This session will focus on trends in and impacts of the COVID-19 pandemic on preventive clinical services, something as preventive medicine physicians and practitioners we care deeply about. Specifically, our three speakers this morning will be discussing pediatric and adult immunizations, cardiometabolic screenings, and cancer screenings. After our speakers, we will have about 15 minutes for questions, so please save questions until the end, and we'll engage in discussion about what you've heard. So I'd like to introduce all of our speakers at this time, and this will be the order that they speak in. So first, we have Dr. Ram Kapaka, who's the Associate Director for Adult Immunization in the CDC Immunization Services Division. In this role, he leads CDC's domestic effort to facilitate and promote vaccination among adults, including work to address the longstanding disparities in vaccine coverage among communities of color. He began his career at CDC in 1998 as Director of the Virginia Division of Tuberculosis Control, and subsequently served in both CDC headquarters and field-based positions, including an assignment to the United Nations System Influenza Coordination Team, which was charged with preparing the UN system for a global pandemic, and an extended assignment to the New York City Department of Mental Health and Hygiene. Next we'll have Dr. Krause-Wood, who you heard from yesterday, but what you may not have heard about Dr. Krause-Wood is that she is a physician-scientist who engages in NIH-funded clinical research and clinical trials focused on adherence to prescribed therapies, management of hypertension and sex differences and health disparities research, engaging local, national, and international women and men with chronic metabolic, cardiometabolic diseases. She is nationally and internationally recognized for her research in medication adherence to antihypertensive medications. In addition to her own research, she is committed to training the next generation of scientific and academic leaders and leads pre- and post-doctoral career development programs, including serving as the principal investigator and research director for the NIH K-12 Building Interdisciplinary Research Careers in Women's Health Faculty Career Development Award, and multiple principal investigator for the Tulane Stimulating Access to Research in Residency. She also co-directs the Tulane Institute for Physician Scientists and the Faculty Physician Pipeline Program and leads the MD-MPH program at Tulane. Tulane, I don't know how she does all that. Dr. Kathy Bradley is one of my colleagues at the School of Public Health, where she is the associate dean for research. She's also the deputy director of the University of Colorado Cancer Center and holds the Bund chair in cancer research. Prior to joining the University of Colorado, she was the founding chair of the Department of Healthcare Policy and Research and associate director of cancer prevention and control at Virginia Commonwealth University School of Medicine. Dr. Bradley is an internationally recognized expert in health services research and health economics. Her expertise is in labor market outcomes of cancer survivors, health policy, and health disparities. Dr. Bradley is on the editorial board of the Journal of Cancer Survivorship and is a member of the National Academies of Sciences, Engineering, and Medicine National Cancer Policy Forum. With that introduction, I'll invite Dr. Kopaka up to the podium for his presentation. All right. Good morning. Thank you all for being here. I'm going to take my mask off so my glasses don't fog up early on a Thursday morning. Thank you for the opportunity to speak. Prior to the pandemic, the infrastructure in the United States for vaccination centered primarily on the pediatric vaccination program. With the very well-known and highly successful Vaccines for Children's program as its foundation, the U.S. immunization program could be considered one of the best in the world. The Vaccines for Children's program, which was established about 25 years ago, is credited with raising vaccination rates among children overall, as you can see in the left panel, as well as closing gaps that existed among children of different races and ethnicities with really very minimal disparities on the basis of race and ethnicity for most of the routine childhood vaccinations and across all different racial and ethnic groups. The Vaccines for Children's program, as I mentioned, is a highly successful program. It provides approximately 40 million vaccines to uninsured and underinsured children annually. It is credited with preventing approximately 419 vaccine-preventable illnesses among children, resulting in direct savings, cost savings of nearly $406 billion since its inception, and indirect cost savings of nearly $2 trillion. So those are real world positive impact. Vaccines for Children's program could be considered one of the most highly successful public health prevention programs in the United States. In contrast, no similar infrastructure existed prior to the pandemic to support adult immunization, and we can best see this illustrated through examples, and I'm showing you one example here. If you look at the proportion of adults vaccinated for influenza during the 2018-2019 flu season, less than 50% of white adult Americans received the flu vaccine that season. If we look at other racial and ethnic groups, the proportion is even lower, between 5% and 11% lower than their white counterparts. But this is not an isolated event of that particular season, but rather something that we've seen over the last many years, and I'm showing you, again, flu vaccination coverage rates in the figure here over the last 10 or so years, and you can see, again, the rates are relatively low, hovering sort of in that 30% to 50% range, and wide, sustained, deep disparities between white Americans and their black and Hispanic counterparts. If we look at other disproportionately affected adult populations, we see similar disparities in adults that happen to live in rural settings or adults with chronic underlying disease or other disabilities. These are real disparities. They have real impact on the lifespan of adults in the United States. In early 2019, well before the pandemic, CDC began to think carefully, reflecting really on 20 years of data such as these on what we could do in a meaningful way, not only to raise coverage rates among adults in general, but to intervene on what have been sort of a pattern, sustained, longstanding, unchanging record of health inequity in the vaccine world. We really began that effort in 2019 by engaging with experts that we felt knew more about this topic than we could ever know because they deal with issues of health disparities and inequities all the time. We talked with people from across different disciplines, not only public health and not only health systems, but people from faith-based communities, from academia, from higher education, and so forth. What we learned from those conversations is that really to address these issues would take a comprehensive approach that focused not only on equipping influential messengers and improving access and availability of vaccination services, but really doing this work deep in communities where people live. We began to think and develop an ecological model, which is illustrated here, where the vaccinated individual is actually influenced by forces at multiple levels, at the national level, the state level, the county level, and finally, in their own neighborhoods where they live and work and interact with their friends and neighbors. Of course, the pandemic hit in early 2020. Very early in that experience, my colleagues and I began to think about what would we do once the vaccine became available? What should we do? We took the lessons that we learned that are illustrated in this slide very much to heart and began to build and design a comprehensive program designed specifically and intentionally to implement this type of strategy at multiple levels. We recognized that we needed to build a program that was built on a foundation that kind of implemented the advice that we got. We needed to equip national messengers, fund national organizations that could develop messages and disseminate them through their chapter networks across the country. We needed to work with community organizations, some very small community organizations, to reach people where they live and work. Then finally, we needed to do messaging in a different way than we really have ever done before, taking advantage of technology and digital media, social media, and so forth to engage the entire population, particularly communities of color, in why vaccination against COVID-19 was really critical for