Information Session: COVID-19 and Communities of Color

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On March 31st, MSK hosted a special information session where our panel of experts addressed COVID-19 vaccine questions and concerns unique to Black and Hispanic communities.

Show transcript

Dr. Carol Brown:  Good afternoon. Welcome to the special Memorial Sloan Kettering session on Covid-19 vaccination in communities of color. We're really glad that you could join us today. I'm Carol Brown. I'm the Chief Health Equity Officer here in MSK, and I'm also a GYN cancer surgeon. I'm really excited that we have a great group of my colleagues to talk to you today and answer the questions that you've sent us about the COVID 19 vaccine, so that we can help you make the right decision for you and your family about whether to get vaccinated. Vaccines, I wanted to start out by saying for those of you that are patients at Memorial Sloan Kettering, Memorial Sloan Kettering is currently offering vaccines for all of our patients. So anyone who's been seen here who live in New York State and are aged 16 years of age or older and you can make appointments by going to the mskcc.org website and self-scheduling. And we're going to give you more information at the end of the session about vaccine eligibility in New York State and in New Jersey so that if you do want to make an appointment, you can have that information available to you. At Memorial Sloan Kettering, we are administering vaccines for our patients in three locations. One is at our  David Koch Center in Manhattan and also at our MSK regional locations in Westchester and in Uniondale on Long Island. So we add appointments every week. So we know about our availability based on the vaccine that we get every week, but we do have appointments. And if you try to make an appointment and don't see one available, just keep checking back because appointments will open up.

So I'm really excited to be joined on our call today, as I mentioned by my incredible colleagues. We have Dr. Esther Babady who is the Director of Clinical Microbiology Service, Dr. Cesar Figueroa Ortiz, one of our Infectious Disease Specialists here at MSK, Hematologic Oncologist, Dr. Melody Smith and our Clinical Nurse Specialist, Felicia Ellerbe and Dr. Louis Voigt who’s Chair of our Ethics Committee at Memorial Sloan Kettering. So I want to welcome all of them and we're going to get started, jump right into what we think is probably one of the most popular questions on everyone's mind. And Dr. Babady is going to help us with that. So, Dr. Babady, can you please give us a brief update on COVID-19 in general? We hear a lot about the variants about the new strains of the virus, and just give us an update on where we are in the New York area, in terms of our battle against COVID-19.

Dr. Esther Babady:  Thanks again, Carol, for the invitation to participate in the panel. So the question is about the battle against COVID-19 right. It's really hard to believe that it's been over a year already, right that we've been battling this virus and it's amazing to think that we are finally able to see the light at the end of the tunnel with the rollout of the vaccines. As we know now, Covid-19 is really caused by a virus that belongs to the Coronavirus family. And this virus cause severe acute respiratory syndrome, Coronavirus too. So in mouthful, so we just call it SARS CoV-2. And so, as it mentioned in the name Coronavirus is the virus belongs to the Coronavirus family. And we have known about Coronavirus for a very long time and many of them actually cause the common cold, which has been part of what has been challenging, fighting this virus, right, because it can infect you and cause absolutely no symptoms. On the other hand, you can be infected by this virus and end up in the ICU or even dying. As many of us know now in the US, we have over 500 million people that have died from this virus. So something that's definitely been a challenge. When you think about the virus itself, it's, what's called an RNA virus. And the reason I'm mentioning that is just to compare to the host like the human host. Our genetic material is containing what's called DNA and I think many of us are familiar with that. The fact that the virus has RNA, which is a variation of DNA is important to understand the variants and where they're coming from. So RNA viruses and the machinery that helps them multiply and replicate, they tend to make a lot of mistake unlike DNA, right. And so, as you accumulate this mistake, we also know them as mutation the virus ends up looking a little bit different from what it started with. So the longer the pandemic goes on, the more the virus is different from the initial virus that started last in December, 2019 so much so that now it actually looks like not a completely different virus, but a variant of the original virus. So that's what we call variant. A virus that has accumulated enough mutation that it's actually starting to look a little bit different. So we use the word variant or strains and not all variant are something that we need to worry about, right. There are hundreds of variant now because you have this mutation that occur in the virus.

What's important to know is that the CDC is actually monitoring at this point five variants and we call them variant of concern. And really the reason for that is that with some of these mutations, the virus may become more transmissible. The virus may cause more severe disease and more importantly for today's discussion, we want to make sure that when we monitor, this virus does not escape the vaccine effect. And so you may have heard of the UK variant, the Brazilian variant, and those are just where these were first identified. So the longer the pandemic goes on, the more of these variant we may see. But as I mentioned at the beginning with the vaccine finally rolling out, we have a chance to get ahead of that and prevent this variant from actually happening. And so I feel like we have a very good chance to finally get, you know, to win this battle, but it is not over yet. And the vaccine is really going to be instrumental in helping us fight this pandemic.

Dr. Carol Brown:  Thank you so much, Dr. Babady. Dr. Smith, can you talk to us about why it is so important that patients at Memorial Sloan Kettering get vaccinated against the COVID virus?

Dr. Melody Smith:  Certainly, thank you. Thank you, Dr Brown. So, you know, we know that at Memorial Sloan Kettering, our patient population is patients who take care of who have cancer and we have many caregivers who are helping to care for those patients. And many of our patients at Memorial Sloan Kettering have compromised immune symptoms. So their immune systems are not functioning at full capacity as a result of the treatment that they've received to treat their underlying cancer. So there's a few reasons why it's important for our patients to consider taking the vaccine. From the data that we've generated over the time that the  vaccine has been administered, as well as from the clinical studies that led to their FDA emergency use authorization, we know a few things that the vaccine does afford. One, it decreases the risk of a patient getting infected with COVID. And we also know that administration of the vaccine decreases the risk of severe COVID in those patients who may contract COVID, it's going to be a less severe course. In addition to that patients who have the vaccine, if they do happen to get COVID, there is a decreased potential for them to be hospitalized, which is also a really important thing and also decreased risk of death. So when we think about the potential benefits of the vaccine for our patient population, for all of those four, I think would be compelling reasons why our patients should really consider taking the vaccine if it's available to them.

Dr. Carol Brown:  Great. Thanks so much. So one of the questions we got is, is the vaccine safe. So Dr. Ortiz, could you please address that? A lot of people are concerned because the vaccine came onto the scene really, really quickly and so understandably they have some concerns about how this happened so rapidly and they really want to know if it's safe. So could you address that?

