIEWGZ WOULD OCCUR OR IN IMMUNO COMPROMISED PATIENT WHERE IS THE VIRUS COULD HAVE EVOLVED OVER TIME AND HADN'T BEEN PICKED UP BEFORE AND THAT'S SORT OF WHAT WE'RE TRYING TO ANSWER. SO LET'S GO BACK TO THAT TABLE THAT THEY SHOWED EARLIER WHERE SHE LISTED A LOT OF THESE STUDIES WITH IMIEWNL O COMPROMISED PATIENTS AND I HAD ADDED HERE OUR OWN STUDY AND THIS IS JUST THE SCHEMA OF THE WHOLE GENOME, SORRY OF THE SPIKE PROTEIN ONLY WITH DIFFERENT DOMAINS IN THE PROTEIN THAT ARE IMPORTANT. THIS IS--AND YOU CAN SEE IN OUR IMMUNO COMPROMISED PATIENTS, THESE PATIENTS HAVE ACCUMULATED OVER TIME SO MANY OF THESE STUDIES SHOW THE EARLIEST TIME POINT AND THE LATEST TIME POINT AND WHAT I'M SHOWING HERE IS REALLY THE LATEST TIME POINT, THE TYPES OF MUTATIONS THAT HAVE ACCUMULATED OVER TIME. AND YOU CAN SEE THAT THERE ARE CERTAIN SPOTS OF THE GENOME WHERE THE MUTATIONS TEND TO ACCUMULATE OVER TIME AND IF YOU COMPARE WITH THE VARIANCE OF CONCERN, THEY'RE VERY SIMILAR POSITIONS SO THERE ARE--SO YOU HAVE OMICRON HERE THAT OF COURSE HAS MANY MORE OF THESE MUTATIONS BUT THEY DO SEEM TO OCCUR WHERE WE HAVE SEEN THEM HAPPENING IN OUR IMMUNO COMPROMISED PATIENTS. NOW THAT DOESN'T MEAN THAT ALL VARIANTS OF CONCERN COME FROM IMMUNO COMPROMISED PATIENTS, INDICATING THAT THERE ARE YOU KNOW POSITIONS THAT APPEAR TO BE FROM THE MINOR VARIANT DATA, WE DO SEE THERE ARE POSITIONS THAT ARE MUTATIONAL HOT SPOTS, AND THAT THESE VIRUSES MAY BE FAVORED IN IMMUNO COMPROMISED HOSTS. AND I WILL LET VERONIQUE CLOSE THIS OFF FROM OUR TAKE AWAYS FROM THESE DIFFERENT STUDIES. >> THANK YOU ELODIE. SO JUST A FEW POINTS BEFORE WE CLOSE, CLEARLY YOU CAN SEE MUTATED VARIANTS EMERGING ON INDIVIDUALS AND WE DON'T REALLY UNDERSTAND TO WHAT EXTENT AND ALL OF OUR IMMUNO COMPROMISED PATIENTS IS, AND THE EMERGENCE OF SUCH VARIANTS IN THE COMMUNITY AND BEYOND, IT'S REALLY IMPERATIVE THAT WE INVESTIGATE WHAT THEIR ROLE IS IN ALL OF THIS, AND AGAIN, WELL WE'VE BEEN PRESENTING CASE REPORTS HERE TODAY, I THINK THIS IS ACTUALLY HAPPENING A LOT MORE THAN WHAT WE'RE SEEING BEING REPORTED IN THE LITERATURE SO I'VE HEARD AND BEEN INVOLVED IN SEVERAL CASES IN THE COMMUNITY OF PATIENTS AGAIN, WITH VERY PROLONGED INFECTIONS AND AFTER OUR CASE WAS PUBLISHED, ELODIE AND I RECEIVED E-MAILS FROM INTERNATIONAL PHYSICIANS WHO ARE TRYING TO MANAGE PATIENTS WITH REPRUITT DESSENT INFECTIONS AND PROLONGED INFECTIONS SO AGAIN, I THINK THIS