IDSA Media Briefing: Fever Pitch: America’s Summer of Mega-Events

Jeanne Marrazzo: [00:00:00] Good morning everyone. I'm Jeanne Marrazzo, I'm the chief executive officer of the Infectious Diseases Society of America, and I represent more than 13,000 physicians, scientists and public health experts whose focus is on the prevention, treatment and cure of infectious diseases. So as you know, the World Cup officially kicks off today. Matches start today, and later this summer, the United States will be celebrating its 250th birthday. So it's a really big summer. This morning's briefing is about how infectious disease experts approach this sort of thing, preparing for large mass gatherings and what the potential disease threats really are, what should be concerned about what we cannot worry about so much. This morning, we're joined by two really spectacular experts. First will be Doctor Rebecca Katz. Doctor Katz is a professor and director of the center for Global Health Science and Security at Georgetown University. Next will be Doctor Krutika Kuppalli is an associate professor in the Division of Infectious Diseases at UT Southwestern, and previously served as the medical director of an Ebola treatment center in Sierra Leone during the West Africa outbreak in 2014 and 2015. Following our speakers remarks, we'll be opening the floor to questions. To ask a question, click the Raise My Hand button or for those on the phone, select star nine and you'll be added to the queue. I'll now turn it over to Doctor Katz.

Rebecca Katz: [00:01:37] Hi I am delighted to speak with you today. It's it's actually evening here in Malaysia, where I've been attending the Global Health Security Conference, in part to actually speak about what we're doing for the World Cup. So the tournament attracts millions of domestic and international travelers coming into close contact across dozens of jurisdictions throughout the entirety of North America. And that's including the site of the games themselves. The base camps, the unofficial and the official fan zones. And I think we all know that mass gatherings always require a coordinated infectious disease surveillance infrastructure. This particular mass gathering is extremely complicated, which is one of the reasons we're taking a bit of a all hands on deck approach. So I am the director of what we call the Health Security Operations Center, or the HSOC. And we stood the HSOC up in order to be a non-governmental public health emergency operations center. The idea is we are working independently, but in support of government in order to monitor potential infectious disease threats that might occur throughout the course of the of the World Cup, and then to also try to support mitigation of health risks. So HSOC is supported by a coalition now of more than 30 organizations. And that includes academic institutions, public health networks, private sector entities, all supporting our efforts to try to collect, triangulate and translate timely, understandable and actionable information.

Rebecca Katz: [00:03:18] So we're integrating various streams of surveillance data that includes a large variety of wastewater surveillance data. But we're bringing in lots of different feeds in order to produce a daily situation report. We are also hosting multiple stand up calls every day for for different stakeholders. And we're also able to push information directly into health care systems when it's required. So we're coordinating with global health organizations through GOARN and with the Pan American Health Organization. We've had over 700 local and state health authorities who have signed up to receive our situation reports, plus probably an additional 60 federal partners. We're also sending our daily reports to FIFA per their request. Uh, we've also set up communications directly with partners at CDC, ASPR, DHS, the military, and we're communicating our findings directly to health departments and affected jurisdictions. So we're also helping to facilitate some of the cross-jurisdictional sharing of information, which can be somewhat complicated in our country. Now on issues of what we're actually tracking. Uh, I'll go to what we reported on yesterday. Um, we're always tracking any emerging events.

Rebecca Katz: [00:04:44] So there's no emerging event that, that is of critical importance right now, which is a good thing. Uh, we were looking at two different epidemiologic situations that were being monitored, um, in different World Cup jurisdictions. So that that included a wastewater surveillance hit for Mpox clade two in California and adenovirus in Washington state. We're also providing updates on some of the global epidemiologic situations that could have potential impacts on the World Cup, but aren't currently. But that allows us to provide updated information on the reported cases and deaths from Ebola in the DRC. And finally, we report on a category we call operational situational awareness. So, um, those are events that may impact the games at some point. But for now are things we're just keeping an eye on. And so for yesterday's report that included um information about leishmaniasis in Mexico. So it gives you a sense of kind of what we're up to. Um, and I do invite anybody who is interested to, to sign up for the, for the CIDRAPs. I'll make sure to put a link to, the site to do so in the chat. So I'll stop there and um, turn over I guess to Doctor Kuppalli.

