Okay, everyone, if we can wrap up our conversations so that we can get started and come to the main room. Our final panel today is about vaccines. Everyone, if we could please quiet down, if you don't mind. Thank you. Our final panel today is on vaccine access and development. I'm joined here by my colleague, Research Analyst Elena Meng from Gabelli Funds, Michelle Cahillie, VP, U.S. Pediatric and Pipeline Vaccines at Merck, Dr. Steven Morse, Professor of Epidemiology at Columbia Mailman School of Public Health, Michael Paas, VP, Head of Value and Access at AbbVie, and finally, Magda Sobieszczyk, if I pronounced that right, Chief of Infectious Diseases at Columbia Irving Medical Center. Thank you, all of you. All right, let's get started. Welcome, everyone. For our vaccine panel, we're going to be focusing on the intersection of science, public trust, and health system resilience. Vaccines remain one of the most powerful drivers of life expectancy and economic stability. Yet confidence has become increasingly polarized. Access remains uneven across income levels and regions, and innovation faces policy and funding headwinds. Today, we're going to be here unpack how we can rebuild trust, strengthen surveillance, ensure equitable distribution, and prepare for future pathogens. I'm thrilled to dive in. Michelle, let's start with you. Vaccine hesitancy now extends beyond misinformation. It reflects broader societal and political divides. From your vantage point of leading the U.S. commercialization at Merck, how has vaccine confidence shifted at the parent and community level? What strategies have worked best in rebuilding the trust? Thanks, Elena. I will answer this question with the lens of pediatric vaccination. I will start by saying that, having been in the space now for a few years, vaccine hesitancy is not a new phenomenon. Actually, there has been hesitancy and questions around vaccination for as long as there have been vaccines. Having said that, there has been an acceleration in hesitancy, in concerns, in skepticism around vaccination over the last 5-10 years. Our research has told us that the percentage of parents who are vehemently opposed to vaccination has increased from around 5% to 10% in the last five years. Having said that, though, a majority of parents today still do choose vaccination for their children. Actually, when we look across, even looking across political parties, we still see a vast majority of parents would choose routine childhood vaccination. It's a little bit different when we talk about seasonal vaccination, like COVID vaccination, for example, which is much more polarizing. When we look at sort of classic routine childhood vaccination that's been around for decades, there is more common ground than we think because the minority tends to be quite vocal. To the second part of the question, which is around trust, and there was a conversation about trust in the prior panel, which I thought was quite interesting. What we see is that the trust in institutions has declined significantly, but the trust in healthcare professionals has not. The pediatrician remains the number one source of trusted information for parents. Of course, there is the trust from local peer influencing bodies. If you have, for example, we talk a lot about the downsides of social media and TikTok and Instagram, but if you have a local pediatrician who's also on TikTok, they can be an incredibly important voice from a parental perspective. Thank you, Michelle. Turning to you, Michael. So how does value and access help counter misinformation and support clearer communication with the public? Yeah, that's a great question. Maybe I'll start with the sort of obligatory pharma disclaimer, which is I'm not here representing my company per se, which is AbbVie. I'm speaking more generally about the industry and specifically about value and access functions or market access functions in general. With that caveat, maybe let me back up a little bit and say, you asked about what does value and access do. Maybe I need to talk a little bit about what that is. Unlike some other pharmaceutical functions where by reading it, you really can't tell from the name what we do, value and access is sort of pretty evident in the title. We focus on the value of our medicines, communicating that value, demonstrating that value, and we also focus on then trying to get access for our patients. Now, this is a thorny problem, as you can imagine, because obviously cost is an element in this equation. You mentioned trust and vaccine hesitancy before, Michelle. I think this is a major issue that we also have to overcome. We also have to know who we as value and access or market access talk to. We talk to the payers or the health technology agencies, the HTAs, and other health decision makers. We are focused on interfacing with entities who make decisions for access for patients at the population level. We need to communicate to them about population-level issues. In order to be effective, we need to be able to bring robust, credible evidence, but put that into terms that the population-level decision maker also cares about. It is one thing to nicely talk about cost-effectiveness ratios and thresholds and things like that. If you're talking to a market that has a budget envelope of money for healthcare and you're outside of that envelope, you can talk about cost-effectiveness until you're blue in the face and it's not really going to matter because ultimately it's about the budget impact. It's coming with