IS A MUCH GREATER PROBLEM THAT WE'RE JUST SEEING WITH THESE CASE REPORTS. I THINK WE NEED TO BE THOUGHTFUL ABOUT THE THERAPIES WE USE TO TREAT OUR PATIENTS. WE, RIGHT NOW, WE DON'T HAVE REALLY VERY EFFECTIVE ANTIVIRALS TO USE TO TREAT OUR PATIENTS AND SO WE FOCUSED--WE FOCUS A LOT ON MONOCLONAL ANTIBODIES AND ON CONVALESCENT PLASMA. NOW WE DO HAVE 2 NEW ORAL DRUGS THAT HAVE JUST BEEN APPROVED UNDER AN EUA RECENTLY BUT NONE OF THESE THERAPIES HAVE BEEN EXTENSIVELY INVESTIGATED IN IMMUNO COMPROMISED PERSONS SO DO WE KNOW WE'RE GIVING THEM THE RIGHT DOSE, THE RIGHT TITERS, ARE WE TREATING THEM LONG ENOUGH? ARE WE GOING TO GET THEM BETTER ABOUT YOU NOT FAST ENOUGH TO PREVENT NEW VARIANTS FROM EMERGING? SO I THINK THERE'S A LOT LEFT TO BE INVESTIGATED THERE AND LASTLY I THINK THERE ARE CONTROL CONSIDERATIONS AND TO PUT THIS INTO CONTEXT, I THINK WE'RE VERY LUCKY TO HAVE A FANTASTIC LABORATORY HERE AND ELODIE AS A RESOURCE WHEN WE ARE TRYING TO THINK ABOUT OUR PATIENTS AND WHAT ON DO ABOUT OUR PATIENTS BUT MOST LABORATORIES AND HOSPITALS IN THE UNITED STATES LET ALONE THE WORLD ARE NOT ABLE TO SEQUENCE VIRUSES WITHIN A COUPLE OF DAYS OR USE MOLECULAR MEANS TO DETERMINE WHETHER OR NOT THE VIRUS IS PRESENT AND THIS IS SOMETHING WE DO FREQUENTLY HERE AT THE CLINICAL CENTER, MOST LABS DON'T REPORT CT VALUES SO WE DON'T EVEN HAVE THAT TO GO ON IN MANY PLACES IN THE COMMUNITY. AND SO WITH THE UC RECOMMENDING THAT FOR IMMUNO COMPROMISE PATIENTS THAT WE SHOULD BE USING A TESTING STRATEGY TO DETERMINE WHETHER OR NOT THEY NEED TO BE IN ISOLATION OR NOT, THAT CAN GET VERY COMPLICATED WITH MANY OF THESE PATIENTS. NOW OUR PATIENTS AS FAR AS WE KNOW DID NOT TRANSMIT HER INFECTION TO ANYBODY IN HER FAMILY. I KNOW WE DIDN'T TEST EVERYBODY BUT WE WERE NOT TOLD OF ANY INFECTIONS THERE, SO WHETHER OR NOT THATEE EVEN OF A CONCERN, WE DON'T KNOW BUT WE ASSUME THAT IT IS BECAUSE AGAIN WE'RE SEEING REPLICATING VIRUS FOR A LONG TIME IN THESE INDIVIDUALS. SO I THINK I'M LEAVING YOU WITH MORE QUESTIONS THAN ANSWERS BUT I HOPE WE'VE PIQUED YOUR INTEREST IN THIS VERY IMPORTANT TOPIC TODAY AND THANK YOU SO MUCH FOR YOUR ATTENTION. NEXT SLIDE. --OF THE WAY WITH OUR PATIENTS WITH THE MOLECULAR TESTING AND TRYING TO BED --UNDERSTAND WHAT WAS GOING ON. DR. TARA P A LMORE WHO WAS INSTRUMENTAL IN EVERY STEP OF THE WAY TRYING TO UNDERSTAND THIS VERY COMPLEX CASE AND I'D LIKE TO THANK OUR COLLEAGUES