Dr. Cesar Ortiz:  Yes, of course. Thank you, Dr. Brown, and thank you to all my colleagues on the panel for allowing me to take part in this very interesting and very timely discussion. First of all, I'm going to say that there are several points that I want to make to answer this question. The first one is has to do with the pandemic itself and at that time when the studies that were carried out to test this vaccines, the time when those studies took off we were in a point in the pandemic when a lot of infections were happening in the community that allow the scientists, not only to get a lot of volunteers, a lot of participants to take part in those studies, but it also let them observe how many infections were occurring in each one of their arms while we call the arms, meaning the groups of people were being tested either with the vaccine or with a placebo, because there were so many infections going on in the community that allowed the scientists to reach the conclusions that they reached, which is that the vaccines are effective and most importantly, that they are safe. So that's one component to that the pandemic itself. Maybe if we had been in a different point in the pandemic when there were not as many cases and not as many infections were occurring on a daily basis probably, we would have not been able to get the results that we got. The second thing that I want to say is that there were a lot of volunteers, a lot of participants, as I mentioned before. I just want to share a number with our patients, which is that about 120,000 volunteers were enrolled in the trials, the three trials that were conducted to approve or to give emergency use authorization for the three vaccines that we have available nowadays, that is a Pfizer BioNTech vaccine, the Moderna vaccine and the Johnson and Johnson's vaccine. So, 120,000 patients, that's a lot of participants. Not only there were a lot of participants, but they were also members of all different races, ethnicities, ages, and medical conditions, comorbidities that allow the scientist to know that in a very diverse population, the vaccines were effective, and they were also very safe. So that's another aspect that has allowed us to know that these vaccines are safe.

The third thing that I want to say is that to this date, we have given a lot of doses of this vaccine. I just want to share with all of our patients that are listening to us 564 million doses have been administered in the entire world as of today as of this morning. We're very close to the point where one in every 10 people living on earth have received a vaccine, a Coronavirus vaccine, a COVID-19 vaccine. And of those 564 million, 150 million have been given in the United States. To this date after many months have gone by, some months have gone by providing the vaccine, we know that no serious adverse events that have been linked directly to the vaccine have been identified. So that's another part that is important to know. And in addition to everything that I have mentioned so far, there are specific agencies in our country particularly the FDA that acts as an independent agency that monitors the side effects and that could develop after the COVID-19 vaccine. So, all of those things together have led us to the point where we are right now, which is that we can say, and we can say to our patients the vaccines are safe and I really think that everyone should consider getting one.

Dr. Carol Brown:  Thanks so much Dr. Ortiz. I just want to touch a little bit on something that you said, and you know, when we're talking about for communities of color, particularly in the black community, in the United States, you know, there's a lot that goes into this question of, is the vaccine safe and you mentioned that worldwide, there were a significant number of people of color, people of African descent, people of Asian descent, Hispanic, Latino people who actually did participate and volunteer in the initial trials. But there's also a very interesting fact that I want to ask Dr. Babady to comment on about the development of one of the vaccines here in the United States and about who was actually involved and played a major role because I think that will be really important for our audience to know about that scientist? Dr. Babady, could you talk a little bit about that?

Dr. Esther Babady:  Oh, yes, absolutely and you know, this is one of those things where, you know, this vaccine involve a lot of people, right. There's a lot of scientists that participated in the development of this, but someone who has played a significant role in one of the newest technology, which is the mRNA vaccine, particularly the Moderna vaccine is a scientist an African-American scientist from the NIH, a woman called Kizzmekia Corbett. And she has been instrumental in moving that technology from something that the scientists had been looking at for several, several years to now a technology that has gone through the FDA and even some of the other independent body that Dr. Ortiz was mentioning right. So Dr. Corbett and if you guys get time, please go look it up, look at her on Google. She gives a lot more information about how they went and developed this vaccine. And she's been a major proponent of people of color getting vaccinated. And it's just an absolute wonderful testament to science and having an African-American scientist woman relatively on being leading this effort, I think is very reassuring for many of us as well.

Dr. Carol Brown:  Yes. I just want to echo that and just tell people in the audience she did several videos on YouTube as the vaccine was being developed and she has a couple that are actually would be amazing for you to have your children watch. She's an inspirational person. If you're interested in inspiring your children to go into a science or technology or engineering or medical field, Dr. Corbett is great and she explains things at a level your kids can understand. And also, you can see that when President Biden went to tour the NIH recently, he took pictures with her in the lab. So, she was really instrumental. And I think this is important because we have to acknowledge as people of color that we have really good reasons to mistrust the science and the healthcare system, and maybe particularly good reasons over the last four years that we might be mistrustful. But I think it's really important and the reason that we have assembled this panel of color for you is also they're all not going to mention this, but I'm going to tell you that every one of these individuals that you are seeing except me has really played an incredibly instrumental and key role in the diagnosis and monitoring Dr. Babady has been a world leader in this and in providing the care, Dr. Smith, Dr. Ortiz, Dr. Voigt and Ms. Ellerbe for our MSK patients with Covid and they're all heroes and yesterday was national doctor's day. So I would say, you know, we're really grateful for them, but this is just to show you that you can trust because there are people that look like you that are involved and at Sloan Kettering that are providing the care, that are getting the shots, that are watching afterwards, to make sure that you don't have a problem so that we really want to bring to you this feeling that you can trust because that's why we're all here talking to you so just wanted to really emphasize that. So next, we're going to switch up a little bit, and we're going to ask Felicia Ellerbe to talk to us a little bit about what you could expect as an MSK patient, if you come to MSK to get the vaccine, what is it going to be like? Because she has worked tirelessly in our vaccine clinics over the last three months, four months so Ms. Ellerbe, can you talk to us about what a patient could expect to experience when they come in to get their vaccine?

Felicia Ellerbe:  Yes. Hi, thanks again, Dr. Brown for asking me to be part of this session as well. So once you have a confirmed appointment for your COVID vaccine. We first ask that you complete the New York State COVID 19 vaccine form that form is to be filled out online. You'll receive a submission ID indicating that you completed the form. We ask that you bring a copy of it to your appointment. If you cannot submit it online, it will be also available for you at the vaccination site. At your visit, you'll receive information about the vaccine that you're going to receive that day, what to expect after you have your first or second injection. And there'll be a brief assessment of any allergies you may have, or any previous allergic reactions that you've experienced. We'll ask, like, have you received any other vaccines in the past 14 days? And you'll have an opportunity to ask and have answered any questions that you may still have. Once your vaccine itself is administered, you'll be asked to stay in our observation area for either 15 or 30 minutes, and that will be based on the assessment that we do prior to administering the vaccine.