trusted information to those healthcare decision makers, but it's going beyond that. It's really translating the information that we develop scientifically and holistically representing the value of the vaccine and communicating that in a way, translating that science and translating that holistic value. There I'm talking about maybe things like productivity gains or educational attainment gains, societal benefits that come with vaccines, translating that more broadly and putting that into terms that might have a broader impact. There are some studies out there, depends on which methodology you use, that say that a dollar invested in vaccines generates somewhere $20-$30 to even $50 in ROI. That is a pretty powerful statement. If you can communicate that along with the benefits that you are bringing and give the healthcare decision makers confidence that the medicine also comes with the sort of prerequisites of safety and all of the other things that you expect to have for medicines, I think that is a start towards changing some of that. We are not always the best messengers for this message. I mean, it is not a secret that pharma has an image problem and a trust problem. Sometimes I think it is better if the message does not come from us. We are going to deliver that message anyway. We have to, to the HTAs and so forth. If we can work, like Michelle said, with some of the trusted partners out there in the healthcare community, PCPs, local pharmacists in your community are highly trusted, actually. If we can provide them with information that's factual, not biased, but they can use it to represent the value of the medicine and talk to patients coming in, I think that's another step in the right direction. That's very helpful. Now, turning to you, Dr. Morse, from a public health perspective, what broader forces are driving hesitancy today beyond misinformation? Thank you. One is fear. I think we've heard a lot about trust, and this is a time during which there is a great deal of uncertainty. I think the world is in many ways in turmoil. It's gotten worse, not better since the COVID pandemic. I think people are fearful. They're uncertain. Many of the same factors that really drive Wall Street are responsible for some of the vaccine refusal or vaccine hesitancy. I'm glad to see you use the word vaccine confidence here. Heidi Larson, who I think coined the term originally vaccine hesitancy, now her project is called the Vaccine Confidence Project. I think it's important to think positively about this. That's one of the problems. There's always been fear. I think the other problem besides fear, besides the political divisions and the misinformation you mentioned, is that in a sense, vaccines have become victims of their own success. In many ways, they really have been so good that people today, especially parents of today, very often have never seen any of the vaccine-preventable diseases that we want them to take or give their children vaccines for. MMR, for example, I'm old enough to have actually had measles. When I was growing up, about 500,000 kids a year in the United States were reported to have measles, according to CDC. Probably more. Now, there are just little pockets, largely of places where you have under-vaccination or other reasons that people do not take the vaccine. They do not think it is a problem anymore in terms of their risk-benefit calculation. They see the risk. There's some possible risk of the vaccine. They don't see the benefit because these are preventable and we've essentially put them out of sight for people. Right. Absolutely. Turning to you, Dr. Sobieszczyk. In a clinical setting, how do you distinguish legitimate concerns from the entrenched anti-vaccine beliefs? How do your approach differ? Yeah. Now, that's a good question. I think it oftentimes starts with a conversation with the patients to try and to really discern and understand what are kind of individual drivers of decision-making for them about vaccines or any actually sort of choices about their healthcare. It starts with an open-ended conversation and open-ended questions, which oftentimes we as providers are not very good at asking yourself, especially since oftentimes we have sort of limited time for these interactions and engagement, and you have to go through a whole series of issues to cover. That's sort of a challenge for sure. I think kind of these open-ended questions really kind of help you discern whether it's someone who just has legitimate concerns that can be addressed about the safety of the vaccines or side effects, et cetera, and how does it fit into their life? Is it convenient for them to get it at this particular time? Those questions can be answered easily versus some of these more complicated questions about really being anti-vaccine or opposed to vaccines because of concerns and things that people see and information or misinformation they see in the media. I think that takes time to address, and it's a process. The way I think about it personally with my patients is it's a journey. We're embarking on a journey about some vaccines are routine, kind of Michelle, as you were saying, and maybe normalizing that the respiratory virus vaccines are just bringing them in the context of something that should be routine, can be given bundled together, your influenza, your COVID, your RSV vaccine if appropriate. Let's give it together. Some of them are on an annual basis. It may take a few months to get people to that time point. It is good to start early to really kind of