AT NCI, DOCTOR'S BAROCHIA AND THEY WERE INTIMATELY INVOLVED TO HELP US UNDERSTAND AND MANAGE OUR PATIENT'S LUNG PROBLEMS. >> AND I WOULD LIKE TO THANK OUR COLLABORATORS AT HOUSTON METHOD AND --HOUSTON METHODIST AND WE ARE WORKING WITH THEM CLOSELY AND SPECIFIC STUDY ON OMICRON AND ALL THEIR SEQUENCE DATA NOW IS OMICRON AND SO WE WILL HAVE MORE TO REPORT SOON AND I WOULD LOAMACYIC TO THANK MY LAB WHO HAS BEEN WORKING REALLY HARD ON SIGNIFYQUENCING ALL THE NIH SAMPLES OF POSITIVE CASES ON CAMPUS AND SO, IT'S BEEN GREAT WORKING WITH THEM ALL. THANK YOU VERY MUCH. >> GREAT, THANKS SO MUCH FOR A REALLY EXCELLENT TALK. WE HAVE A BUNCH OF QUESTIONS, BUT FIRST I WANT TO REPEAT THE CME CODE, WHICH IS 37963. THAT'S 37963 AND I PRACTICE TOO AND STEVE ALMOST MESSED ME UP THERE SAYING IT EARLIER. ALL RIGHT, SO WE HAVE A BUNCH OF QUESTIONS THAT ARE RELATED TO DIFFERENCES IN--SO HOW DO THESE MUTATIONS CONTRIBUTE TO BOTH INFECTION IN THE PATIENT BUT MOSTLY INFECTIOUSNESS VERSUS SHEDDING, VERSUS TRANSMISSIBILITY, CAN YOU GO INTO MORE DETAIL ABOUT WHAT SOME OF THESE MUTATIONS SPECIFICALLY IN THE S1 PROTEIN, HOW THOSE ARE GOING TO AFFECT TRANSMISSIBILITY AND INFECTIOUSNESS AND THEN TO FOLLOW UP WITH THAT ALSO, TO WHAT EXTENT DO YOU THINK THAT THE PHENOMENON OF THIS VIRUS SIMMERING AND MUTATING IN AN IMMUNO COMPROMISED PERSON BEFORE THEY EMERGE INTO THE HEALTHY POPULATION, YOU KNOW HOW MUCH DO YOU THINK THAT ACTUALLY WOULD CONTRIBUTE TO VIRUS TRANSMISSION? >> ALL RIGHT, SO THE FIRST QUESTION EMILY WAS WHAT ARE THESE DIFFERENT MUTATIONS DOING PHENOTYPICALLY, RIGHT? IS THAT THE QUESTION? >> YEAH, SO, WE'RE INTERESTED IN YOU KNOW, OKAY, SO THESE IMMUNO COMPROMISED PATIENTS THEY HAVE THE VIRUS LONGER BUT WHAT DOES THAT MEAN IN TERMS OF BOTH WITHIN PATIENT, DURATION OF DISEASE BUT ALSO TRANSMISSIBILITY AND INFECTIOUSNESS, BECAUSE IF THEY'RE PC R POSITIVE THEY COULD JUST BE SHEDDING VIRUS. >> RIGHT. SO THE REASON WE KNOW THEY'RE NOT JUST SHEDDING SO WE KNOW THEY'RE SHEDDING VIRUS BUT THAT THE VIRUS IS ACTUALLY REPLICATING SIMPLY BECAUSE THE FACT THAT WE'RE ABLE TO SEQUENCE THE SAMPLE THE SEQUENCE MEANS THE VIRAL LOAD IS HIGH ENOUGH TO SEQUENCE AND PHENOTYPICALLY WHAT DOES THAT MEAN FOR TRANSMISSION, YOU KNOW YOU KNOW A VIRUS CAN HAVE MUTATIONS THAT DO DIFFERENT THINGS, WE HAVE A MUTATION THAT LEADS TO EITHER BETTER TRANSMISSION AND THAT MAY BE BECAUSE IT TENDS TO EITHER ACCUMULATE