Dr. Carol Brown:  Great. Thanks so much, Ms. Ellerbe. So Dr. Voigt, we were just talking about the issue of mistrust probably well-founded of the system among communities of color. Can you please talk to us Dr. Voigt about why we're all doing this? Why we're all on this call right now? Why is it so important that our MSK patients of color get the COVID vaccine? You've had a lot of experience with this. You've worked on the front lines. What can you tell us about this, about the difference in terms of Covid in communities of color? Dr. Voigt, you've got to un-mute.

Dr.  Louis Voigt:  The most famous phrase in 2020 and 2021. Thanks for inviting us and for putting us together as a group to talk to our patients at MSK particularly of black, Latin X and Asian communities of patients. The Covid-19 pandemic has unveiled one of the dirty secrets in American healthcare system, which is that we have a tale of two countries. A country for people who are affluent, educated and that group is probably maybe divided along racial lines as well. And another country where people are marginalized, they do not have access to healthcare and even when they do, they are under insured and they cannot afford it. But we often tend to analyze healthcare as a tiny little unit on its own. And I think that's the mistake that patients and all of us as physician make. Healthcare is part of a bigger society, larger society, and healthcare is the result of education. So if you do not have access to education, you do not have access to jobs, you cannot, you put yourself at risk of living in certain condition that will continue to cause your health to be deteriorating throughout your life. And that's what we often talk about a variety of factors and you would hear when you read papers even in the lay press like the New York Times or other papers, you would hear people talking about social determinants of health. It's a big term, but what it means is if you couldn't have access to housing because of traditional policies of the federal and state government, and I'm talking specifically about red lining and depending on where you live, your school system could be better, but it is not. You create a vicious cycle where you are stuck in poverty and you end up having low paying job, jobs that you cannot perform remotely. And that's what happened during the Covid-19 pandemic patients who could not work remotely had to work every day and they get exposed to COVID to the virus and many of them got sick.

Many of them ended up going to the hospital and many of them died. And I can give you a perfect example at the beginning of the pandemic in the spring of 2020, when there was a bus driver in Michigan, who ended up dying as a result of that, he was a black man. And he said that before he died, he said, I know I'm going to catch COVID and I'm going to die because all of these people climbing into the bus, they coughing and they are not wearing masks. And you have other examples of people working in the supermarket and all of that. So who fill this out these jobs, it's often blacks, Latin X and sometimes Asian Americans. So that's the primary reason you had more minority patients affected with Covid-19 compared to white patients and there is nothing racist about that. All of this is factual data. So one can understand why all of us are animated with the enthusiasm and the strong will to welcome to all of you to get vaccinated because you represent the highest risk group in our population. And if our patients with cancer also are other much higher risk of catching Covid-19 compared to the average individual. So if you are a patient with cancer and you happen to be black, Latin X, or Asian, your risk of dying and your risk of catching it, your risk of being admitted and your risk of dying is way higher. And I cannot tell you how many of our patients at Memorial with cancer, I cared for in the ICU and many of them died. So that's the reason I am pleading with all of you please do what you can and get vaccinated.

Dr. Carol Brown:  Thank you so much Dr. Voigt. And I think for our audience, I mean, that is the passion that you just saw, that we all have. We're here because we care about you and we're here because as physicians and scientists of color who work at Memorial Sloan Kettering, we are committed to making sure that no more of our patients die of this disease and that we make sure that we do everything that we can to make sure that this disease stops ravaging the greater community of color of black people, Latin X, Hispanic people, and Asian people in the greater New York area. And so I think Dr. Voigt really just very clearly laid out how we all feel and I think honestly, that's the most important message for you to take home is you're trying to make your decision is, you know, we're here because we've seen what happens and that we're now very happy that we actually have something to offer you, to protect you and your family. So we want to make sure that we answer all of your questions and concerns, so you can make the decision that's right for you and your family. And along those lines, let's get back to some of the questions about how understanding exactly how does this vaccine with this new technology mRNA technology, how does it work? I think people are used to things like the flu vaccine or when they get their kids, the measles vaccine or the mumps vaccine. But Dr. Babady could you talk a little bit about how the COVID vaccine works and maybe how it's different from something like the flu vaccine or the mumps or measles vaccine that our audience is a little more used to?

Dr. Esther Babady:  Yes, absolutely and I just, still so listening to Dr. Voigt and just taking it in because he couldn't have said it better, right, like this is like a tale of two different countries. And now we have a vaccine and we really want to make sure that people of color really consider taking the vaccine to protect themselves but also to protect their community, right, because the more of us are vaccinated the more our communities are safe. I will just take a step back and maybe describe how a vaccine works. What was the idea with the vaccine? Many of us are familiar as Dr. Brown mentioned with the flu and the measles and really the role of a vaccine is to essentially trick your body into thinking that it's been exposed to an infection. And traditionally how we have done it is by using maybe the entire virus and just making it weaker so that when it's given to you, your body recognizes it, your immune system develops antibody and remembers it when you actually get an infection that this has been something foreign and you need to attack it. We have an absolutely exquisite immune system as human being. And this is something that we take advantage of with vaccine and there's a variation on that thing. So you could use a vaccine that's completely attenuated or dead, and then helps your body figure out that this is foreign, or you can just use pieces of the virus whatever other pathogen and we're just going to focus on the virus right now. So for COVID-19 we have multiple vaccine, but one of the newer one is what is called an mRNA vaccine and this is the one we talked about Dr. Corbett being involved with and it's that novel technology where instead of giving you the entire COVID-19 virus, that's been maybe made weak, we just use a piece of the genetic material.