Jeanne Marrazzo: [00:06:04] I'll go ahead and ask Doctor Kuppalli to comment. Krutika, we're wondering what we really should be worried about. Um, as opposed to what we hear the most about. So please go ahead and and chime in.

Krutika Kuppalli: [00:06:18] Great. Thank you for the opportunity to be here today. Um, so I'm in the state of Texas, which is going to be having a major role during the current World Cup. Uh, there will be matches both in Dallas and Houston, and we have more World Cup games than any other state. Additionally, it's the home of the International Broadcast Center that is going to bring more than 2000 media of the, um, 2000 media to the region. Um, so Texas has taken a proactive approach through the development of a Texas World Cup infectious diseases hotline. It is a partnership between the Texas Department of State Health Services and the University of Texas, and I am one of the medical directors for this initiative. The hotline provides clinicians with 24/7 access to infectious diseases experts from across the University of Texas. So this includes UT Southwestern in Dallas, UT Houston, UT San Antonio, and UTMB in Galveston. And clinicians will be providing guidance with the evaluation and management of travelers who may have unusual infections and the potential public health concerns during the tournament. Um, from my opinion, it's an example of how states can strengthen preparedness by connecting frontline health care providers with specialized expertise in real time and ensuring that patients receive appropriate care while avoiding unnecessary panic or alarm. Uh. When people think of infectious diseases in international events, we often focus on high profile diseases like Ebola.

Krutika Kuppalli: [00:07:48] And while Ebola is understandably capturing much attention these days with the worsening outbreak in DRC, the reality is the risk of Ebola being introduced in spreading during World Cup is extremely low. It is important for people to remain vigilant, but I'm going to talk a little bit about the diseases we are most worried about. So probably highest on the list is going to be measles. We are currently seeing an increasing measles activity globally, including here in the United States. It's one of the most contagious viruses known and can spread rapidly in crowded settings, especially when you have people from different countries and communities coming together who have different susceptibilities and immunity profiles. Uh, large international gatherings create opportunities for exposure, and fortunately, measles is preventable. And ensuring that routine vaccines are up to date is probably one of the most effective ways to protect individuals and communities. We also know from prior large, mass world large mass gatherings that sexually transmitted infections can increase. This is not unique to World Cup, but it is a pattern often observed when large numbers of people travel, socialize and engage in new sexual partnerships. Public health, messaging about safer sex practices, testing and access to prevention tools such as prep and doxy-pep are important components of preparedness. In addition, we expect to encounter the infectious diseases that we see all the time. So respiratory infections, such as influenza, Covid 19, and other seasonal pathogens, can spread throughout crowded venues. Gastrointestinal illnesses can spread through contaminated water, person to person contact, especially when hand hygiene is adequate. Finally, because the tournament is going to be taking place during months where travelers should be mindful of mosquito borne diseases, it's important for people to remember to protect themselves. So using simple measures such as insect repellent and wearing protective clothing when appropriate.

Krutika Kuppalli: [00:09:50] So what can the public do that is really important. So first and foremost, making sure their vaccines are up to date, particularly measles and influenza. Second, practicing good hand hygiene and respiratory etiquette. This will help prevent them from getting things like norovirus, which we can sometimes see, uh, transmit during these large mass gatherings and things like influenza and Covid. Um, third, stay at home or avoid crowded settings if you're feeling ill. You don't want to expose anybody else. Uh, fourth, use safer sex practices and seek testing when appropriate. Uh, use insect repellent and take precautions to prevent mosquito bites, especially if you're outdoors. And finally, seek information from trusted public health sources rather than relying on rumors or misinformation that can spread rapidly online. Uh, so preparedness is not only about the public, it's also about ensuring that our health care providers and communities have the information they need. Uh, it is important to educate clinicians about the diseases they are most likely to encounter. Provide clear pathways for consultation and reporting, and helping communities understand the steps they can take to protect themselves through initiatives such as the one here in Texas. Along with clinical education programs and public outreach campaigns, I think that we can have a safe and wonderful World Cup. Thank you.