EITHER LOAD SO THAT TRANSMITTING IS EASIER BECAUSE YOU HAVE MORE THAN YOU'RE EXPELLING WHEN YOU SNEEZE FOR EXAMPLE, BUT THERE ARE ALSO MUTATIONS THAT EVEN IF YOU'RE NOT TRANSMITTING BETTER BUT YOU ACTUALLY CAN ENTER CELLS BETTER, WHICH I GUESS IS A KIND OF TRANSMISSION, SO THERE ARE SPECIFIC MUTATIONS WITH DIFFERENT PHENOTYPES LIKE THAT, NOW THERE'S SOME THAT HAVE BEEN WELL CHARACTERIZED AS WE UNDERSTAND THIS VIRUS MORE AND MORE AND THERE ARE TEAMS WORKING ON INVITRO EXPERIMENTS AND INVIVO EXPERIMENTS SO IN ANIMAL MODELS WHERE THEY ARE TESTING SOME OF THESE MUTATIONS. SO MANY OF THE MUTATIONS WE'VE SHOWN FROM THE VARIANTS OF CONCERNS, SOME OF THEM ARE WELL CHARACTERIZED LIKE THE 501 FOR EXAMPLE, AND THERE ARE OTHERS THAT ARE NOT SO WELL CHARACTERIZED SO THE QUESTION TO INFORM THE INVITRO EXPERIMENTALIST OR INVIVO EXPERIMENTALIST IS TO GIVE A LIST OF SOME OF THESE MUTATIONS THAT APPEAR TO BE RECURRING LIKE THESE HOT SPOTS WE'VE SEEN AND THEN TEST THEM TO SEE REALLY WHAT IT MEANS, BUT TO TELL YOU TODAY FOR THAT PATIENT WHAT IT WOULD MEAN FOR THAT PATIENT, UNLESS WE HAVE THAT EXPERIMENTAL DATA WE DON'T REALLY KNOW WHAT IS HAPPENING WITH THAT PATIENT. I DON'T KNOW IF THAT ANSWERED THE QUESTION. >> --WE'VE SEEN REPORTS COMING OUT RECENTLY ABOUT POTENTIAL VARIANTS CROPPING UP IN HIV POSITIVE PATIENTS OR SOMETHING LIKE THAT, HOW MUCH DOES THIS CONTRIBUTE? YEAH SO THAT'S THE QUESTION, IT WAS THOUGHT THAT ALPHA CAME FROM AN IMMUNO COMPROMISED PATIENT WITH THESE PATIENTS THAT ACCUMULATED AND SOME POINT A MUTATION THAT MADE THAT VIRUS MORE TRANSMISSIBLE HAD OCCURRED AND SO THE QUESTION, 1 OF THE HYPOTHESIS WITH OMICRON IS THAT'S WHAT HAPPENED ALSO, PROBABLY AN UNCONTROLLED HIV, YOU WOULD HAVE HAD THIS ACCUMULATION OF MUTATIONS AND THEN THIS VIRUS TOOK OFF. NOW WE DON'T KNOW IF THAT IS THE CASE, IT'S JUST A HYPOTHESIS AT THIS POINT. IT'S POSSIBLE, BUT WE--YOU KNOW WE HAVE TO THINK ALSO, THERE ARE DIFFERENT TYPES OF IMMUNO COMPROMISED, THERE ARE PEOPLE WHO STILL HAVE PARTS OF THEIR IMMUNE SYSTEM THAT DOES FUNCTION, IT'S--THERE ARE DIFFERENT ASSPEBTS, YOU KNOW THE DIFFERENT CASES THAT LISTED THEY DON'T ALL HAVE THE SAME SORT OF IMMUNO COMPROMISE. AND WHAT YOU CAN IMAGINE IN SOMEBODY THAT WOULD BE HEAVILY IMMUNO SUPPRESSED, IS THAT THE VIRUS DOES REPLICATE, BUT IF YOU HAVE NO IMMUNE PRESSURE AT ALL, THIS SIGNIFY HAVE YOU SEEN COULD JUST ACCUMULATE RANDOM MUTATIONS