their health, the health of their families, and their communities. In 2021, as I mentioned, just as the vaccine was becoming available, we implemented this program. Very early in the effort to initiate COVID vaccination of the public, it became very apparent that without a concerted effort to advance vaccine equity, which is a term that became something that was known to the public all of a sudden, that without those kinds of concerted efforts, the same patterns that had been seen with every other vaccine, at least on the adult side, would emerge with the COVID vaccine program as well. You can see in this example from early 2021 from Chicago, the left figure shows the distribution of the population on the basis of race and ethnicity, with the darker blue illustrating neighborhoods that are predominantly white, the lighter blue predominantly communities of color, and the right panel is the proportion of adults in those communities, those same communities that were successful in getting their first dose of COVID vaccine. This is February of 2021. You can see the obvious correlation between the two panels. There was commentary in the press and in other circles, such as what you see in that clip or that quote from USA Today, that vaccine distribution was not seen as fair, and it wasn't fair. Now, over a year and a half, or I guess a year and a half later, through the efforts, really multifactorial efforts at the federal level, at the state level, and at the local level, and across different agencies, what we see is that what were pretty wide disparities on the basis of race, ethnicity, and the COVID vaccine implementation program, most of those disparities have closed. You can see at the far right of the figure there, the proportion of adults, the proportion of white adults that have received at least one dose of the COVID vaccine is nearly indistinguishable from the proportion of black and Hispanic counterparts who have also received at least one dose. Again, obviously, there were many factors that drove the closure of these disparities, including employer vaccine mandates, for example, but we shouldn't minimize the impact of the work that has been done in communities in partnership with a variety of organizations. There we go. All right. And so, what you see here are data, really, that we received from our partners, from the Partnering for Vaccine Equity Program, and you can see this kind of work through the investment of $156 million in federal funding, that most of which went to over 500 community-based partners to reach nearly 180,000 spokespeople, reach providers, reach people where they live. This was one of the single largest investments the federal government made in a concerted effort to address longstanding disparities. Now, I want to take us back in time to the dawn of the pandemic, to the beginning of the pandemic, to tell you the story of what happened with the pediatric vaccination program. It's a very, very different story. Despite having a robust infrastructure for pediatric immunization, one of the best in the world, it was really not sufficient to counter the forces of the pandemic, and you can see in this slide, which illustrates the differences week by week in vaccine ordering providers, ordering vaccine through the Vaccines for Children Program, those orders plummeted within a few weeks after the national pandemic emergency was declared, and that means that the number of children that were receiving the vaccines that they need to receive to prevent all of those childhood illnesses that we thought went away were not getting those vaccines. While you could say that this was sort of the immediate effect of the pandemic, we now have emerging data to suggest that while vaccination rates among children have started to recover, they've never actually recovered back to their pre-pandemic levels. In this example from North Dakota, what you can see on the figure at the sort of upswing at the right represents the proportion of kindergartners in North Dakota who are unvaccinated for the seven routine childhood infections, and that portends sort of a potentially dangerous future for us all. What started in 2020 as a fear of in-person visits, parents not bringing their children to pediatricians for vaccination because they were afraid either their child or they would contract the coronavirus, with the COVID vaccine has become an intense politicization of the COVID vaccine, and to the extent that the COVID vaccine represents a proxy for vaccination in general, we really do fear a sustained impact on vaccination in general. If we look at this analysis among adults and adolescents across different payer types, so these are different types of insurance, different types of coverage, insurance coverage for vaccination, the claims under across those different types of payers have never recovered to the pre-pandemic mean, which is depicted in that red bar that goes across the center of the graph. So you can see sort of ups and downs, but we're still well below claims as they existed in 2019. So the message here is that without a concerted effort, without a specific effort to counter the forces that came about as a consequence of the pandemic, there is a real risk of sustained long-term declines in vaccinations across the lifespan. All right, so what do we do about it? Well, I think it really centers on the success with which we address two important challenges. Number one, we need to figure out the best way to sustain progress that was real progress that was made particularly in adult immunization, but really across the age span in reducing disparities on the basis not only of race and ethnicity, but on the basis of other demographics. And we can do that by building new partnerships and promoting activities that exist at the community level. The success with which we do that is a challenge. And then the second is addressing the risks, as I mentioned just a minute ago, of sort of these long-term declines that are in part related to the politicization of the vaccination enterprise in general. And that really transcends the lifespan. All right, well, what are the lessons that our experience during the pandemic can give us? Well, first, as I mentioned, one of the things that we started out doing on the adult side, which really has expanded across the lifespan, is to use messaging and do messaging in a very different way than CDC traditionally done, or maybe public health in general traditionally had done. And it's really to leverage social media, digital media, and other online portals to disseminate affirmative, authoritative, accurate messaging. And so what you see in this slide is an illustration of some of that work done by partners in the Partnering for Vaccine Equity Program. On the left side, you see an initiative by the NAACP, their Backstop campaign that they disseminated through TikTok and Twitter and other online chat opportunities to promote vaccination, particularly in African-American populations. And then on the right-hand side, you see a similar campaign from UnidosUS focused on Latinx communities speaking about vaccination in not only in English, but in Spanish, and using messaging that speaks to people in their communities. This kind of work is not only useful in influencing what an adult, the decisions that an adult makes with respect to vaccination for themselves, but it can also influence the adult as caretaker for their families and adults as the decision maker for their children. And what you see here is a three-phased approach that CDC implemented during the pandemic, where phase one was using electronic means to distribute messaging, promoting the virtues, if you will, of pediatric immunization to a variety of audiences. Phase two used formative research to tailor those messaging to craft messages and formats that might resonate more with a variety of different populations. And then more recently, a new messaging campaign, again, on promoting pediatric immunization distributed through a variety of online portals, including Instagram and Spotify, as you can see here. All right. The second lesson from the pandemic, and really an important one, is the value of the United States having a robust and comprehensive adult immunization infrastructure. The story I tell people is that go back in time to February of 2021, when the vaccine first became available to the general public. Do you remember a time when the vaccine was in great demand? And we had vaccine in the United States. We had plenty of vaccine in the United States. But what we didn't have is the programs, the state and local infrastructure to actually deliver that vaccine. And what you saw were people traveling to different states to get vaccinated, people sort of not necessarily being entirely truthful about their