So, we talked about RNA and how the instruction and the genetic information for the virus is contained. So, mRNA you'll hear that as part of the virus is just another variation on that thing where the M stands for messenger. And what it means really is that the vaccine is designed to take information that the virus will use to go from the genetic material to making protein basically component of the virus and the way it makes this protein is using mRNA. So the scientists what they did is basically take the mRNA, put it in the little lipid or nanoparticle and inject them. So it's not the entire virus. It's just a little piece that's going to make a protein that's on the surface of the virus. So when you get that, your body goes, likewise, this is not human it's foreign. I need to make antibodies and making antibody to this because it's only a piece of the virus there is really no risk for you to actually become infected with that. And what is really nice about this is that once the mRNA is inside, it makes that protein, your body recognizes this. It basically gets cleaned up by your human, that immune system. So it's not going to stay around and I know that some people have been worried about the mRNA getting integrated. It wouldn't do that partly because it's not that stable, remember that this is a virus that's not really smart and makes it a lot of mistake. So it gets digested and it gets destroyed and then goes away. But then the body remembers that, and this is just one of the virus that one of the vaccines that has been developed and the two companies that makes the mRNA virus, the Moderna and the Pfizer. So those were the initial virus that got approval for use in patient.

Dr. Carol Brown:  So that's, I think a really great point that you're making because I know a lot of people have expressed concerns to me about this mRNA getting injected into our bodies and becoming a permanent part of our DNA and then maybe potentially changing. But what you just told us is that that's not scientifically possible for this particle, this mRNA, it's not possible because it doesn't hang around long enough and it's not possible because it's a foreign thing that comes into your body. And your immune system is not going to take that. It's going to kill it, chew it up and spit it out. It doesn't have the ability to replicate or reproduce itself or expand like the alien in your body. It can't. So I think that's a really important, but it's understandable why people might think that because they're not, this is a new thing, but it really, it's not possible for it to hang around and become part of your own DNA. So I think that's really an important thing to understand.

Dr. Esther Babady:  Yeah and that's what I wanted to, even at the beginning of the discussion, make the point that the genetic material is actually so different from our own genetic material, even the way it replicates. And with this vaccine, unlike the flu vaccine, which we use in attenuated virus that gets replicated in believing or not eggs, right. That's how we make the tons and tons of the vaccine. And that's why we purify and inject into you. Here we are only using a little bit, so it's not even the entire genome of the virus that goes inside the vaccine so there is like zero risk of it integrating anywhere in your body.

Dr. Carol Brown:  Great. So, I wanted to get back to Dr. Smith and just ask us, Dr. Smith specializes in treating what we call liquid tumors or cancers that are of your blood cells, your red blood cells, your white blood cells, and that's her area of expertise. And so wanting to ask her, you know, we have a lot of patients, maybe some of you that are on this call who are actively getting treatment for your cancer. You're getting chemotherapy. Maybe you're one of her patients and you've had a bone marrow transplant, or you're preparing to get one. So Dr. Smith, can you tell us about for patients, who are in active treatment meaning they’re getting chemo, they're getting radiation, they’re getting ready to have surgery, is it safe for them to get the Covid-19 vaccine?

Dr. Melody Smith:  Yeah, no I think that's an excellent question and particularly for our patient population given that many of them may be getting active treatment or some of them may be in a follow-up, in remission and to have a little bit more of a larger interval since their last treatment. You know, as I was mentioning earlier, many of the treatments that we give to treat cancer, our medications, chemotherapy, radiation, even transplant that have an impact on the immune system. And as a result of the impact that they have on the immune system, they can decrease our body's ability to mount a response for example to a vaccine. So I think it's really important for patients at our center who were getting active treatment that they discuss with their primary oncologist, whether or not really the timing for when they should consider getting the vaccine, because we know that if you have a compromised immune system, I think Dr. Babady just really did an excellent job explaining about the science of both the mRNA and adenovirus based COVID vaccines and really highlighting the important role that our immune system plays in producing antibodies to these vaccines so that we can have protection against Covid when we encounter it. So given that we know that the immune system plays an important role in patients who have had a recent chemotherapy, transplant, and the immune system is suppressed or decreased in function then we have to wait certain intervals of time following that therapy before getting the vaccine to ensure that our body mounts an adequate immune response. So the vaccine is certainly safe for patients with cancer, but it's just advisable to think about the timing in relationship to your therapy.

Dr. Carol Brown:  Thanks so much. And Ms. Ellerbe you know, you've done a lot of work actually administering the vaccine and watching people after they get it. So could you talk to us about whether, if somebody gets a vaccine, are they still able to get or transmit Covid-19 after they've gotten vaccinated and what would you advise as the best way to stay safe after you've gotten the vaccine?

Felicia Ellerbe:  So, Dr. Brown, I think we know already that it is still possible, even though we have these very effective vaccines that have been proven effective in clinical studies and even in recent real life study, right where the CDC looked at 4,000 participants first responders. We've seen that it is very effective, but it is still possible to acquire the virus and even transmit it. So we're not going to stop doing what we already know works, right. The best way to stay safe and protect others even after receiving your Covid-19 vaccine is don't stop doing what we already know works. What is that? Wear, wash and watch. Continue to wear your mask in public at all times, continue to practice good hand hygiene by washing your hands and lastly, continue to watch your distance and practice social distancing while avoiding congregate settings when possible. Okay, so we already know that that works. We're not going to stop doing that even after you received your vaccine. That is the best way for you to stay safe and to protect others around you.

Dr. Carol Brown:  Right. Thanks so much. So, Dr. Ortiz, just building a little bit upon that in terms of the vaccine my first question I have is, you know, Ms. Ellerbe mentioned it's still possible to get Covid after having the vaccine. And I think there's a lot of information just today and yesterday about the variants. Could you, you know, as infectious disease specialist, could you talk to us a little bit about these variants that everybody's reading about and whether the currently available vaccines, the three currently available vaccines actually protect against those variants?

Dr. Cesar Ortiz:  Yes, absolutely. That's a very good question. And it's also very common in our patients. As Dr. Babady explained to us very, very well, you know, these variants are just changes that occur in the structure of the virus and that in some occasions may make the immune system, it may make it hard for the immune system to recognize those viruses or those variants. The short answer is we don’t know fully yet, however, we do have a glimpse of hope in some studies that are being carried out. remember there were the clinical trials that initially approved the vaccine. and what those trials told us was the vaccine is very effective at preventing. symptomatic Covid-19 that is an infection that gives the symptoms, but there are other trials and other studies that are currently being carried out and are still being conducted that are looking at all these other questions. Some of those questions are does it protect me against this variants. So far, there seems to be evidence that is coming out, that at least this mRNA vaccines that is the Pfizer BioNTech, I'm sorry, and the Moderna vaccine offer a very good protection against some of the variants that were mentioned before the UK variant and the South African variant, meaning that those sorts of variants that appear initially in the UK and in South Africa. So we are hopeful that those vaccines, the mRNA vaccines are going to be protective against that. Now we will have to continue to see once those trials continue to provide us with results, have continued to provide us with data. We should have answers to this and many other questions that are very common, but so far the evidence that is starting to come out looks very good. So there's reason to be helpful for sure.