Jeanne Marrazzo: [00:11:10] Thanks so much, Doctor Kuppalli. That was a masterclass. Brief masterclass in how to protect yourself with mass gatherings like this. And while the World Cup in America is 250th, you know, might seem to be big special events this year, as Doctor Kuppalli said, anytime there are large mass gatherings of people, ID experts have been and continue to be really integral to preparedness and response to keep people safe. And as both of you noted, um, surveillance, active surveillance is critical, um, as are ways to detect, prevent and treat across multiple jurisdictions. One of the things I really liked about both of your comments is emphasizing the role that local health departments have, along with clinical networks and academic networks, really, really important ways to keep people safe. As we know, this is a tough time for many local health jurisdictions. There have been lots of cuts to public health. There have also been some compromises at the national level. We know there has been an exodus of people, some forced, some not forced from some of our partner federal agencies. Nonetheless, we know the people who are still there are working around the clock in many cases to try to keep us safe.

Jeanne Marrazzo: [00:12:26] I think the last thing I'll mention is that, as you heard pretty clearly, Ebola virus, hantavirus. Those are the least of our worries. You can never say never, but you really have to think about some of the common things. Doctor Kuppalli in particular mentioned mosquitoes, vector borne diseases. We now, because of increasing temperatures, it's over 95 degrees today here in DC. We now have um, endemic cases of some vector borne diseases that we never saw originating in the United States, from malaria to dengue to chikungunya virus. So protecting yourself from bites and also being careful about heat related illness is going to be really, really critical, uh, at some of these events. So, um, thank you. That was an excellent overview. So I think we'll go on to move questions. Looks like we're lining up with some nice questions as a reminder to ask a question, you can click the raise your hand button. Or for those on the phone, uh, select star nine and you will be added to the queue. So our first question is from Anthony Stitt at Healio. Anthony, please go ahead. Unmute your line to ask your question.

Caller 1: [00:13:36] Hi. Thank you so much for hosting this call today. Um, I have a question here in regards to potential outbreaks, has communication between local, state and federal health agencies improved since Covid 19, in your opinion?

Jeanne Marrazzo: [00:13:54] So I can start by commenting on that. I would say that, um, improved, uh, would be a tall order. And the reason is not because, um, people are less willing. I think everybody realizes that, that that's a critical component to these kinds of efforts. The challenge really has been, as I mentioned, the compromise of the workforce. Um, so compromise of the workforce, both at the federal level and also at the health department level. You know, one of the things we're really always concerned about at IDSA is the pipeline of, of people not just who are infectious disease physicians, but everybody else who works in this space, from public health to epidemiology to hygiene people. And just to mention that we actually have proposed a federal program called the Bio Preparedness Workforce Pilot. We would love to get that funded. It's a relatively small program, but anything that we can do to increase the the workforce, I think, is going to be critical to foster that kind of dialogue. Krutika or Rebecca, did you want to comment on on what your views are in this space right now? I mean, Krutika, you've been really involved with the Texas folks, which is exactly what we need.