eligibility for the vaccine. The reason for that is because there was no existing infrastructure to vaccinate adults. The president's fiscal 23 budget proposal takes a first important step in trying to address the absence of an adult infrastructure in the United States. The proposal calls for the establishment of a Vaccines for Adults program, which is modeled after the successful Vaccines for Children's program that you all know and that we described earlier. And as proposed, it provides a safety net for the subpopulation of uninsured adults. The program, as proposed, comprises four major elements. One, funding to purchase all 14 ACIP-recommended vaccines for that adult population that is uninsured. Funding for national program operations, including both at CDC but also distributed across the states. And then funding to reimburse providers for the act of vaccinating their adult patients. And then the fourth element is the program to actually run that reimbursement system, which is something CDC has never done before. And then finally, the proposal calls on the government to leverage existing resources to continue some of the community-based equity promoting work that was initiated during the pandemic. Were Congress to implement, to enact this proposal and Vaccines for Adults program to be implemented, it would be a major step on the path to establishing the kind of adult immunization infrastructure that the United States needs. Why should we do it? Because we can prevent disease among adults, yes. The other reason we should do it is because it prepares us for the next pandemic. We won't see lines of cars waiting for their vaccine appointment because there's only one vaccinator in a community. All right, so really kind of in summary now, in the long term, the work to promote immunization in the United States really rests on sustaining and scaling vaccine equity efforts across the age span. And it requires engaging communities in ways that we, at least at the national level in public health, haven't done previously. And the three elements that are really at the center of the strategy for the future is to support adult immunization across the nation, for example, through a Vaccines for Adults program as proposed. Engaging people in different ways, online, digitally, through social media, through chat rooms and so forth. Talking to people where they actually receive information using language that they understand, using terminology that they use in their everyday lives. And then finally, doing this work with organizations that are of the community. This cannot be the government asking people to get vaccinated and government at any level. It needs to be friends convincing people that vaccines are safe, they're effective, they save the lives of the patient, they save the lives of their families, and they save the lives of their communities. So thank you very much for your attention, and I'd be happy to answer questions during the QA period if you have any. And I'm going to turn it over to my colleague. Thanks. All right. Well, as we just covered primary prevention, we're now going to move into areas around secondary and tertiary prevention. So I'm pleased to be talking about the impact of COVID-19 on routine medical care and preventive services primarily focused on cardiometabolic diseases. We'll cover three main topics. One, talking about the importance of cardiovascular health for individual and community health resilience. Identify the impact of COVID-19 on cardiometabolic disease prevention and management services and then end up with strategies to address the barriers and improve cardiometabolic disease prevention as well as control. So for the first, you know, throughout the height of the pandemic, it seemed like every death was a COVID-19 death. But when we look back at the data, it's important for us to remember that although COVID-19 had a significant impact in our society, the leading cause of death remained cardiovascular disease. And as you can see from this report, it is twice the rate of the deaths from COVID-19. Now, one of the most important modifiable risk factors of cardiovascular disease is hypertension. Now, it's important because of its high prevalence in our communities. Over a billion people worldwide have hypertension. We also know that it is, it has two constructs for management, including lifestyle changes with weight loss, healthy diets, physical activity, but also pharmacotherapy. And almost all patients need a combination of both to achieve the blood pressure thresholds. If you look at where we looked in the U.S. before the pandemic outbreak, what you see from this heat map is that you see the darker the areas, the higher the age-adjusted prevalence rate of hypertension. You can see it's clustered in the south, the deep south, gulf south, the areas of the highest rates, also known as the stroke belt. You may also recall that many of the areas in these deep south states were also the ones on the radar during the COVID-19 pandemic with regards to COVID-19 mortality rates. Now, as I mentioned, there are two constructs. One is lifestyle changes, and the other is pharmacotherapy, and almost all patients need both. If you look at where we looked in the patients 65 years in age and older, this is prior to the pandemic, they have the highest rate of hypertension. And just to talk about sex differences, women have a higher rate of hypertension in the 65 year and older group compared to men. What you see, the darker spots indicate high rates of non-adherence. Notice the similarity in patterns between high rates of hypertension and non-adherence. And when you put a diagnosis of hypertension with high rates of non-adherence, that usually translates into uncontrolled blood pressure and then subsequent increased risk of cardiovascular disease, stroke, heart failure, myocardial infarction. So this was the state of affairs before we even got to the pandemic. Now, they mentioned I do a lot of work in adherence, so you have to have an adherence slide. And the National Council on Patient Information and Education defined low adherence as America's other drug problem. Lack of adherence to antihypertensive drugs is the most important cause of failure to achieve blood pressure control according to the World Health Organization. But importantly, patient non-adherence is a $300 billion problem. And this was before the pandemic that we had this. So as you know, at one point in the pandemic, early in the pandemic, Louisiana, but specifically New Orleans, had the highest case fatality rate in the nation and possibly beyond. When we looked at residents in Louisiana, specifically in New Orleans, with COVID-19 who died, look at this outline of the underlying comorbid conditions. Under the cardiometabolic diseases, number one, 51% of them had hypertension, followed by diabetes, heart disease, obesity, and congestive heart failure. Of course, there were other non-cardiometabolic diseases associated with it first, but it's pretty alarming, especially after looking at the heat map we saw earlier. This, during the pandemic, really created the perfect storm. We had a lot of people with high rates of underlying conditions. We had a virulent virus that we knew nothing about, and this was translating into higher mortality rates, particularly in our vulnerable, minoritized, and marginalized populations early on in the pandemic. So another thing for us to keep in mind, you know also in these areas, and you know in the southern states, you've seen the data, but other areas also have issues with obesity. Obesity is another factor, and it was listed under those list of underlying conditions. But a study showed that individuals with obesity had a 1.61 higher odds of mortality than individuals who were not obese. In a study of over 48,000 adult patients, they looked at physical inactivity to determine if it was associated with higher risk of severe COVID-19 outcomes. And what they saw in the patients who had COVID-19, who reported consistently being inactive in the two years preceding the pandemic, they were more likely to be admitted to the ICU and die compared to those who reported being more physically active. Again, we bring back in the lifestyle factors. So importantly, and it was mentioned by my colleague in the earlier presentation, during the early stages of COVID-19, and we've been working diligently through the Community Engagement Alliance Against COVID-19 Disparities, funded by the NIH, and I'm very pleased and humbled to be one of the PIs in Louisiana for that program, the inequities with respect to COVID-19 case rates and mortality rates that we saw in our older adults and our black, Hispanic, and American Indian populations was just completely unacceptable. It's completely unacceptable. And we