Dr. Carol Brown:  Great. And then could you also address for us Dr. Ortiz about side effects when people get the vaccine because again, you've overseen and been responsible for thousands and thousands of our patients getting the vaccine, what kind of side effects can somebody expect?

Dr. Cesar Ortiz:  Well, the way to answer that question is side effects are common. However, they are mild, meaning that the vast majority of side effects that patients are going to present, even though the vast majority of patients are going to have some form of those side effects are going to be mild and they are going to be transient. The vast majority of the side effects do not last more than 48 hours. In some cases, it may last about a week in very, very rare cases. But the vast majority of patients will only have symptoms for about 48 hours. Now that symptoms are those, the most common symptoms are headache, chills, sometimes you can have a fever, sometimes you may feel fatigued. You may have a headache and also the other very common side effects are what we call local side effects, which are the side effects that you present at the site of the injection itself. And those side effects may be pain, maybe redness, maybe swelling but again, these are transient. Sometimes in certain cases, patients may need to take dose of Tylenol for example, or Ibuprofen, Advil, some of these over the counter medication and the side effects really disappear very quickly. So, we have not really, as I mentioned before, in the previous question, we have not really seen any side effects that are serious and that have been directly linked to the vaccines. So that's something to keep in mind. So this vaccines, again, continue to have a very good safety profile, meaning that they tend to have very common but mild side effects.

Dr. Carol Brown:  Great. Thanks so much. So, Dr. Voigt, one of our listeners asked if African-Americans have been impacted so heavily by Covid and communities of color, as you explained, doesn't it follow that people of color and patients of color are going to be more likely to have side effects and are they more likely to have long-term side effects from the Covid vaccine?

Dr. Louis Voigt: This is interesting to look at it that way. The reality is the reason that certain communities and remember in New York state and particularly in New York city last year, around that time, it was primarily black and Hispanic, Latin X and also Asian American, but to a lesser proportion. We were bursting at the seams of hospital in the hallways, in the emergency ones, in fact, being turned away in some instances until they get sicker. So, it does it at the end of the day, we need to be very clear. There is no difference genetically speaking, or you mainly speaking or scientifically speaking between what we, as human being construct as black, white, and all of that. In fact, I remember vividly my kids asking me, what do you mean this person is white? They look like beige and all of that. We created this construct to essentially create differences between ourself. When you operate Dr. Brown on the white woman or a black woman, they all bleed. They all have the same ovarian cancer that you are trying to save their lives from. So, the reality is there are no difference between a white person, a black person, an Asian person, when it's come to having an infection.

However, within each race, there are people who are going to be at higher risk, depending on a variety of conditions. Some of them have to do with their socioeconomic conditions. Some of them have to do with the chronic illnesses that they are fighting and that's the reason I said, if you have cancer and you receiving immunotherapy, lymphoma leukemia, that Dr. Smith treat every day by giving patients chemotherapy and bone marrow transplant, this patient immune system is affected by this type of cancers and their immune system also when, even when they are being treated their immune system take times to recover. And that's the reason she has to counsel her patients about when is the ideal time for them to receive the vaccine. So the reality is it has nothing to do with race that because you have more black people, more Hispanic or Latin X people or more Asian compared to white people who catch Covid-19, therefore they're going to have more side effects. I read it on social media. Remember, by the way that there was a time at the beginning of the pandemic, those of us who will remember, and I'm trying to keep all these memories in my head because it's important as we move forward as a country to remember those lessons.

There was a time on social media, do you know what we were hearing and reading that black people don't catch Covid and it was a disaster. That's what people were saying at the beginning of March and it was a disaster. So we need to remember that there are other factors that cause people to be at higher risk if you smoke, if you're obese, if you have high blood pressure, if you have diabetes, if you have cancer, particularly if you have cancer of your lungs. So, these are the factors and we should shut down the noise and the rumors and the disinformation that is happening in social media and focus on the reality that if you are at a much higher risk for Covid-19, you need to get the vaccine. I cannot repeat it enough. You have cancer you are in a higher risk group. You are fighting for your life. You are coming at MSK. We want to help you. And we are genuine into telling you that. I, for example, if I were living alone and I didn't have social contract, okay, I may choose not to take the vaccine, but I work in an ICU when people can’t breathe, I have to open their mouth and put a tube there and hook them to a machine. And sometimes they cough and despite the fact that I have mask and all of that, there is a possibility that I may forget and then I touch my eye and I can catch the virus. That's the reason all of us on that panel did get vaccinated. So, it is extremely important that as patients with cancer, you need to understand, and I'm talking to every single one of you who is listening to this conversation. It is extremely important for all of you to understand that when we are pleading with you to get vaccinated, it's because we want to save your life and do not hear people saying it's over. It is not over. When we have 80% of our population vaccinated, that's when perhaps we will be able to say we have herd immunity. So, you as a citizen of this country, as a black, Latin X, and Asian individual, you have a moral responsibility towards your own community to be vaccinated.

Dr. Carol Brown:  Thank you so much, Dr. Voigt. So, just following up on that, a couple of more kind of logistical and simple questions, first for Dr. Babady and Dr. Ortiz, you know, there are different types of vaccines available. There is three different ones. So, if you could just briefly talk about just mention what the three are and then I'm going to have Felicia talk a little bit about, you know, who is eligible to get vaccinated at MSK.

Dr. Esther Babady:  Yes, absolutely. So, we've already touched upon the mRNA vaccines and in the US the process for vaccine to go from clinical trial to actually being administrated as Dr. Ortiz mentioned earlier, it goes through the FDA and there's all these other independent body looking at them. But once all of this is done and the vaccine get what is called during a pandemic in emergency use authorization. So, the FDA said that those are safe, those are efficacious, you can give them to people. And like you mentioned, we have three of them so far that have received in EUA from the FDA. Two of them are the Pfizer vaccine and the Moderna vaccine. Those two are mRNA and we've already talked a little bit about that, right. So it's just a piece of that message on which protein to make and most of the vaccine aim at making what is called a spike protein, again on the surface of the Corona virus. So those are the first two that received approval and have been available since on November, December. And most of the information we have right now is, is about the impact of this virus.