THAT ARE--YOU KNOW THAT CAN BE COMPLETELY NEUTRAL AND THEY NEVER GET PUDGIERED BECAUSE THERE'S NO PRESSURE FOR THEM TO BE PUDGIERED, RIGHT? BUT IF YOU HAVE PARTIAL IMMUNITY, YOU CAN SEE SOME SELECTION PRESSURE THAT HAS OCCURRED SO CAN YOU ARGUE THAT IN AN IMMUNO COMPETENT PERSON YOU COULD ALSO HAVE MUTATIONS THAT HAPPEN BECAUSE THE VIRUS IS TRYING TO EVADE A VERY STRONG IMMUNE RESPONSE OF AN IMMUNO COMPETENT PERSON BUT THE SARS-COV-2 IS AN ACUTE INFECTION SO THAT THE VIRUS DOESN'T HAVE THAT MUCH TIME TO EVOLVE WITHIN AN ACUTE INFECTION. AND SO, THAT'S WHY THERE'S SORT OF THIS BALANCE BETWEEN LONG INFECTION, LOW IMMUNE PRESSURE, SHORT INFECTION, STRONG IMMUNE PRESSURE AND THERE MAY BE SOMETHING IN BETWEEN THAT COULD LEAD TO SOME OF THESE VARIANTS OF CONCERN. >> SO HERE'S A FOLLOW UP QUESTION FROM DR. COLLINS, YOU ANSWERED SORT OF THE FIRST PART SO WOULDN'T THE SELECTION IN AN IMMUNE ON O COMPROMISE PATIENT BE DIFFERENT THAN IN AN ANIMAL AND ALSO AS YOU MENTIONED IN AN IMMUNO COMPROMISED PERSON? BUT DOESN'T OMICRON FIT 1 OF THESE BETTER THAN THE OTHER? >> THAT'S A VERY GOOD QUESTION, IT'S NOT CLEAR TO ME WHICH 1 FITS BETTER. THERE'S SOME ARGUING FOR THE ANIMAL RESERVOIR HYPOTHESIS AND I DON'T KNOW HOW STRONG THE EVIDENCE IS FOR THAT AT THIS POINT, JUST LIKE I'M NOT SURE THE EVIDENCE IS ALL THERE EITHER FOR THE IMMUNO COMPROMISED PATIENT HYPOTHESIS. SO, I DON'T KNOW, I DON'T KNOW WHAT THE ANSWER IS. I THINK THERE HAS BEEN A LITTLE BIT MORE--INITIALLY IT WAS THOUGHT, I REMEMBER WHEN OMICOON CAME OUT, THE ANIMAL RESERVOIR PEOPLE WERE LIKE, YOU MUST BE ANIMAL RESERVOIR AND OTHERS WERE SAYING I HAVE NO IDEA BUT AT THIS POINT, I THINK IT'S 50/50 MAYBE, YOU KNOW, WHERE IT CAME FROM. >> GOTCHA. ALL RIGHT, LET'S GO OVER TO QUESTIONS ABOUT THE IMMUNE SYSTEM. SO THE FIRST PRESENTATION FOCUSED ON THE ROLE OF ANTIBODIES IN INFECTION, COULD YOU COMMENT ON THE ROLE OF VIRUS SPECIFIC T-CELLS, IN CLEARING AND HOW THAT MIGHT AFFECT THIS PROCESS. SAME QUESTION FOR ME, SO I'M NOT AN IMMUNOLOGYST SO I WON'T BE ABLE TO DETAIL BUT WHAT I THINK IS CLEAR IS THAT IN IMMUNO COMPETENT PATIENTS, THAT WHAT CORRELATES WITH CLINICAL IMPROVEMENT IS THE FORMATION OF ANTIBODIES AND I THINK THAT'S VERY CLEAR. IT'S ALWAYS BEEN VERY CLEAR FROM THE BEGINNING AND THAT IT'S ALSO VERY CLEAR THAT THE PATIENTS WHO ARE--WHO DON'T HAVE THAT ANTIBODY PRODUCTION JUST DO NOT DO WELL AND SO, AGAIN, I THINK