knew that there had to be something that had to be addressed, not only in understanding the disease prevalence in those groups, but also understanding the underlying mechanisms and making sure that we knew how to address this going forward. So all of this signaled, based on what I've shown you already, is at the onset of the pandemic, we had low health resilience. We had low health resilience. No way to really combat this. And that is an important factor in determining human vulnerability. And that vulnerability to any disease or disaster we know is a complex issue. It's dependent upon social, economic, health, and cultural dimensions. And vulnerability has two constructs, one being susceptibility, which is the degree of exposure to the disaster or the virus or the disease or the environmental exposure. Then resilience being the second construct, which is our ability to cope and recover from the disaster. So vulnerability reduction programs need to decrease susceptibility and increase health resilience. And as preventive medicine physicians, preventive medicine and public health experts, it is our call to action to help address the areas around individual and community health resilience. The good thing about resilience is that it's not like innate. It can be learned and you can change it. You can build resilience, but it's like building a muscle. It's going to take time and deliberate processes to make it happen. In our community, we need to look at our healthcare systems. We need to be addressing social determinants of health. We need to be looking at our marginalized and vulnerable populations who have higher underlying health conditions and lower health resilience just at the get-go. And we need to address these if we hope to build our resilience and be better prepared for the next disaster when it comes. So Dr. Lloyd-Jones outlined a term, if you will, cardiovascular health metrics. So instead of focusing on disease, we're going to focus on health metrics, things that are positive. And the list on the left is nothing that is a surprise to any of us. These were the same variables that came forward in the real causes of death publication several years ago. You see smoking, body mass index, physical activity, healthy diet, total cholesterol, blood pressure, and fasting glucose. And you can get points, depending on how you respond to the questions, on whether you have ideal, intermediate, or poor cardiovascular health. Won't read them all, but let's just take smoking status as an example. If you have never smoked, or if you quit over a year ago, you could be considered as ideal cardiovascular health for smoking and get two points. If you are a former smoker, but you quit within the last year, you're intermediate, and you get one point. And if you're a current smoker, you get zero points. Now, what the data have shown, as they've looked at this over time, is as you increase the number of cardiovascular health metrics, there is a significant linear relationship showing as you increase the metrics, you decrease the relative risk of cardiovascular mortality. And interestingly, you decrease the relative risk of all-cause mortality. In addition, in a study done using patients from the multi-ethnic study for atherosclerosis, they looked not just at cardiovascular disease, but looked at other diseases, like cancer, chronic kidney disease, dementia, and found a very similar relationship. As you increase the number towards ideal cardiovascular health and increase the number of health metrics, the risk of those other diseases was substantially lower than if you rated in the intermediate or the poor category. So, one of the things that we're having to deal with is we know that the prevention strategies that were population-based measures that are highly effective in controlling and containing infectious diseases and flattening the curve, we know they work, but they may have had some unintended consequences with respect to cardiovascular health. So, you know we had reduced access to healthcare facilities, there were stay-at-home orders which kept people huddled together in one living arrangement, social distancing, decreased contact to high areas like people with no grocery stores, limited access or no access to gyms, concerns about contamination of fruits and vegetables. And the implications of this is that they hindered patients' adherence to cardiovascular disease prevention. It was not intended to happen, but people's response to these mid-week but people's response to these risk mitigation measures resulted in such. So, the detection and management of thereby reduced cardiovascular health with the potential to amplify racial disparities because we know that many of the individuals in these vulnerable groups and racial groups and other marginalized communities may have been even more adversely affected to the general population. If you look at this study, a systematic review and a meta-analysis assessing the impact of the first COVID-19 lockdown on body weight, what you see is an assessment of these four studies in the first bar of data that's looking at BMI after the lockdown. The second group of data looks at the BMI before the lockdown. And this third column of data is the mean differences in BMI comparing before to after the lockdown. And what we saw was a significant mean difference in increase in BMI associated with the lockdown of 0.31. So, now we're gonna talk about the impact of COVID-19 on cardiometabolic disease prevention and management services. So, you may hear a little bit more about this because this, of course, is not just chronic disease, but also cancer. I'm just gonna highlight the cardiovascular areas of this. This was four nationally representative cross-sectional studies conducted over multiple time intervals in the US. Nearly 60,000 adults responded to the survey and we had nearly a 70% cooperation rate. Won't cover all of these findings. You can read them. But interestingly, that people with more chronic conditions, more medical conditions, and this was namely hypertension, diabetes, heart disease, were more likely to cancel or postpone their healthcare visits. We also saw that in this study, there were weak associations by race, ethnicity, and income associated with canceled or postponed visits. But it was also very interesting that anxiety, depression, and concern or perceived cardiovascular COVID-19 risk was more strongly associated with canceling visits than those who didn't have those disorders. So, the authors concluded and said, although it's an observational study, it's not causal, but it certainly signals something in such a large study that those patients with multiple cardiometabolic diseases will likely need outreach to make sure they're getting attention to the control of their chronic diseases, access to medications, and that if they have already established anxiety and depressive disorders, they may need a special outreach to ensure that they're getting the services they need to control their disease. So, when we looked at the impact on health services use and chronic disease management, Swiss electronic medical records of patients with diabetes, hypertension, and COVID-19 reported a 17% reduction in consultation, a also reduced in blood pressure counts around 35%, and a 33% reduction in hemoglobin A1C counts, signaling people just weren't coming in to check these. In Michigan, a web-based survey identified decreased medication adherence to chronic diseases. They were either just having trouble getting the medicines, they were forgetting to take their medications, and as you know, this leads to poor control of disease. In looking at the impact on chronic disease care and acute cardiovascular care, a survey of 202 healthcare professionals from 47 countries all signaled that there was a reported reduced access to care for chronic diseases, and during the height of the pandemic, only about 14% of them continued face-to-face visits. And telehealth is great, but it doesn't reach all communities. The systematic review on the care and management of patients with acute CVD also revealed decreased ACS and stroke admissions, also showed there were shortened lengths of stay in the hospital, and longer symptom-to-door lines. So, you know, you say, oh, well, gosh, there were fewer people coming in with heart attacks and strokes. That's right, they weren't being admitted with it. I'm afraid many of them were dying at home. We all heard those stories in the early phases. When looking at the impact on metabolic control and type 2 diabetes, this study in Turkey looked at patients who did not have diabetes with those who did have diabetes, and they looked at three main areas. At the top, there are multiple, you know, variables related to weight and BMI. Then there were variables related to glucose control, and then at the end are several variables related to lipid control. And what you can see is that there was both groups increase weight during COVID-19. But what's interesting, if you look on the right-hand side, and the far right-hand column, where it's BMI adjusted, what was really quite interesting was to see a significant, even after adjustment for BMI, a worsening of glucose control and triglycerides in those patients with diabetes. So the key findings were body weight gain in patients with type 2 diabetes and healthy adults, but also this is reportedly the first study to show the impact of the lockdown on worsened glucose regulation and increased triglycerides in patients with type 2 diabetes, independent of their body mass index or weight gain. So when we look at the impact on routine care for hypertension, and I told you this is one of the most important modifiable risk factors, the centers of excellence, our excellence centers of the European Society of Hypertension, did a survey. There are 52 excellence centers, including 20 European and three non-European. The median visit rates of hypertensives seen per excellence center was 1,500 hypertensive patients. 