Krutika Kuppalli: [00:15:09] Um, yeah. So I think that, you know, at the local and state level, there is a lot of communication. We've been having a lot of meetings, not just with the health department, but with other stakeholders. And also, um, we are going to be having daily huddles, uh, during World Cups. So I think this will be an opportunity for there to be a lot of sharing of communication, especially given that we're in a state that's so large, uh, where, um, and we have games in two major cities here. So I do think that there is a lot of collaboration and I think not just our public health individuals, but a lot of clinicians doing work to try and help educate people on the lines, and that are going to be on the front lines of this outbreak and or sorry, this event. Um, and so sorry, Ebola on my mind. Um, so I think we're going to have, um, we've, you know, been doing a lot of work. And I think that, you know, as Doctor Marrazzo said, um, uh, it's not for a lack of communication and people wanting to help. It's just the pipeline of potentially having the number of people available to do this work.

Jeanne Marrazzo: [00:16:14] And thanks for calling out clinicians. Remember, you know, clinicians in emergency rooms, primary care clinics, they are the front line, right? They are the people who may see the weird rash, um, that may see the odd, you know, presentation of whatever it is. And, and they're being vigilant and then knowing who to call that, that chain of events, you would think it would be obvious, but it isn't always obvious. And one of the beautiful things I think about these efforts is really calling those out. And in fact, to that end, I want to just point out we've shared in the chat two nice links. One is a link to Doctor Kat's Health Security Operations Center so you can know what's happening there. And then the other one is from Doctor Kuppalli, the Texas World Cup hotline. So very, very useful information. Okay. Um oh go ahead.

Krutika Kuppalli: [00:17:03] So I mean, just as a follow up to what I said and what Doctor Marrazzo said, um, you know, in addition to the communications with public health and local and state officials, um, we've been doing a lot of education here in the healthcare system. So clinicians that are on the front lines will know about what threats to think about, to know about who to contact. May it be local public health, may it be regional or state. So I think, um, you know, I just really wanted to emphasize that we've been doing lots of different things to engage people.

Jeanne Marrazzo: [00:17:33] Great. Thank you. Well, I'm going to ask Doctor Katz to comment on the next question. This is an emailed question. Um how long will it take for an outbreak or cases to show up after one of these mega events? What do you think?

Rebecca Katz: [00:17:48] Well, I mean, you gave me a hard question to comment on, in part because the, the, um, correct but least satisfactory answer is it depends.

Jeanne Marrazzo: [00:18:00] Exactly. It's okay. That's what I would have said too.

Rebecca Katz: [00:18:03] I mean it depends on what we're talking about. Um, uh, as Doctor Kuppalli mentioned, I think one of the, one of the things that we are all, um, deeply concerned about is measles. Um, the, in part because it's so contagious and that we are seeing, we have had, um, certainly increases in the numbers of cases, not just in, in the US, but also in Canada and Mexico. Um, and in some of the, the countries that are, and the fan bases that are coming in from around the world. It's hard to say like when when something might show up because there's a difference between whether you might see an event that occur at the stadium itself or in the population. And you're, again, you're having a lot of mixing and a lot of different environments. Um, one of the cool things to, and cool being the technical term here, um, the, the, one of the things that, that we can do though with measles is, which I think is quite exciting is looking at the wastewater surveillance data. So, uh, we are monitoring measles in the wastewater in, I think, 140 different jurisdictions across the country.

Rebecca Katz: [00:19:22] And what is exciting about that is that if you see measles in the wastewater, you get somewhere between 5 and 7 day early warning before when you might see a patient show up at an emergency department. Um, so that is in our world, a tremendous amount of time to be able to to take action. So if you see something, you can get word to the health care systems. You can get word to the infection prevention control people at hospital systems, and you can get word to the public so that, um, individual families that may have been reticent about vaccinating in the past may change their mind and do change their mind, in fact, when they see measles in a community. So again, I think, um, I think there's a lot of opportunity and there's a lot of, um, there's, there's possibilities for surveillance, but it, again, it all goes back to what condition we might see and how long it might take to show up in a population.