get people to the point of being ready to take a vaccine. It does take time. I think patients sort of always say, "I don't want you to be judgmental. I don't want you to lecture me. Just give me the facts. Give me the information in a very kind of non-judgmental way." The other thing, we talked about the role of providers and also community members and influencers because people, yes, I find that people listen to their providers, but they also listen to kind of their trusted sort of either trusted influencers on TikTok or Instagram and elders, church leaders, et cetera, other kind of community members. I think it's kind of there needs to be sort of partnership with these entities also to really kind of change people's thinking and bring them to the point of where they're ready to get vaccinated and sort of then kind of understanding the implications of it for their health and the health of their community. Yeah. Having the right people advocate to the right group of people. Now, we want to dive in a little bit about access and affordability. Michelle, with COVID funding winding down right now, what are the biggest risks to maintain equitable broad access? I will tackle this from the lens of pediatric vaccines. And as a person who's worked in many different countries around the world, you might be surprised to learn that from a pediatric vaccines perspective, there's actually very good access if you consider access to mean reimbursement or the ability to pay for that intervention. The reason that I say that is when we look at commercial coverage, insurers are generally very willing to cover vaccines. They're also mandated to cover vaccines that are recommended at a federal level. Even my hypothesis would be that even without that mandate, our conversations with payers is that they are generally seeing vaccination as a very cost-effective intervention, which I think you just had mentioned. From the point of view of those children who are not covered through commercial insurance, there is a program which is called the Vaccines for Children Program. It was actually instituted in the 1980s under the Ronald Reagan administration at the time, which provides zero-cost coverage for children who are not covered by commercial insurance. That is actually 50% of America's children are covered by that program, which is immense. I would say that access from that perspective is in quite a good spot right now in the pediatric space. We certainly hope that will be maintained over time. Now, if you think about access a little differently, which is access to the right information or access to healthcare, you may take a little bit of a different lens, and then you will start to see some of these pockets of undervaccinated children. That's for reasons that are not so much to do with cost as they are to do with other drivers of access. Right. Let's take a broader look internationally. I think the U.S. has done a really fantastic job on this. Michael, to you, let's say in a constrained pricing environment worldwide, how do you preserve incentives for innovation while keeping vaccines accessible? Yeah, that's a super important question. I think I'll start by saying, let's just understand the economics of biopharmaceuticals. If you want to sum it up very simply, they're risky, expensive, and lengthy to get them to market. Companies are in the business of profit and need to earn at least money sufficient on what they're putting out there in the marketplace so that they can keep making products and investing and elevating those products, getting better products to the market. We benefit today from so many second, third, fourth, fifth generation products that wouldn't have come if the first generation didn't survive. That's an important thing to understand. You can talk about all that stuff to a market, a lower middle-income country that just doesn't have the money, the budget to pay the price that, let's say, Western markets are paying. This is a problem. I think health economics and cost-effectiveness kind of goes out the window when you're talking about budget impact and budget constraints. This is where you have to get creative and flexible and think about what are the levers that you can manage if you work in a partnership with countries or with governmental or non-governmental agencies, public-private partnerships. You've got price that you can work on as a lever. You've got volume that you can work on as a lever, and you can manage the risk or the uncertainty. Here I'm talking about the uncertainty maybe for the market, for the country, because maybe they're not fully confident in the benefit of your medicine. You can also talk about the uncertainty on the manufacturer side, which is they're not confident that they're going to have enough demand in the market so that they can actually profitably sell their product. That's where you have creative and innovative solutions that have come up since the mid-2000s, like the Gavi Alliance and work that was done in pneumococcal conjugate vaccines. You've got COVAX, essentially consortium and pooled purchasing that happened in multiple countries, but in Europe in particular, I think spent tens of billions of dollars to basically make advanced market commitments and advanced market contracts for volume. Manufacturers were then able to develop the vaccines knowing that there was a market there, and a negotiated price point was also acceptable to the markets. The benefit also to the markets was they secured supply of vaccine, which in something like a