85% of these excellence centers locked down or shut down for nine weeks. So no surprise that the number of patients treated per week decreased by 90%. But importantly, 60% of the patients had limited access to medical consultations elsewhere, and 36, nearly 37% of the patients stopped their RAS blocker therapy. When we look at the impact on lifestyle behaviors on the stay-at-home orders with chronic coronary symptoms, a cross-sectional study done in France reported that 45% declared a reduction in physical activity of more than 25%. 26% of smokers increased their smoking and tobacco consumption by more than 25%, and 24% of patients increased their body weight more than two kilograms. Other things happen that are modifiable cardiovascular risk factors in the general population. This was no surprise after being through multiple hurricanes in the New Orleans area. Alcohol consumption increases, dietary quality worsens. You go to junk food and high salt, high sugar, and the food intake increases while you're dealing in these situations. So the potential impact of COVID-19 related to unemployment has also been looked at. And a study conducted in New Zealand, which is a high-income country, they modeled the indirect effects of higher CVD incidence due to high unemployment rates to pandemic-related unemployment projections. And in this, they estimated that the cardiovascular disease-related loss ranged from over 23,000 to over 36,000 health-adjusted life years. And when they looked at the additional healthcare systems cost associated with this, it ranged from 209 million to 346 million in U.S. dollars. No, you know, minor losses here. So now let's turn to addressing the strategies and the barriers to improving cardiometabolic disease prevention and control. And these are gonna be incredibly important as we look to improving our health resilience and advancing health equity, not just during the pandemic, but also after the pandemic and in preparation for the next. So we know that there were several barriers, key barriers for cardiovascular prevention. Just quickly, cancellation of health visits and screening visits, you know, not going to the healthcare system. Physical inactivity, food insecurity, and dietary equality were all very important barriers to contributing to this. So the solutions in looking at the cancellation of non-essential visits, there's many ways we can address this. One, putting into place systematically ways for patients to get their medications refilled, especially for these routine meds like antihypertensives, anti-lipids, et cetera, and also for diabetes medications. Making sure that they've got longer refills, 90-day fills instead of 30-day fills to ensure that they've got a continuous access to medications, and the use of telehealth. But we'll talk a little bit more about that. Telehealth is great, but it has to be able to reach everyone in order to be fully effective. And looking at physical inactivity and addressing that, we can coach our patients, coach our community centers, and help our patients understand that if they can't go to the gym, there's still things that they can do. If they can't go outside, they can do yoga in their home, they can walk in place, they can do short bouts of aerobic activity in a very small space in their home, and they need to be encouraged to do so. More recent data showing just doing any activity is better than no activity, and doing multiple small bouts is as effective as doing long bouts. So this can work in flexible work schedules, important that we do. In looking at food insecurity, and this, of course, dramatically impacts our vulnerable communities and must really be addressed, but the patients in our communities need to be educated on the consumption of better foods. So if you can't or you're fearful of the fresh fruits and vegetables, get frozen, not canned. The canned are high in salt, high in additives and sugars. The frozens are not. And so if you're afraid of what's out there on the shelf, do these other things and make healthier choices. And the shift for me, you can use, these are lower-priced things. If you're using legumes, lentils, and nuts as sources of protein are another way to do this, and they're non-perishable and can last a long time and not have to worry about having to go frequently to the store for other sources. So we need to be proactive in making sure that our individuals, but also our community and community leaders can educate our people about these options. So recommendations for managing cardiometabolic diseases. I'll sum up a few points I've already made. One, we may need to do and should do targeted messaging for patients with chronic cardiometabolic diseases about their disease management and disease control and how to access the lifestyle measures as well as their medications. We wanna make sure we ensure access to healthcare by providing this ongoing management, access to medications, as well as being aware of potential inequities. For instance, smartphones, internet, computers are not equally available to all. And that's been an area that may not have been as focused on, and not only in our urban areas, but in our rural areas, which has a mix of people of color and non-people of color. So we must be very aware of this and be sensitive that they may not be getting access, even though we think, well, we have telehealth, everyone has access, so we must be aware of that. So hypertension, I've talked a lot about it already, but there's several things that we can do for hypertension, including making sure people use home blood pressure monitors, make sure that they have equitable access to the health resources, ensure that if we implement virtual healthcare, that it's lifting all boats, and that they have a way, if it's conference call or telehealth or whatever, that we're increasing the adherence to lifestyle modifications as well as medications, and that we really should reach out and engage with our community partners to address the barriers and increase the team-based care approach that has the outreach to patients that have these multiple conditions, and possibly have comorbid anxiety and depression, which may increase their risk because they do not access the healthcare system. So with that, I will conclude my presentation, and we'll take questions in just a minute, and I'll turn it over to my colleague. So good morning, everyone. It's a pleasure to be here, and I'd like to add my welcome to Denver, Colorado, from the Colorado School of Public Health, and to thank Dr. Miller for the invitation, and my two colleagues who did a fabulous job in teeing up my talk. And to all of you for being here in person. How many of you are just really tired of Zoom presentations? Yes, everyone. Everyone except for my dog, who likes to Zoom bomb every single presentation I give. So this won't be quite as entertaining as that, but it's an opportunity to get to talk to all of you. So I'm going to focus on cancer. And we know that cancer screening saves lives. And then we think about, though, what happens when screening is delayed? Late-stage diagnosis. Higher mortality comes with it. Increased cost. And I'm going to talk about this a little bit more later on, but this isn't just increased cost to society. I'm a health economist. We used to always make our pitch around costs and think about societal costs. Why is it everybody should be concerned? But increased costs in cancer is something we should all be concerned about at the individual level. Driving in this morning, there was a feature on NPR, a cosponsorship with