Jeanne Marrazzo: [00:20:22] Yeah. Thank you so much. And I did want you to comment a little bit more specifically on the wastewater. I think that actually is really helpful to my mind. I think to summarize what what Rebecca said, really, I think when you detect it depends on two things. First of all, you know, we've talked a lot about the incubation period of various infections. So for measles, 7 to 21 days. So it could show up pretty quickly. Remember, for hantavirus, everybody was freaking out because the incubation period could be as long as 40 plus days. So and we have seen cases right in some of the people who were exposed on the, on the, the cruise ship that that emerged quite late after exposure. So I think that's the first big variable. The second one is how intensively are you monitoring? If you don't look, you're not going to find it. Right. That's why wastewater surveillance is such a beautiful, um, I think tool because you can look for very small numbers of particles of genetic material and you can do it relatively frequently, in fact, daily. Um, and you can pick up things very, very, very quickly as Doctor Katz said. So if you think about that, you know, you could conceivably detect things very early. On the other hand, if you're thinking about some other infections, you may not show up until later. Obviously a norovirus outbreak, which is probably one of the biggest things that's most likely to happen, is going to be pretty obvious pretty fast. The third thing I would say is the the syndromic presentation of some of these infections is going to help you detect these things early. So really good question, very complicated answer. Okay. We have another email question. And this is a really hot topic. So um, I'm going to just punt it to either of you. And anybody can jump in. You can both comment. Should there be screening or enhanced health protocols for admission into these events? Either of you want to comment? What do you think? What is the role of screening in these in these settings and depends on what you mean by screening.

Rebecca Katz: [00:22:23] Yeah. Again, I think it's really what are you talking about? Um, and I and you know, are you there are, and whether you're looking at something that is punitive or whether this is just for information gathering. So there are environmental sensors, sensors, there's ways to monitor, you know, who has temperature increases. There's, um, there's honestly all the, all the wearables, right? So you can pull data from wearables, from people who might be in an arena that would give you information about, you know, the, well, people are still actually trying to figure out the best way to use that information for, for surveillance and, and in real time monitoring. So I think it's, it's, it's again, a question of kind of what, what exactly are you, are you asking about? And then, um, and then how do we look at things in a way that are able to take productive action and not just punitive?

Jeanne Marrazzo: [00:23:19] Yeah, I would say, I think, um, certainly not thinking punitive measures here. And I would guess by punitive, you mean not letting people in, uh, by, um, if they exhibited certain signs or symptoms. I certainly don't think we're there yet. We have looked at syndromic screening. Um, and we of course do that at airports. We've done that, not us. But people have used that as a public health intervention, largely exit screening from countries affected by really serious illnesses like Ebola virus or Marburg. Um. Entry screening, in contrast, at places like airports is really fraught because people can be febrile or have a fever for lots of reasons. They can have a low grade fever that doesn't mean anything. And then that shuts them down a pathway that really is not productive and is very laborious. And then the third thing is people can take anti-fever medications. So, you know, if you're concerned and you really want to get through the screening, you can do that. So I think, and I'm going to ask Doctor Kuppalli to comment because she mentioned something really critical. I think the most important thing is educating people about not showing up if they have concerning symptoms. So if you're throwing up and you have diarrhea because you might have norovirus, please do not sit next to me at at the World Cup event. You know, if you have a respiratory illness. Think about wearing a mask. If you paid $11,000 for a ticket or whatever. Um, an N95, of course. Or, you know, don't come. So I think that that's the sort of level of sophistication we're at, which is not really sophisticated, but hopefully puts some of the responsibility and knowledge on people who are attending. Krutika, did you want to comment on that at all? Because I know you're probably thinking about this a lot, and you've written a lot about the value of exit and entry screening.