pandemic, you want to make sure that you actually have supply. There are all kinds of strategies that are out there already that I think many companies have explored and countries have explored to work on that sort of price, volume, and uncertainty equation. You have to start again with value and make sure that people understand the value of that medicine. If they understand the value, then you start to talk about, okay, how can we find a solution to make sure that all the appropriate patients can get access to that and that you guys have, you manufacturers, let's say, have a business. In the Gavi case, that worked very well. In fact, they created second-generation vaccines as a consequence of that. They had continued business in those markets, and it vaccinated over, I think, 200 million children. That's a great example. Now, let's expand a little bit from the global systems angle. Dr. Morse, so how do you think an improved global surveillance direct strengthen the equitable vaccine manufacturing and distribution? Thank you for that question. As you know, this is a personal kind of passion of mine, so I appreciate the question. I think surveillance is important in every aspect, really from the beginning right through the time that we were seeing effects or looking at the effects. When you think about the eradication of smallpox, for example, the one human infectious disease that was actually eradicated by human activity, that was done through vaccination. In the end stages, the later stages, instead of being able to do mass vaccination, which was the original plan, but it was not feasible, the idea then was to do surveillance and then what Bill Foege called surveillance containment, the ring vaccination we hear about, so that you would do surveillance in an area where there might be a problem of pockets of smallpox or cases and then vaccinate around there, vaccinate the surrounding communities to prevent the disease, to prevent the infection from moving because you had all these people who had now been protected and were no longer susceptible. Surveillance played a real role there, but I think it can play a role everywhere. Equity is a problem with something like vaccines because biologicals in general are much more difficult to produce than many of the medicinal chemical products. I think there's a lot of interest in trying to regionalize vaccine manufacturing, in which case you could concentrate once you found there was a problem. You could concentrate, for example, Mpox, formerly known as monkeypox, Clade 2B, the West African variety, which had actually been a problem for a number of years in Nigeria. Had there been good surveillance and a good approach to providing the vaccines that we have, this probably could have been stopped long before it became essentially a pandemic worldwide. There are, I think, a number of ways in which we can improve not only equity, which is, I think, still a major problem. Yeah. These are great questions. Also our awareness. Yep. Turning to you, Dr. Sobieszczyk, what are some, let's say, practical barriers clinic patients face? Is it insurance, eligibility, workflow when implementing new vaccines, for example, like RSV? Yeah. That's sort of something that's very much kind of at the forefront of the minds of the health system and also the clinic and the clinician. I think some of the practical barriers, kind of real world, when you're in the trenches in the clinic, a lot of it sort of also comes down to kind of having the time to even bring up the issue of sort of vaccines. You due for your vaccine today or it's vaccine or respiratory viral infection season is coming up. Let's get you vaccinated. When I say time, it's because oftentimes these conversations are not simple, as we talked about earlier, and they get left to the end of the appointment. Oftentimes they sort of get forgotten. Even that tiny little thing, such as kind of having time during the encounter to bring up, especially new vaccines, it's a big barrier kind of when implementing something. In terms of kind of thinking really about the workflow, what is the workflow in the clinic going to look like so that that individual is not inconvenienced, doesn't have to stay much longer to get the vaccine administered during their encounter? What is influenced by that are simple things or seemingly simple things like where is the vaccine stored? Does it have to be in a temperature-controlled setting? If so, can that be in a pharmacy that's distant from the clinic or a pharmacy that's sort of adjacent to the clinic or close to the clinic? That really has implications for going to get that vaccine. How is it stocked? How many do you have in your clinic so that when you're having that meaningful encounter with a patient, hey, are you ready to get vaccinated today? Yes. Oops, where is the vaccine? Do we have it? Do we not have it? That kind of figuring all of that out in advance is really important. I think sort of creating kind of reminders and prompts for providers to remember to bring up the issue of the vaccines and kind of an eligibility. Are you above the age of X, Y, and Z, and are you eligible for that vaccine? That even actually sort of are sort of bigger barriers than talking with insurance companies about whether or not it's reimbursed because, as we talked earlier, majority of vaccines, if they're authorized and approved for that particular age group, it's not an issue in terms of getting them reimbursed in the clinic. Right. Now we have talked about trust. We have talked about