Kaiser News Network, about the rise in medical debt. 41% of adults in this country have medical debt. Cancer is the leading cause of medical debt. So when we think about a delay in diagnosis and the increased cost, which is absolutely astronomical, it affects every single one of us. None of us know what our insurance covers until we need it. And then last, the habit of regular screening is broken. Much like my puppy, we get in the habit of doing something a particular way. And once that habit is broken, it's so hard to get it reestablished. So we'll think about those things. So this is what I'm going to cover. Some nationwide patterns that we've all observed during this time. Healthcare utilization, piggybacking on what Dr. Krause-Wood just mentioned. Cancer screening patterns, bringing that into Colorado, showing what we've observed here, which are likely to be similar to some other parts of certainly the Rocky Mountain region of the country. The consequences and then discussion, and then we'll open it up for question and answer across our entire panel. There was an estimated 9.4 million cancer screenings missed across breast, colorectal, and prostate cancers. This doesn't include cervical cancers, melanomas, skin cancers, all of which can also be screened. The sharpest decline was during the shutdown period of the pandemic. And then once things opened back up, cancer screenings weren't the first thing on people's mind, and that's if they could get those cancer screenings, where there was considerable delay. We saw some recovery around July or so, and it's recovery of the baseline rate, not that bump, that rebound you would expect to see after a long period of inactivity. And then among people who use telehealth, screening was the highest. And I think this is kind of an interesting point. Telehealth, you can't get your screening through telehealth, but it shows a connection to the healthcare system. It may indicate people who are already health conscious and staying connected to their provider, but it may also be those with chronic conditions who are continuing their telehealth, and it underlines the role of the provider, all of you, in making sure people get their screenings. Those messages that you keep giving your patients that you're pretty sure they're ignoring, this would suggest that even in a telehealth environment, they're listening. They're continuing to go and get their cancer screenings, and more likely to jump back into that screening behavior if they've had a chance to talk to you. So here's the pattern that we observe. We look at breast, colorectal, and prostate screenings, and you see this huge dip. Breast comes back at about that even rate, but not with the bump we would expect. Prostate really rebounds. Colorectal cancer hasn't made it back just yet. Probably related to the prep, the time away, because once people were able to resume their lives, this wasn't the first thing they wanted to do, is to go out and get a colonoscopy, right? So, you know, it's bad enough to be locked down and put away, but now go do that. So we're not seeing the rebound there, but also a critical cancer screening. Here we look at a study from New England that found significant decrease in cancer screening for the control patients compared to the pandemic period. And you look at how there was already down in some areas and then starting to rebound. Diagnosis quickly in the months following the pandemic period, it suggests that misdiagnoses may be less than originally proposed. But this was the only study that found that, that suggests that these differences weren't so big and there was this jump back. But if you're the person that then misses your screening, the 58-year-old woman who decides, well, gee, I need a mammogram in March. Your health system then cancels that appointment. You've got to reschedule, get back on the document, go in and find that you have a lump and now you have stage two breast cancer instead of stage one. You're pretty sure it's because of the pandemic. It's because of this shutdown. And there are many, many cases just like that, that we're seeing in our own cancer center that have come out. People coming in with later stage and that data are just now becoming available that we're understanding the impact. Those who continued on hormonal replacement therapy but did not get screening for their endometrial thickness and later being diagnosed with endometrial cancer. Symptoms that people knew they had or suspected but went undetected and then when they went to make an appointment to get seen, long, long delays experienced. Not unsurprisingly, there are racial and ethnic differences. Just like we saw with screening and with cardiometabolic disease, we see this in cancer screening. These populations are at high risk to begin with and they were less likely to come back in, particularly among Hispanics. In cervical cancer screening, prevention and treatment is one of the places that we had almost eradicated cervical cancer through pap smears. Really brought down the rates. At one point in our history, cervical cancer screening was the leading cause of cancer death among women. With pap smears and now HPV screening, we really changed all of that. The pandemic brought that down. HPV vaccination rate dropped by more than 70% in March. Cumulative rates of over 1 million doses. Cervical cancer screening decreased by 94% during the stay at home orders and about 35% below the historical average during that time. A place where we had made remarkable improvements, remarkable strides in improving outcomes for women. So why did screening rates decline? Unemployment and screening is one of those relationships. Unemployment, you're out of the workforce, you lose your healthcare insurance if you are under the age of 65. You also lose that connection to other people. And for those who work in places that encourage cancer screening, you lose that messaging. So there's this relationship, this positive relationship between the decline in employment during that time and the decline in use of healthcare services, including cancer and screening. So a 1% increase in unemployment led to an increase in mortality for breast and colorectal cancer, this downstream effect that occurred. Change in attitude. Among the elderly, the high enthusiasm for screening was the greatest factor for those who chose to continue the screening. So people who were already dedicated screeners went back. Those who were tenuous, unlikely to go back. So this is the group that you're always urging, always reminding, that really benefit for those reminders and that connection to you. And they're the ones who tended to really drop off. They were reticent to begin with. And this just reinforced that behavior. So that, again, underscores the role that you all play in continuing to keep individuals in there and getting these critical screenings that they need. As a result, 36,000 missed breast cancer cases during this time, 18,000 missed colorectal cancer screening, 2,600 missed cervical cancer screenings, under which the population of missed cases apply across the board. Unclear, I'm sorry, to which populations these missed cases apply. Lung cancer screening actually did not show as big of effect. And that's because very few people get lung cancer screening. Given the low baseline rates, it's hard to dampen it down further when it's already a low cancer screening. So we didn't see that same level of a decrease as it related to the pandemic. Turning now to what we see here in Colorado, we were supported by a grant from the National Cancer Institute to take the Colorado Cancer Registry and merge it with the all-payer claims data. And for those of you that are unfamiliar with these data, they're claims, medical claims data that we get from both public Medicaid, Medicare, as well as private payers, pretty much across the board. And we were able to merge it then with the Colorado Cancer Registry, and we can start to see a change in late-stage diagnoses. And we can take all the claims without that merger and look at screening patterns. And what we saw is that rates increased faster coming back from Medicare managed care relative to fee-for-service. So these managed care programs actually do do a good job of encouraging preventive behavior, even following the pandemic. Screening rates also recovered quicker in urban areas where access was easier. And they increased for most payers following the months of the lockdown, but not ever to the pre-pandemic levels. Here's the thing about this data. It's all-payer, meaning if you're uninsured, you're not in that data, where we would expect to see a much greater decline. Overall, healthcare utilization in Colorado dropped by 26% from the start of the pandemic in March of 2020 to the end of 