Krutika Kuppalli: [00:25:03] Yeah. So I think that I agree with everything that Doctor Katz and Doctor Marrazzo has said. I think that, um, we a need to think about how we're going to use the screening that we're doing to inform public health and the measures that are going to be taken. Um, and I also think that a large part of what we can do is also educate people, right? So they know if I have this symptom or if I'm feeling this way, maybe I should stay home and not expose a bunch of people. Um, but I think, you know, when I think a lot about, um, exit screening and entry screening, I agree with Doctor Marrazzo what she said, I think exit screening definitely makes sense. But um, when you have entry screening and particularly if people are worried about there being um, negative repercussions to having something like a fever or symptom, there's going to be, um, the desire to try and potentially hide that right or circumvent that. So I think that, um, when we talk about these things, we need to be clear about what we're talking about, but then also clear on what the, uh, actions will be. Um, if there are positive results.

Jeanne Marrazzo: [00:26:12] Yeah. Thanks. I really appreciate that. Um, again, people will always find workarounds, right? Um, particularly if they've invested a lot to, to get to some of these events, these, these events are not cheap, um, either to get admitted to, but also to travel to. Um, and so, um, not saying that people are going to intentionally expose other people to illness, but I do think that, um, there are a lot of reasons that, uh, entry screening in these contexts really just don't make sense. Um, okay. Thank you very much, both of you. Uh, the next question is from Pien Huang at NPR. Ping, please unmute your line and ask your question.

Caller 2: [00:26:53] Thank you for doing this. Um, I have a question for Doctor Katz. I mean, you know, you all have been talking about how it's tough times for public health. There's workforce and funding issues. And I'm wondering if the Georgetown HSOC is in direct response to what the government isn't doing or capable of doing at the moment. And I've also heard of the CDC infectious diseases dashboard that's being shared across jurisdictions. I'm wondering, is that different? Is there overlap there?

Rebecca Katz: [00:27:18] So. It's a nuanced answer. Um, because I think it is incredibly important to underscore, as Doctor Marrazzo said at the, at the start, um, that, there are there's a lot of activity going on. It's going on at the at the local, state and federal level, right. There's a tremendous amount of work that is happening. Cdc has their dashboard. They are they have a team that has stood up. Aspr has a team. There is a group at DHS that is working. There is, um, there are jurisdictions that they don't have the time, but they should be writing textbooks on, on, based off of the work that they are doing. Um, so, so there is a tremendous amount of effort underway. That being said, um, there's also, you know, there's very clearly been been changes in resource allocation that there has been changes in workforce, uh, and the, and the, and there are people who are, are stretched. Um, so that alone would be one thing. The second thing is, um, you know, we've left the, the United States is no longer a part of the World Health Organization. So that also then complicates how data are shared. Disease surveillance information is shared across international borders. Um, and then on top of that, this is a particularly complicated mass gathering giving, given that we're dealing with at least 48 different jurisdictions and more. If we're counting the fan zones.

Rebecca Katz: [00:28:52] So, will there be duplication? I really hope so. Right. That's kind of the point. Um, but also we know that there is so much going on that we, we can all that, that, that there is, there's enough space to, um, I mean, we'll put it in soccer terms. I gotta, we gotta play the field. There's a huge field to cover and we're all trying to cover it. So and we're working in support of each other. So, um, yes, CDC has a thing. They are looking at stuff. We have data that they don't have, but we are sharing directly with them. They're sharing information with us so we can help share it back with some other jurisdictions. Right? So there's a lot of things that are being that are being shared. It's it's not, it's not terribly elegant, right? Um, in part because, uh, because this is a little bit of duct tape and dental floss pulling all this together. But, um, but we're, we're all working hard to make it work. And there's a tremendous amount of goodwill, right? Like there's a huge amount of folks from across lots of different parts of the community, um, from, from the private sector, from healthcare, from public health, from academia, who are all just trying to figure out how they do their part. Um, and, and again, is some of it duplicative? Duplicative? Sure. Right. But again, I think that, that, that has the potential to be a good thing here.