A few weeks ago, the FDA also gave a EUA to the Johnson and Johnson vaccine. And that one is a bit different from the mRNA. It's actually called a viral vector vaccine. And in this particular instance, instead of just taking mRNA and putting it in a nanoparticle and giving it to you, what scientists have done is used another virus that the body may really mildly react to or not react at all and empty that virus and put information from Covid inside of the that particular virus. So it serves as a vector or essentially a transporter is, you know, imagine it's an empty virus and you put the virus inside and it goes inside your body and makes this protein again the spike protein. So they all are targeting the same part of the of the Covid-19 vaccine. So those are the three that have EUA approval. And last week a fourth one completed the clinical trial; it's called the AstraZeneca. It's also a viral vector vaccine. And the initial data that's coming out from the trial is showing that it also is really good at preventing symptomatic disease, so severe Covid or death, which ultimately all of these vaccines are doing and it's really the important thing. And as Ms Ellerbe mentioned, some of the data now is showing that some of these vaccines actually even prevent infection so it's not just that you're not going to have symptoms. You're not even going to get the infection in a great majority of people. So those are all just really, really good. And to everybody's point is, you know, these vaccines are really good. If you get offered any one of these three options and soon fourth option, the side effects are mild and to Dr. Ortiz point they are transient. So, any of these vaccines would be really great option to take.

Dr. Carol Brown:  Dr. Ortiz could you just focus on, so on MSK, I have a medical record number at MSK, and I'm going to sign up, am I going to be able to choose which of those vaccines I'm going to get and does it matter?

Dr. Cesar Ortiz:  The answer is unfortunately, no, we cannot really choose, which vaccines we're going to get, or we are going to give. However, I want to put a lot of emphasis on what Dr. Babady just said. All the vaccines that we have available right now in the United States are highly efficacious at preventing severe disease and death from Covid-19. That is something that is absolutely important for us to know. The numbers have been a little misinterpreted because some vaccines have been said to be efficacious at 95% and others said 94%, others said 70% and so on and so forth. The reality is that these numbers are not comparable. These vaccines cannot be compare one to another. The way to answer if one vaccine works better than the other is to do what we call a clinical trial, where we gave one group of patients one vaccine and the other group of patients, the other vaccine. And then we see how they work in those populations or in those groups of patients that has not happened so far. So, we cannot really compare one to the other and the other thing that I wanted to mention is that this vaccines, the studies that were done to approve this vaccines were done in completely different settings. For example, the Moderna vaccine was done exclusively in the United States for example. The Pfizer vaccine was only in the United States, but also other countries like Brazil and South Africa and so on and so forth. Those were done earlier as well during the pandemic. Whereas the Johnson and Johnson Jansen vaccine was assessed at later during the vaccine, when we already started seeing, you know, different circumstances, we already had treatments, we already had all sorts of other things that were that are also important to take into account whenever we want to assess how this vaccines do. So the best vaccine that you can get is the one that is available for you. Whenever you come to your appointment, whatever vaccine is available that day, that's the best vaccine for you and that's the vaccine that you should get.

Dr. Carol Brown:  Thank you so much. That's such an important point. So, Ms. Ellerbe we touched on this earlier but can you tell us again who are we able to vaccinate and I just want to mention, you know, Dr. Ortiz said we can't control it. And again, for those of you live in New Jersey, you know, it is the state government in New Jersey and in New York State that control all the vaccine for everyone in that state. So any healthcare institution or CVS or Walgreens or anything in New York state is determined by the state government and the state health department, they control the flow of the vaccine. So at Memorial, the reason we can't be a hundred percent sure how many appointments we're going to have available next week is that we don't know until like a week before how many doses we're getting and what type of vaccine we're going to be given, you know, until that week before, and that's basically the same thing in New Jersey as well. So, I really want and you know, unfortunately right now, because of governmental things beyond our control if you're an MSK patient and you live in New Jersey, we are not allowed by the New Jersey government to give you a vaccine, even though we have places in New Jersey. So please write to your Congressman and your mayors and everyone, and say, you want to be able to get vaccinated. but Felicia is going to talk to us about, again, this is an important message for us to hear who, who can we vaccinate at MSK?

Felicia Ellerbe:  So right now today, MSK patients aged 16 years and over can get a vaccination. So if you have an MRN number, a medical record number, you're a patient at MSK, you live in the state of New York and you are aged 16 or older, we can vaccinate you, you can go onto our website and schedule your vaccination appointment. At the end of this session, we're also going to provide additional resources where you can check other eligibility criteria. But today 16 years old and older patients at MSK who are New York state residents can make a vaccination appointment.

Dr. Carol Brown:  Great. Thank you so much. So I have a couple more specific questions about the vaccine. So, Dr. Babady is this, you know, we heard about these variants and things. So is this a vaccine like the flu vaccine that we're going to need to get every year or are we going to need to get booster shots for the Covid vaccine do you think?

Dr. Esther Babady:  Yes, that's an excellent question and as all my colleagues have said, right, I feel like we are still learning. The clinical trials have ended, but one of the things that happens with the vaccine data is that we keep monitoring all of these people that were in the trial to see how long the immunity lasts and so far most of them are still immune. Because of the variant and because of the nature of this vaccine depending on how we deal with the pandemic, right, as the more people get vaccinated, the less variants are able to develop, we may get ahead of that and not necessarily need a booster but it is likely that, you know, it may end up being something like the flu vaccine, or maybe not exactly like the flu where we get it every year, because the flu also develops a little bit differently as far as mutation, but it might be every two year, but I think all of this is going to be determined by when we get ahead of the pandemic and we are not quite there yet, like someone said, it's not over, right. And because of that, a lot of these manufacturer of vaccine, so Pfizer, Moderna, they all already are looking into that information. Do they need to change or update the vaccine, the current vaccine to include the variant or at least what the vaccine looks like? No, so that this vaccine can be tweaked a little bit and given again. So, I don't think we know the answer to this. I think we're going to have to keep, watch and see how long we remain immune to this first and second to see if more variants develop, hopefully not. And are we going to need a vaccine specific for that? But I hope that, you know, the immune system, like I mentioned earlier is exquisite, right. While you're presenting it with this particular form of the vaccine, you know, there is enough similarity between that. And even the variant that I don't think it will completely zero. I think we'll have some protection and might just need a little bit of a boost from now and then, so there's hope for sure.