2020. Visits by cancer survivors decreased 22%. These are people who were already diagnosed and treated for cancer. Their follow-up visits for recurrence, screening, and regular surveillance decreased by 22%. And it's indication that most cancer survivors skipped their primary care, but kept some of their specialty care visits. And by the way, those that were in the middle of chemotherapy experienced delays, as did those in radiation. Our health center at CU Health was able to keep some of their infusion bays open, but there was a delay of those in the middle of treatment. And think about how you would feel if you were that person. These show the rates of rebound in screening mammograms by payer. And there we see that our best, our biggest rebound comes from those who are covered by private insurance, something that you've heard that access to care is what drives whether or not you get care. And the biggest key of access is your healthcare insurance. Privately insured do better. We show that managed care across the board does better than fee-for-service. And then our lowest area, down at the bottom, is our Medicare fee-for-service and Medicaid. This pattern persists across the board here with these declines, Medicaid, regular to commercial insurance. So these disparities that we see in cancer are going to widen in the next few years. It's so discouraging as someone who studies cancer disparities and what we can do to minimize them to see that we've only widened them again, even with Medicaid expansion in a state like Colorado, as opposed to where Dr. Carralzo-Wood is in states that are less likely to expand Medicaid where we expect those differences to get much wider. And this just continues to repeat this story, comparing fee-for-service to Medicaid managed care. And this focus on prevention, how much it matters in a managed care system, as opposed to fee-for-service and it's left up to the individual. So what are the consequences of mis-screening and the implications for our healthcare delivery system? The increase in late-stage disease. Appropriate cancer screening can help early discovery. We all know that. This increase in late-stage disease, where treatment is less effective and a heck of a lot more costly, is going to be part of the outcomes that we see post this period. Increase in late-stage cancer. This one study in California found that a significantly lower percent of patients were diagnosed with stage 1 breast cancer and is significantly higher with stage 4 metastatic disease. Again, an area where we had made such incredible progress in preventing late-stage disease and preventing mortality from breast cancer. We're now going to see that bump up again. Consequences are increased prevalence of preventable cancers, increased costs due to late-stage cancers, higher mortality, and greater inequities as a result of this period in cancer alone. And going back to the cost, many insurance plans are now high-deductible plans. And a lot of folks choose them because they're so much less expensive. And it increases what they perceive as their monthly out-of-pocket cost. It really catches up to them when diagnosed with a serious disease. The cost of cancer treatment, especially with the new immunotherapies and oral treatments, which are incredible breakthroughs. They're really important for people who are employed and getting treatment because they can take them orally. But they're absolutely unaffordable. They're over $150,000 to get these kinds of treatments. If you're in a high-deductible plan and you've got outrageous co-pays, there is just no way. But you cannot quit your job because that's your only source of health insurance. It's estimated that the average American family cannot afford an unexpected payment of $400 in a single month. That is how close the margins are. Get diagnosed with cancer and at a later stage, and it really changes. It doesn't just change, though, for those who can't afford a $400 fee. It changes for all of us. Very few people can afford the out-of-pocket payments associated with the treatment of $150,000 or more. It makes a difference. So this is something we all have to pay attention to, not just the mortality messages that each of you diligently give your patients, but to talk about the financial impact on them if they are diagnosed with the disease. That's not what they're thinking about. Everyone's terrified of cancer, but to get this financial impact that goes with it is going to lead to the non-adherence. They're going to not adhere to these drugs that are very dose-sensitive. So they cut back and they get all the side effects but not the benefit, not doing them a favor there. And mortality of cancer goes up when a patient reports having financial distress. So the downstream effects are incredibly important. This rising cost, as I just mentioned, moving forward, I think it's a time that we need to call on companies, on healthcare providers, on those in the nonprofit sector, and others to really step up. And that's a quote from President Biden when he launched the second phase of his Moonshot Initiative. Now, we haven't heard anything about the Moonshot Initiative since Ukraine, since all the other catastrophes that have happened. This has just disappeared completely from the news. It's disappeared from my world as a leader in a cancer center. We're not hearing anything about this, meaning that all of the money and all of the investments and this was mostly going to be around prevention, to cut cancer mortality by 50 percent, largely due to prevention. None of that's being mentioned. So our big opportunity, I think, to make progress and move forward has been overtaken by other things in the news. So it comes down to the providers, to the employers, to the individuals to take that responsibility up and not incur these incredible mortalities, the loss and the gains we've made over time, and also these costs. There are ways to improve screening rates, expansion of coverage. Medicaid expansion makes a huge difference to the low-income uninsured. No co-pays for these screening, even small co-pays of those less than $10 can make a dent into whether or not a person gets screened. And then at-home options where available. Also targeted, intensified efforts to those who are less likely to be the ones that come in. Systematic nagging does have an effect and a positive net. We all know that. And then personal invitations wherever possible. That connection to you, even if through telehealth or electronic means, makes a difference. So thank you all for your time. Thank you for your presence. It's been a pleasure to talk to you this morning. Thank you to all our speakers. What a wonderful group of experts we assembled. I hope you agree. So much good information there. We want to get right to questions. We don't have a ton of time. So if you want to move to the two microphones here and you can just line up behind the microphones and we will just fire off questions. If we can try and be as concise with the question and maybe the answer as we can be and get through as many of these as we can. That would be great. And I think our speakers probably have a few minutes afterwards if there's some lingering questions. So I'm going to start over here on the right. I feel like you guys get ignored a little bit over here because the podium's over here. So we're going to start over here. Go ahead. Hi, I'm Lily Buzhaki. I'm an addiction medicine doctor. So, you know, I work both in an inpatient or residential setting and then also outpatient. And I, you know, so I have access to these patients who stay about a month or more in our residential facilities. And then they I see a lot of them for MAT. I'm not a primary care doctor, but, you know, I definitely do as much screening as I can. The issue is that insurances refuse to cover anything that we do outside of just providing the Suboxone. And as much as I urge my patients to see their primary care doctor, lots of them, most of them don't have one. And those that do just, you know, don't feel like making an appointment, especially since they're already seeing me. So I was wondering if someone could comment on that. Yeah. Tough issue. Is this on? I think that's a really tough issue. I don't know if anybody wants to comment. But what I was thinking about when I was listening to all these presentations was we have this health care system, right, that drives what we have seen here to some degree. And some of this is as a result of our system, right? And you're describing some of those pitfalls of the system we have. I think there's this bigger issue, and maybe that's another talk somewhere else in the conference about our health care system and how it's organized and financed. Sure. And I'll make a big point. Okay. Thank you. An excellent