MOST OF THESE PATIENTS WHO HAVE B-CELL DEPLETION HAVE SOME T-CELL IMPAIRMENT AS WELL. SO, BUT AGAIN THE SPECIFIC ROLE OF THE T-CELLS UNFORTUNATELY I CAN'T--I CAN'T TOUCH ON BUT CLEARLY--SO I THINK, YOU KNOW T-CELLS ARE CLEARLY IMPORTANT AS WELL, BUT OF COURSE I CAN'T SAY MORE ABOUT THAT. >> OKAY, THE NIH PATIENT WITH PROLONGED SARS-COV-2 INFECTION WAS NEGATIVE IN THEIR MP SWABS BUT POSITIVE IN THE BALL, CAN YOU SPEAK OUT, DO YOU KNOW HOW OFTEN THAT OCCURS AND DOES THIS LEAD TO US MISSING OTHER INFECTED PEOPLE? SORE IS IT LIMITED TO THE SEVERELY IMMUNO COMPROMISED? AND ALSO IS THIS IMPACTED AT ALL BY VARIANTS? >> SO YEAH, I CAN ANSWER THE FIRST PART. I DON'T KNOW HOW FREQUENTLY IT HAPPENS BUT IT HAPPENS NOT INFETAL COMPARTMENT - -INFREQUENTLY AND IT HAPPENS IN IMMUNO COMPROMISED PATIENTS AS WELL. AND WHEN THIS HAPPENED WE STARTED TO TALKING TO COLLEAGUES AT OTHER INSTITUTIONS WHO SAID OH YEAH, WE SEE THIS, WE HAVE PATIENT WHO IS COME IN AND YOU KNOW WE SWAB THEM, THEY'RE NEGATIVE AND THEN YOU ACTUALLY LOOK FOR DEEPER SAMPLES AND THEY'RE POSITIVE AND I THINK WHAT'S HAPPENING THERE IS JUST THAT YOU KNOW PEOPLE WILL HAVE MORE VIRUS IN DIFFERENT PARTS OF THEIR AIRWAY AND THAT'S WHY WE DO GO LOOKING FOR DEEPER AIR WAY SAMPLES WHEN WE SUSPECT SARKINGS KICKOFF 2 INFECTION BUT WE HAVE NEGATIVE TESTING AND WE DO THAT ON A REGULAR BASIS. AND THERE ARE SOME PATIENTS WE DON'T TRUST, DO NOT HAVE SARS-COV-2 INFECTION UNTIL WE GET THOSE SAMPLES AND THOSE MAKE US FEEL BETTER WHEN THEY'RE NEGATIVE. SO I THINK IT'S PECULIAR THAT AFTER THE BALL THAT SHE THEN HAD POSITIVE ORAL AND NASO-PHARYNGIAL SWABS. I CAN'T EXPLAIN THAT, I'M NOT SURE WHAT HAPPENED THERE OTHER THAN PERHAPS WE WERE JUST GETTING DEEPER INTO HER INFECTION AND IT'S SUDDENLY BECAME POSITIVE, I'M REALLY NOT SURE. I THINK WHAT WAS INTERESTING IN THIS PATIENT IS THAT IF WE LOOKING BACK ON IT, IF WE HAD HAD BALL SAMPLES, WHEN SHE WAS HAVING THESE MILD SYMPTOMS WHICH WE HAD BROUGHT UP BUT AGAIN IT'S AN INVASIVE PROCEDURE AND DECLINED IT, MAYBE WE WOULD HAVE BEEN TIPPED OFF EARLIER THAT HER VIRAL LOAD MAY HAVE BEEN HIGHER, YOU KNOW DEEP DOWN IN HER LUNGS AND MAYBE WE WOULD HAVE THOUGHT DIFFERENTLY ABOUT THIS CASE. I THINK--I KNOW I WOULD HAVE THOUGHT DIFFERENTLY ABOUT THE CASE. SO, TO ANSWER THE QUESTION, WE DO SEE THIS, I RECENTLY WAS AT ANOTHER HOSPITAL LAST WEEKEND AND I HAD THE SAME SITUATION A PATIENT WHO JUST