Dr. Carol Brown:  Great. So, I just want to say briefly, you know, people wonder if I already had Covid so I don't need to get the vaccine. That is not true. And we've actually had some change it used to be that you were told if you had Covid, don't get the vaccine for three months, but that has even changed. And it's very important if you've had Covid that you do go ahead and get the vaccine. If your questions have been answered satisfactorily and you feel like this is the right decision for you. Don't let the fact that you already had Covid keep you from getting the vaccine because there are variants, you could get it again and it's really important. So, the last thing I want to touch on before we kind of talk a little bit more individually about why for us, it was important to get the vaccine. Dr. Smith, can you talk for this audience in particular about their ongoing cancer treatment and screening and follow-up visits and why it's so important that our patients still follow up with us even though the pandemic is going on?

Dr. Melody Brown:  Yeah, no I think Dr. Brown, that's a really important point, you know, at the height of the pandemic this time, last year and into the spring and summer, a lot of doctor's offices, ERs weren’t seeing their routine care of heart attacks and strokes. And I think it was something that many of us scratched our heads about wondering what was happening with the patients who still have these ongoing co-morbidities that might still cause issues for them, even in the setting of pandemic. And you know, now that we're over a year into the pandemic, there is a lot of hope with the development of these three vaccines and another one on the horizon potentially. As more and more people are vaccinated that we are going to come out of this and we also have had a really good discussion today about the importance of trying to ensure that there's timely vaccinations so that these variants that are emerging don't continue to emerge or cause a situation where the vaccines are not as efficacious. So, you know, when we think about ongoing treatment, either for cancer or other underlying health conditions, it's very important to ensure that we maintain our follow-up and our treatment so that when the pandemic doesn't we can be in is, you know, healthy and well have a position to continue on with our lives and enjoy interactions with our families and loved ones once this is all over. So I think that's really important. And I think Ms. Ellerbe mentioned earlier on, you know, we know now again, over a year in what we can do to, when we go to our doctor's offices, when we go to our appointments what we need to do to help to protect ourselves, wearing a mask, social distancing, washing our hands. And when we are not at the doctor's office and when we're going about our day-to-day lives, really minimizing large crowds again, as a part of social distancing. So I think we have a lot of tools, ways to keep ourselves and our families safe and healthy but continuing on with your treatment again for cancer care or other underlying health conditions is going to be really important so that we can move on from the pandemic and continue on with our lives.

Dr. Carol Brown:  Thank you so much, Dr. Smith. So, I think we're going to end on talking a little bit about from each of us about why for us personally it was important to get vaccinated and I do want to emphasize I think Dr. Voigt just said it, you know, again, this session is not to tell you, you have to get vaccinated. We really, we recognize that everyone knowledge is power and we want to make sure that you have the knowledge to make the decision that is right for you. And for this audience, if you have a cancer diagnosis and we may be some of the doctors that treated you or treated a family member, Dr. Voigt explained to you why we're here. And I would ask you to think about it like this. If you're a cancer patient and you came to Sloan Kettering, you came to Sloan Kettering to save your life. And so it's really almost as simple as saying, this is something that it's not as intense as having a radical debulking for ovarian cancer, it's not a bone marrow transplant, it's not, you know a lot of the other things that we have to do for you to help save your life from your cancer. It's two injections and it can have some side effects, but if you think about it like that, you all are so brave and you've gone through so much to save your life. This is one more thing that can save your life and on the balance, it doesn't even remotely compare to what many of you on this call have already been through and come out on the other side of. So we hope that we've given you some information. So now Dr. Voigt actually already told you why he got vaccinated and why this is important because he told you he has been in the ICU. He's seen patients dying. He knows what's going on. So I want to start with Dr. Ortiz. Can you just tell the audience a little bit about for you personally why was it important to get vaccinated and why is it important for you to be here today spreading this message?

Dr. Cesar Ortiz:  Yes. it's important for me. Let's start with the second question. Why it's important for me to be here and I think is it's very meaningful for me to be able to share my knowledge with our patients, because having been a doctor in the middle of this pandemic, you know, that started a year ago and it's still ongoing to this date, I have seen our community suffer and I have seen our communities suffer disproportionately and that's not to take away the pain and the suffering that has also taken place in other communities and non-minority communities. But I have seen many of my patients who are African-American or Latin X or native American or Asian suffer from the severe disease, this disease that even if you survive this disease you may have a sequella, you may have long-term symptoms. So, I think that that's why it is so important and as you mentioned, I think that knowledge is power. And I think that contributing by sharing this knowledge is the best thing that I can do for our communities. And second, why was it important for me to get the shot? It was important because I wanted to do it for my patients, first and foremost. I am in a hospital. I work in the hospital. I go in and out of rooms and I wanted to make sure that I did not, that I was protected myself so that I could protect my patients and also it was a very exciting moment, it was the last thing that I did last year. I got my first shot on the 31st of December at 6:00 pm before I left home that was the very last thing that I did. And I felt that I was taking part of something very, very big, which was our first step towards defending this pandemic. So I want you to feel the same type of excitement that I felt. so there you go. That's, those are my reasons.

Dr. Carol Brown:  Thank you. Ms. Ellerbe, can you address those points please?

Felicia Ellerbe:  Sure. So, I feel very passionate about this subject matter. It was important for me to get vaccinated, to protect those around me, my patients, my family, my mom, who's an older person with health challenges herself. It was very important I felt for my circle to see me get the vaccine and do okay, because I knew that that would have an impact on their decision to get the vaccine or not. I trusted the science and I thought that it was that important. And I also think that it's important for us to be part of panels like this, because there's so much, so much misinformation out there. There are so many elements that would like to plant seeds of distrust and doubt and everything in our community. And I just think it's so important to take the real information, the true facts and put it out there so that people know that what's out there floating around on social media is not, that should not be where you get your information. So I think these types of panels are so vital, very vital.

Dr. Carol Brown:  Thank you so much, nurse Ellerbe. Again, she's a frontline hero in this battle and we're very grateful to her for her work. Dr. Smith, can you please address why you're here today and why it was important for you to get vaccinated?