point, by the way, is that it's set up with the health insurance point I made about access being what determines whether or not you get care. And the reason why managed care organizations do a better job and focus on prevention is because of the business case. They're held accountable for the cost, and they don't want to have to pay rising costs, and so they put a lot more into prevention. I think it's making that business case at the end of the day for the health insurance companies that they need to focus on prevention, no matter where it comes from, and that you have these high-risk individuals, but you can cut their overall cost. Now, that's not for you as the individual provider to go out and to make that cost, but it's certainly something for us to make that case and to do a better job of it. So thank you for that point. Sure. Thank you. This is Lynn. I'm from UW Medicine, University of Wisconsin, Preventive Medicine Residency. I have a question for Dr. Croso-Wood about adherence of cardiometabolic disease. During COVID-19 pandemic, I think it also inspired the healthcare system with new models to deliver care. For example, in the VA system, there is this pharmacy medical management, which in between in-patient visit, in-person visit with a primary care physician, a pharmacist can call the patients and collect their at-home blood pressure readings, glucose readings, and adjust their medication accordingly, and if their blood pressure is high or glucose is high, they can call the patient in to see a provider earlier. So with the presentation that we have seen decreased adherence for those care treatment, do you think those new method hasn't kicked in yet, or is it because we're now addressing the root cause of non-adherence? This is an excellent point. These models that are emerging at the VA, and they're being adopted by other institutions where essentially they're allowing even the pharmacist to manage the patients and titrate their medications if they're licensed to do so, to make sure that they're getting the control of blood pressure in a timely manner by having ready access to someone via virtual technology. So we're seeing this being adapted and adopted across, but kind of similar to what our prior question was, not everything is covered, and what we find is that what gets done is what's being paid for, and in the course of my time in hypertension and working on medication adherence, I have seen these pharmacy-led models show data indicating that it works, but they often fizzle out because there's not a payment structure for it. But I do believe that many of the insurers are coming to understand that by having the shared responsibility and improving blood pressure control across the spectrum that everyone will benefit from lower blood pressure, better disease control that comes from better adherence. So the short answer to your question is absolutely, these models, I'm hearing more about them coming back online, some new, but some are actually revived, coming back online for some innovative structures incorporating a team approach to addressing medication adherence for these chronic conditions where patients really benefit from multiple touch points and from individuals in the healthcare system that are a little bit closer to where they are in their healthcare management. So great question, and I'm hoping we continue to see these expand beyond the VA and other places. Thank you so much. Angela Michelide, ACPM Headquarters. Dr. Kopaka, you presented that 86% of the Asian population has received at least one COVID-19 vaccine. What is the reason, in your opinion, for this compared to other populations, and what lessons can we learn to assist our outreach and uptake with other populations? Thank you for the question. You know, first of all, I think it's kind of thrilling to us that sort of focus on vaccine coverage rates to see a population so, you know, enthusiastic about getting the vaccination. I think the reasons behind that are multifactorial and in many ways yet to be well defined. COVID vaccine is really not the only vaccine where we've seen higher rates of uptake among Asian American populations. And I think one of the drivers, but certainly not the only driver, has to do with sort of the cultural standards, community standards within those subpopulations in the communities in which they live. And so I think there's tremendous amount of work to be done in the coming years to actually tease out what is it about what parents teach their children about vaccination that then just gets translated into how we do things as a family, how we do things as a people. Very much in the same way that we do know, for example, that one of the drivers of disparity in the other direction in the African American population has its roots in sort of 400 years of sort of disparate and unjust treatment of a population in this culture. So, you know, you can sort of see those cultural drivers in all different directions. And I think, you know, it's a long-winded way of saying I don't have the real answer to your question other than to say that it's likely related to kind of a community level cultural standard. It's a wonderful research question, is it not? It absolutely is. Thanks. Thanks, Angela. I think, unfortunately, we just have time for one last question, and so we'll go back over here. Thank you. Hi. I'm Arlene Seed. I am the public health physician for vaccine preventative diseases. My question is, as you develop that adult model for vaccine for children, we have a touchpoint school. We put our clinics in schools. Our children get vaccinated. But adults don't have that single touchpoint. Some people, and I think this is work, we've used pharmacies as a touchpoint for vaccines. And I know that if we use them for a touchpoint for medications, we get pushback from the organized medicine area. Are there other areas that you see as possible touchpoints for adults? And have you had any pushback from physician groups in terms of using non-physicians to administer these vaccinations? An amazing question. And I think what you've touched on is the reality that what works for children actually doesn't work for adults. So the process of adults vaccinated is a very different one than for children. It's sort of going in and out. Anyway, so I think as we move forward in developing the model, first of all, I wouldn't discount the role of the pharmacies as a vaccinator. Maybe this will be better. Yes. All right. But, you know, our thinking about how to get adults vaccinated going forward really does center on the role of the pharmacist as the vaccinating professional that is more likely to see adults, you know, more regularly than their primary care provider. With respect to pushback, I think we're sort of early in the evolution of this. Certainly there hasn't been a tremendous amount of pushback from the sort of physician organizations with respect to the role of the pharmacist in the COVID vaccine implementation program. And certainly we've seen pharmacists on the adult side as an important site of vaccination for flu vaccination. So I'm, I guess, a little bit less concerned about the challenge in using, in having pharmacists as, for example, vaccines for adult providers. A second touch point, particularly for populations, at-risk populations or community health centers, which is where those populations not only get their medical care, but they also seek and obtain other services. So it's a little bit like the medical home model that we see on the pediatric side, but for adults. And then finally, another important venue for vaccination that at least existed on the, in the pre-pandemic world, and we'll see to the extent to which it reemerges as people come back to work, is employer-based vaccination. So we all know about employment-based flu vaccination, whether or not that could potentially expand to include other vaccines remains to be seen. So I think the message here is, is that we're on the pediatric side, for good reason, the pediatrician is the primary vaccinator of, of children. On the adult side, we have to actually invoke multiple different kinds of providers if we're going to get the job done. All right, unfortunately, we're out of time. We could talk a long time. So if you want to come up and maybe ask a question, that'd be great. I know people need to get on to the next session. Lots of great sessions. Hope to see you there. And one more round of applause for our great presenters. Thank you so much. And thank you for your excellent questions.

COVID-19 pandemic

preventive clinical services

pediatric immunizations

adult immunizations

cardiometabolic screenings

cancer screenings

disparities

social determinants of health

healthcare systems

barriers

cancer treatment

chronic diseases