accessibility. I want to dive in a little bit more about science, about innovation. Dr. Morse, given your work with the Nobel laureate Shimon Sakaguchi on regulatory T cells, how could new understanding of immune tolerance shape the next generation of vaccines? Yeah. Thank you. I think the immune system is really one of the things we're beginning to appreciate and understand. I had the honor and pleasure when I was a young faculty member at Rockefeller of collaborating with Shimon, who is really, it's a testament, I think, to perseverance in science as well as brilliance that he had ideas about autoimmunity and how that could be controlled. We now have things. We have concepts like the regulatory T cell, which can be applied in a number of different ways. I think there are many applications, for example, for the regulatory T cell, certainly controlling autoimmunity and trying to modulate the beneficial versus the perhaps less beneficial effects of vaccines in some individuals. There may be people who do not respond well. That also is part of the immune system we're beginning to understand. The regulation of the immune system is an important part of understanding not only autoimmunity, but how we can improve the response, possibly even the duration of vaccines. I think what it indicates is that this is the host response in the immune system, which for a long time was thought to be almost a black box in essence, is really beginning to be much better understood and now can be applied at the molecular level. Much more is understood about how these cells can be manipulated to do things that are beneficial. That is in every aspect, vaccines, but also cancer. There are concepts. Peter Medawar, years ago, a Nobel laureate of some years ago, actually had the concept of developing cancer vaccines. There have been thoughts about that that I see are coming back. There is just a lot of untapped potential there. To expand on that, Michael, turning to you, so how do you communicate the broader societal and economic value of new vaccines technologies to, let's say, payers and policymakers? Yeah. Again, a great question, and it's a little bit of art and science, I would say. There's not necessarily one formula to it, but I think the first thing is to approach it from a broader definition of value than often gets put out there, which is just talking about cost or cost offsets or things like that. I like to think about value in more holistic terms. We're thinking about what's the clinical value, but we're also thinking about what's the economic or health economic value of the product. Beyond that, what's the value to society or the humanistic value to the patient, right? I think we need to be able to get underneath the concept of value a little bit and also recognize that not every stakeholder that we talk to, not everybody we talk to about our product will care about all of those dimensions of value. That's a reality. The sort of company or the progenitor of that vaccine need to be able to articulate that, right? It starts with sort of that holistic concept. I think if you go walk down the street and you bump into a health economist, of which disclaimer number two, I'm not, but if you were to bump into one and ask them what they thought about vaccines, they'd say, well, those are positive externalities. They would say that these are things that have value beyond the use that the person who takes it has, right? You get things like herd immunity. You get disease avoidance, right? You get productivity. You get all these benefits to a broader group in society that's actually not factored into the price of that product. I think we need to have that conversation. I think we as pharma industry need to get better at telling that story in a way that's impactful. Not tons and tons of spreadsheets and models and things that aren't trusted, but also working with academia, working with other third parties who can lend their voice and credibility to what we're also saying about this broader holistic value of the product. I think it starts with doing that better and then recognizing sort of pragmatically that not everything I care about or say is valuable about this might be equally valuable to who's listening, right? And be able to navigate through that. Absolutely. Now let's talk a little bit about commercial readiness. Michelle, vaccine launches, as we all know, depends on ACIP, state uptake, and payer readiness. What would most help streamline and accelerate the future vaccine access? Yes. Product launches are important. I think it was mentioned earlier that the way that we think about product development is it's time-consuming. One of my teams launched a product this year. That product was in development for more than 10 years, full of risk all the way through that 10-year journey. There is regulatory risk. There is, of course, it's very capital-intensive in terms of manufacturing, really setting up the infrastructure to manufacture a product to be able to make it available worldwide or even only in the US. Inherently, product launch is risky. This year, it has felt more risky than usual just because there has been so much uncertainty in the environment. I think the first thing I would say is from a leadership point of view, the key piece is to figure out what are all those milestones along the way to launch a product that we can influence and how can we approach that with a leaning in kind of a mindset. How are we going to work with stakeholders? How are we going to work within a shifting environment