Jeanne Marrazzo: [00:30:20] Yeah. Thanks. Doctor Katz. I mean, the bottom line is I think nobody likes an outbreak and we need more shots on goal. Um so that's, that's really what's what's happening here. And again, I want to thank you and your center for for stepping up so, so, so nicely. Um, okay. We have an emailed question. Um, would you go to one of these events? What would your advice be to friends and family? Let's get real here.

Rebecca Katz: [00:30:44] If I could afford a ticket. [laughs]

Jeanne Marrazzo: [00:30:49] [laughs] Okay. So unqualified yes from you. What about you, Doctor Kuppalli? You gave us fantastic advice already. So I think you you kind of have already said, as I said, written the brief textbook on this approach.

Krutika Kuppalli: [00:31:02] Yeah. Um, so if I were going to go to an event, I think I would do all the things I talked about. Right. Make sure my vaccines are up to date, make sure that I'm practicing good respiratory etiquette. Make sure that, um, I'm practicing good hand hygiene, making sure I'm protecting myself from, uh, vector borne diseases. Um, you know, here in Texas, it's super hot. Um, so I would make sure to also maintain my hydration because I think one of the other things we're quite worried about is heat related events. Um, that being said, um, you know, I also think that if you're going to be in a stadium full of 97,000 plus fans, like here in Arlington, um, I would probably also do a little bit of self monitoring after the fact. I wouldn't necessarily, um, you know, prevent myself from going out, but I would definitely be a little bit more heightened on making sure I don't have any symptoms related to anything that I could have caught at one of these events.

Jeanne Marrazzo: [00:31:59] Thank you. So my personal protection kit, hand hygiene sanitizer, mosquito repellent, sunscreen, hydration, and maybe a mask in there just in case I get sick while I'm there. Okay. All right, I like it, I like it. All right. We have one final emailed question. What are some consideration for future events like the Los Angeles Olympics in two years? What should we be thinking about to, um, so that we're either having an evolved conversation from this one, or we're looking back fondly on how we prevented any problems happening at these events this summer.

Rebecca Katz: [00:32:37] I'm happy to jump in quick. I mean, I think that, um, all of us in this space have an eye on LA 28, um, that this is, we are, we are working deliberately to address the summer games, but we're also every, every day is something we are learning and then iterating on so we can be better prepared for, for the Olympics in two years. Um, and integrate that into the, what is kind of a normal two year planning cycle. So what are we learning around surveillance? What are we learning about, uh, rapid sharing of information? What are we learning about ensuring that the, the public health community is, is closely tied up with the health care community? Um, and ensuring that there's the ability to do surge capacity as well. So I think, um, the, the, the, there's a lot, and there's probably a much more articulate way to, to approach it. But I will tell you from our perspective, um, the, the after action report, we do, um, following the, the completion of the games on July 19th, um, is very much focused with an eye towards, towards that next largest mass gathering that we're going to have for a sporting event in the US.

Jeanne Marrazzo: [00:33:56] Great. That's super. Um that's terrific. I think the one thing I would add to that too is that, um, with, as we're facing with this, this, these events, unprecedented percentage of, of people without measles immunity, um, you know, largely because of declines in, in immunization and heightened risk for infection, um, given the outbreaks that we're seeing. So the one thing I would hope that we're dealing with in 28 is less of that. Hopefully the measles epidemic in particular can be controlled with some of the classic public health measures. I realize I left one thing out of my personal protective kit. Um, I was I should be more generic. And I would also include condoms and prep if it's relevant for people. And I should know that given that I'm an sti HIV person. Um, so thank you for pointing that out. Um, critique, that's really important. Okay. Well, I think that we are, are going to wrap it up. Um, that was incredibly helpful. I want to thank both of you, especially Doctor Katz, for joining us from many, many, many time zones away. Um, as you all know, if you want more infection, if you want more infections, come to us, but don't get more infections. If you want more information on the Infectious Disease Society of America, please visit us idsociety.org. Thanks for joining us and stay safe and hydrated out there by.