KEPT TESTING NEGATIVE AND THANKFULLY, KEPT ON ISOLATION BECAUSE THEY ENDED UP BEING POSITIVE ON A BALL. ARE WE MISSING PEOPLE? I HOPE NOT BECAUSE I THINK EVERYBODY IS SO CAREFUL NOW AND ESPECIALLY IN THE HOSPITAL SETTING, PEOPLE ARE KEPT ON ISOLATION WHEN THERE'S SUSPICION EVEN WITH NEGATIVE TESTING. >> SO RELATED WHAT HAPPENS TO THIS PARTICULAR PATIENT'S ORGANIZING PNEUMONIA ONCE THE VIRUS WAS CLEARED? BUT THEN ALSO WHAT WAS THE--WHY DOES THE CDC GUIDANCE FOR OUTPATIENT IMMUNO COMPROMISED PATIENTS SUGGEST ISOLATION FOR A MINIMUM OF 10-20 DAYS? DO YOU THINK THIS IS TOO SHORT? >> YEAH, SO FOR THE FIRST QUESTION FOR THE ORGANIZING PNEUMONIA, I THINK WHAT HAPPENED IN OUR PATIENT IS THAT YOU KNOW SHE--I THINK MAYBE SHE HAD A COMPONENT OF ORGANIZING PNEUMONIA WHICH IS JUST AN IMMUNE DRIVEN PROCESS OF TRYING TO HEAL THE LUNG BUT CAUSING DAMAGE AT THE SAME TIME BUT I THINK--I THINK HER SYMPTOMS WERE ACTUALLY FROM SARS-COV-2. BECAUSE I THINK WHEN WE CLEARED THAT VIRUS OR INFLAMMATORY MARKERS THAT HAD NEVER BEEN NORMAL, NORMALIZED. AND SHE NO LONGER NEEDED OXYGEN AND I THINK THAT THE ENTIRE TIME WE WERE SEEING THIS WAS COVID THE ENTIRE TIME. WE DID WEAN HER STEROIDS SO WHEN YOU PUT SOMEONE ON STEROIDS YOU CAN'T JUST STOP THEM IMMEDIATELY AND SHE SHE WAS ON SOME STEROIDS FOR A COUPLE OF WEEKS WHILE WE'RE WEANING THEM DOWN AND SO SHE DID GET SOME TREATMENT FOR ORGANIZING PNEUMONIA BUT I THINK AT THE END OF THE DAY, THIS WAS REALLY MOSTLY DRICH BY THE VIRUS. --DRICH --DRIVEN BY THE VIRUS. THE SECOND WAS ABOUT ISOLATION, I THINK THE REASON IT'S LONGER FOR PATIENTS THAT ARE IMMUNO COMPROMISE -ED IS BECAUSE WE KNOW PATIENTS HAVE LONGER INFECTIONS AND THEY TEND TO HAVE REPLICATING VIRUS FOR LONGER AND THAT'S WHERE THAT 20 DAYS COMES FROM. DO I THINK IT'S TOO SHORT? WELL THE CDC DOES SAY IN IMMUNO COMPROMISED PATIENTS IT SHOULD BE AT LEAST 20 DAYS BUT TALK TO AN INFECT YOWZ DISEASE SPECIALIST BUT THEN WE ARE LEFT WITH TRYING TO FIGURE THIS OUT AND THAT'S YOU KNOW THAT'S WHERE IT GETS COMPLICATED WHERE IN A HOSPITAL YOU CAN ASK FOR SOME OF THESE SPECIALIZED--ELODIE, AND DR. DASS IN NLM AND ASKING THEM ABOUT CT VALUES AND WHAT THEIR THOUGHTS ARE ON WHAT'S GOING ON, SO, DO I THINK IT'S TOO SHORT? FOR SOME IT IS AND FOR SOME IT'S NOT? THERE'S REALLY NO CLEAR ANSWER THERE. I THINK FOR SOME IT'S CLEARLY TOO SHORT. BUT IT DEPENDS. >> GREAT, SO IT'S 1:00 O'CLOCK. IT'S THERE ARE MORE