to be able to anticipate the scenarios that are going to emerge? How are we going to ultimately be successful? The other thing I would say about launch now and more than ever from an industry point of view is that it's really all about speed. Because we have a limited time when the product is on the market before LOE, loss of exclusivity, it means that we need to be getting ready for launch years ahead of commercialization and engaging with stakeholders and helping the market really understand what is the value of this new asset and then breaking down every step. How do we get the product to market? How do we shorten our supply chain requirements? How do we get to commercial coverage as quickly as possible? Every single element of that launch needs to be evaluated for speed and effectiveness in the environment that we're in today. Understood. Now, before I open to the Q&A, Dr. Sobieszczyk, what does anticipatory R&D pipeline look like for, let's say, pandemic preparation or for neglected diseases? Yeah. No, that's a tough question. In the absence of having a crystal ball where you can kind of predict exactly sort of what's around the corner and where you should be investing, I think some key things to keep in mind. Maybe also just to sort of say that one thing that we've definitely noticed is that there's been a waning interest in pandemic preparedness. I feel like unless there was sort of a disaster that just happened or is about to happen, you kind of forget about the fact that there may be new ones around the corner. I think some of the things of kind of key elements of what this anticipatory R&D pipeline should look like are kind of things investment essentially in surveillance. We talked about, and this is surveillance, disease surveillance, sort of what pathogens are circulating in the communities and populations in the world now and what is around the corner in order to be able to sort of anticipate kind of what kind of an intervention or vaccine needs to be designed. I'm actually a big fan of sort of this concept of environmental and wastewater surveillance, which when done right can really lend amazingly rich information with sort of the genomic tools that are available right now to understand what is kind of this geospatial and temporal prevalence of certain pathogens. How are they emerging? Where are they emerging? How are they evolving over time in order to kind of anticipate what do you need to design to what kind of a vaccine or therapeutic do you need to design in order to sort of kind of be ready? Sort of coupled with that, I think is also sort of the idea of investing in basic science research. I mean, I think we all know it's important. One thing I would sort of emphasize is that there's a lot of kind of exciting work happening kind of in the multi-omic world, transcriptomics, genomics, proteomics, where you can actually sort of understand kind of you need to understand what is the impact of the environment, health, microbiome, et cetera, and human and your kind of host genetics on the response to the vaccine, the immune response to the vaccine. How is the vaccine going to behave in a certain environment? Knowing that, I think, will help us sort of design or helps us design better immunogens, better vaccines, understand what do you need to target on that pathogen in order to be ready for that mutated pathogen or kind of whatever is next around the corner. You can even perhaps develop vaccines that are effective against multiple pathogens. Can you imagine that? Like you're telling someone, you only need one vaccine. You don't need five. You only need one vaccine. I think that's a reality or something that's possible, especially with the help of, dare I say, AI, which can kind of help shorten that timeline of sort of understanding what kind of epitopes do you need to include in the vaccine and how to kind of understand the vaccine effectiveness. Just one other thing, kind of investment in clinical trial infrastructure to kind of test these products and then investment in implementation science research so we can understand what is kind of the evolution of public trust, public readiness, stakeholder readiness to kind of implement and deploy these vaccines when they are ready to be deployed. Because you're right, it's expensive to bring these products to the clinic, to the population. How do we shorten that pipeline? I think we have some tools available that will enable us to do that. We just have to kind of use them wisely. Yeah. There's certainly a lot going on, a lot of effort going into this space. Now let's open for questions. Please raise your hand if you have a question. Hi. My name is Mahim. I'm a student at the Mailman School of Public Health. I'm interested in pediatric public health policy and curious to learn from Michelle on what suggestions you have on translating policies so that way parents are better informed about vaccines and are more likely to comply with the guidelines when there is so much confusing information that we can say from a consumer standpoint. Yes. That's an important question. I don't think I have the answer necessarily, but I can say that I have spent in the last few years a lot of time talking to immunization managers, for example, in states or in cities to really try to understand some of how this works. How does a policy go from policy through to implementation? It's a little bit where we were going on the vaccine confidence front. I think it's incredibly, it's not just about the content of how information is