Dr. Melody Smith:  Yeah. So, I'll also start with why I'm here today. I would echo Ms. Ellerbe’s point that I think that it's important for me personally, and I think for many of us to model the understanding of the vaccine and to share our knowledge. I have always very long had the perspective that all of the education and understanding that I have gone through and where I am today is not about just me or my agenda, but really about giving back to my community, to my family and so I think it's really important because I know how, when I see someone who looks like me, either a woman or an underrepresented minority, a black woman, sometimes hearing that perspective helps me to see, oh, that's somebody who I can relate to and so I hope that what I share today may help to allow someone else to understand and maybe take down some of the veils that you think of when you think of people in medicine or science that were, you know, from the same communities as you and we just want to share our knowledge. So that's really why I'm here today. And the reason why I got the vaccine is, so I live in New York, but I'm not from here. I was away from my family for a year because of travel, given concerns for Covid. And also as we've discussed, I work with patients who are immune compromised and so I wanted to be very cautious in my patient interactions that I didn't accidentally or inadvertently transmit Covid to them. So it was really important for me, for my patients first and foremost, and then also, so that I can interact with my family in a way that I feel that it's safe for me to get the vaccine. So I was eager to get it when it was available.

Dr. Carol Brown:  Thanks so much. Dr. Babady.

Dr. Esther Babady:  Yes. So, I think, I mean, it would be unique compared to the rest of the panel in the sense that I am usually not in front of patient or ever in front of the patient, right. My job here is directing the laboratory that are actually diagnosing patient with infection. 2020 and this pandemic has been something that has just I don't even know what the right word is for that right, in the laboratory, I'm used to seeing sample that are positive for infection, but never to the level that we experienced. The emotion and the amount of testing that we had to do starting in March and continuing all the way in the summer and the end of the last year was so overwhelming to me. I couldn't even imagine what my patient facing colleagues were dealing because in the lab, just, I remember March 11, when we had our very first positive, it was like, wow, it is here. We have Covid  in the hospital. Within a week, we had hundreds of positive. So it really drove the point to me that this was a serious infection and this pandemic was really bringing a lot of serious secondary infection, even in the hospital and as Dr. Ortiz mentioned this whole idea of long Covid like you have symptoms from patient even from last year that you still hear as they're suffering. And we have even patient, when we look at some of the testing that we are doing that were positive last year, and they may still be shedding, particularly our immunocompromised patient. So for me, when I think about that, I think about how much testing we had to do. I think about some of our patients having this virus around for much longer.

There was never any question about getting vaccinated. So, I want you to get vaccinated because I had that experience of, I have never seen anything like this, even from someone who usually works in the lab I don't see patients and then this communication with all of my colleagues was also the same. Similar to Dr. Smith, my family does not live or my extended any family does not live in New York and I have not seen my parents for over a year or so. That opportunity to get vaccinated and protect myself and be able to start planning right, to go visit them, I think is very important and part of the reason that I got vaccinated and when the vaccine was available for my husband, he got the J&J vaccine. There was never any hesitation. Why I'm on this panel is what everybody else say I feel like, as you mentioned, knowledge is power. I have a lot of insight in terms of this infection and I was just so thankful for the opportunity to actually be able to share this information with patients and just explain what the virus is, what the vaccine are. I usually don't have that opportunity and I'm just so thankful that I get to do this and would love to keep doing that and be available to answer a lot of questions. So, thank you again so much.

Dr. Carol Brown:  And so we're going to end with Dr. Voigt, who I think again, if you could just reprise Dr. Voigt for our audience, you know, why you're here and what experiences, I think what you said really hit me that remember what it was like a year ago. So could you just speak to that again, about your personal experience being on the frontline and your obvious knowledge and commitment to communities of color and your experience being an emphasis, like, please just close us out with your inspiration and passion about why this is so important for you to be here today?

Dr. Louis Voigt:  I would start by saying something that perhaps we have not talked about, which is Covid-19 is a preventable disease. So, we cannot prevent death, but there are a lot of things that we can prevent, including Covid-19. And because we from the scientific community put together her knowledge, we were able to come up in record time with several vaccines to confirm that Covid-19 is indeed a preventable disease, So there is last year where I was terrified and I spent sleepless nights thinking about, in fact, all of us thinking about the same thing, what will happen if we suddenly have 400,000 New Yorkers with Covid-19 and we have 200,000 beds, even when we opened the Javits Center and we have a boat in our pot to accommodate patients, remember that that's what we were dealing with. What will happen if we do not have enough ICU beds? And hydroxychloroquine was not working, it never worked. That's what we were dealing with at the height of the pandemic and to compound it, if you live in New York city or in any place in the five bowers, every 30 minutes in your street, there was an ambulance passing by, sirens blazing, even when you wanted to forget, you could not.

And that's the reason New Yorkers toward the end of spring and at the beginning of summer, we started brining on part to celebrate with all these essential workers we were trying to help their fellow human beings. I didn't go into medicine to see passively, to stand by and see people suffering and dying. I went into medicine because of the firm conviction that science can make a difference in people's life. That's the reason we do not have plague anymore. Plague is a feature of the middle ages. That's the reason we as human race, we were able to eradicate polio. That's the reason we, as a human race, we were able to avoid children dying of measles and rubella and all of that. So that's the way we also need to approach Covid-19 as a preventable disease, as a preventable illness. And we should not have these deaths lying in morgues because we as this community didn't do our part. I am here today and I took the vaccine for a simple reason because I care and I care about blacks, I care about people who look like me because, George Floyd showed it and there is a trial going on where you have so many, African-Americans so many Latin X in jail, jobless, fighting to survive and they all want the same thing to be able to send their kids to school, all of us, to achieve some degree of independence and to live with dignity. So that's the reason I'm here and I think there is one tiny thing that you in the audience listening could do to help yourself and your community, achieve that dignity. Think about it and make your decision about the vaccine. But for my part, I think you should do it.

Dr. Carol Brown:  Thank you so much. I want to thank our panel. You all are amazing. And again you know, I can just tell you that each one of these individuals have been on the front lines and their contributions have been essential to keeping our patients at MSK safe and helping treat them and helping get over this pandemic but it's not over yet. And we want to give you some information to show you. We've talked a little bit about, you know, if you are an MSK patient, but if you're not an MSK patient or if you want to try to get the vaccine somewhere else, other than MSK these are the links for New York and New Jersey that you can go to, to check eligibility guidelines, as well as most of these link you to an app or something that will let you schedule appointments. And we have a lot more information. We are also going to be reaching out to you while we are providing you some more information, those of you who have attended. And I just want to, again, thank our panelists and thank the MSK staff who put this together and wish everybody a good evening and stay safe out there. Bye.