QUESTIONS SO IF YOU DON'T MIND I'M GOING TO ASK A FEW MORE IF THAT'S OKAY. EXCELLENT. OKAY. >> SO THERE WAS A REQUESTY ABOUT ANY CONCERN THAT THE USE OF MUTE O GENICS AS [INDISCERNIBLE] ELEVATE CONCERNS? WHAT DATA DO WE NEED TO INSURE THAT THIS ISN'T HAPPENING IN HEALTHY OR IMMUNO COMPROMISED PATIENTS? >> YEAH, I THINK THE DATA WILL BE LOOKING AT THE VIRUSES AND JUST LOOKING AT WHETHER THERE ARE MUTATIONS FOR ANY ANTIVIRAL, YOU'RE ALWAYS LOOKING AT ANTIVIRAL RESISTANCE. I DON'T KNOW IF THAT DEPENDS WHAT WAS TARGETED OR THE PARTICULAR 1 IS THE ACTUAL POLYMER ACE THAT IS TARGETED SO I THINK WE'LL JUST BE LOOKING. >> GREAT. CAN YOU SPEAK A LITTLE ABOUT WHY THERE MIGHT BE MORE SELECTION FOR ANDROGENIC CHANGE OR SOMEONE WHO'S NOT RECEIVING THERAPEUTIC ANTIBODIES. >> SO I DON'T KNOW WHY THERE WOULD BE NECESSARILY MORE, IT SEEMS THERE ARE ANDROGENIC CHANGES THAT OCCUR AND YOU KNOW I DON'T KNOW. I DON'T KNOW WHY WE WOULD EVEN SEE SOME OF THESE LIKE OMICRON, THESE ANTIGENIC SITES IF IT IS AN IMMUNO COMPROMISED PERSON, WHY YOU WOULD SEE SOME OF THESE MUTATED SITES SO I DON'T KNOW THE ANSWER. >> OKAY, I THINK WE WRAP UP WITH THE LAST 1 HERE, DO WE KNOW HOW TD TYPES AND LOCATIONS OF MUTATIONS FOR THE DIFFERENT VARIANTS IMPACT THE SEVERITY OR LOCALIZATION OF THE DISEASE FOR IMMUNO COMPETENT INDIVIDUALS AS--AGAIN WE SAW TAKEN--THEY DELTA WAS NOR SEVERE THAT OMICRON SEEMS TO BE. >> DO YOU MEAN THE LOCATIONS AS IN THE TISSUE TROPISM, OR IF THERE ARE PARTS THAT THE RESPIRATORY TRACK. SO THERE ARE FOR EXAMPLE, IF YOU LOOK AT OMICRON, THERE ARE SPECIFIC POSITIONS THAT ARE ASSOCIATED SO FOR EXAMPLE, THE WAY THE VIRUS ENTERS THE CELLS, THE RECEPTORS IT USES. IT USES A SLIGHTLY DIFFERENT ENTRY PATHWAY AND SO IT'S THOUGHT THAT THE CELLS THAT WE HAVE IN OUR LOWER LUNGS OR THE LOWER RESPIRATORY TRACT DON'T HAVE NECESSARILY THE RIGHT PATHWAYS FOR THE VIRUS TO ENTER SO THAT THE VIRUS TENDS TO INFECT MOSTLY CELLS FROM THE UPPER RESPIRATORY TRACT. SO THERE ARE SPECIFIC MUTATIONS LIKE THAT BUT WILL DETERMINE DISEASE SEVERITY BECAUSE OF THE TROAPISM OR THE LOCATION THAT'S AFFECTED BY THE VIRUSES, SO THERE ARE MUTATIONS THAT HAVE BEEN ASSOCIATED WITH THAT SPECIFICALLY, YES. >> GREAT. ALL RIGHT, WELL THANK YOU BOTH VERY MUCH, THIS IS AN EXCELLENT TALK AND CHECK BACK LATER TO SEE WHAT THE NEXT COVID TALK WILL BE, WE HAVE A FEW MORE LINED UP AND WE WILL SEE YOU ALL NEXT TIME. >> THANK YOU.