transmitted. It's also about the voice, the who is transmitting. I think it's been said a few times. Who is delivering the message is really key. What I find interesting is that the more our world has become globalized and information has become accessible everywhere, the more local voices have become the most trusted. We talked about, I think you'd said, faith leaders and local influencers. Pediatricians are very trusted and rightly so. I have to say I've worked with many different types of doctors in my career, but pediatricians are the best. Those are really the voices of trust in terms of translating policy objectives into implementation. Yeah. I'm sure there are other opinions across the panel. If I can just add to that, I think an important component is you're right, kind of having these trusted voices on an individual level is incredibly important. I think empowering these voices to be able to deliver that message is incredibly important and providing them the right tools over time to be able to do that. Education and training and for providers as well, actually, so that they have the confidence in being the trusted voices to deliver these messages, I think it's important. We sort of talk about how kind of that type of education has to start at the medical school level and the public school level, et cetera, where kind of you can empower these young individuals to be able to kind of deliver these messages. I think it's important. Thanks. Hagen Wenzek, I'm curious. We just heard a lot about multicancer screening and using different types of sampling to understand whether there is already cancer and then thought about how to get to the intervention site seamlessly. Thinking about the prevention side and now the medical prevention through vaccines, where do you see maybe new developments or what might have a strong impact from the data that you can gather from all these tests that are being done for the cancer diagnostics and early detection so that you can develop better vaccines that prevent all of that from happening because you have all that data? Yeah. No, that's a good question. I think one way, and it's about sort of understanding the host, what is kind of the susceptibility of that host to cancer, but also the susceptibility of that host to infection. Because that host sort of immune system, for example, sort of shapes the response to the vaccine and shapes the response to the pathogen as well. Kind of understanding what that dynamic is from the samples that are collected sort of in other settings, actually, I think is incredibly valuable in understanding what is going to be this kind of dance between the host and the pathogen. You introduce the vaccine into it, and how is that modulated by the vaccine. I think kind of having a clear understanding of exactly kind of the host susceptibility to cancer and other sort of infections and what are kind of the underpinnings of their immune system will be incredible, has the potential to be incredibly helpful in understanding how to kind of personalize and almost do almost like precision vaccination for that individual. I think that's kind of where the excitement is. At least sort of that's how I see it. Yeah. These markers also represent potential targets. We have a number of targeted therapies that are based on unknown genes that are expressed. In some cases, they're growth factor receptors that are expressed or overexpressed in cancer cells. It's interesting that the mRNA vaccines that have become so useful and so important now, beginning with SARS coronavirus 2 and COVID, were originally really thought of as being anti-cancer agents. They haven't really reached that stage of development yet because they've been so useful as vaccines, but hopefully that will open up the door. Thank you. Follow to his question. Do you think AI could help to facilitate and probably connecting all the dots together to make it possible? Can you speak a little bit louder? Yeah. Speak a little bit louder. Yeah. I follow up with this question. Do you think AI technology could help to facilitate the process and also connecting the dots when it's probably impossible to be connected before to facilitate the process? Hello. Not an AI expert, so third disclaimer of the day. But we have a lot of people internally who are researching, leveraging AI in early development through to commercialization. I'm sure you do as well, right? Yeah. This is everybody's doing it. As I think we said earlier, one of the fundamental problems is the time it takes for things and the cost. The cost is often because you have a lot of mistakes, things that do not work. If you can reduce the number of those things, and there are a lot of companies that are aiming at early development and discovery to try to reduce the false paths you can go down and spend money on and focus in on things that are likely to be successful, you can shorten that timeline potentially. You may be able to make something better than maybe just pure trial and error would have done as well. I think there is a lot of promise. There's a lot of hype, but there's also a lot of activity and investment going on in AI, in the application to therapeutics, vaccines, you name it. Yeah. No, I completely agree. I think sort of the way I also think about it is that we're generating a lot of data and a lot of information about even the immune system's response to a vaccination, sort of transcriptomics, proteomics, et cetera, genomics, to kind of understand the influence of sort of other factors. It's a whole lot of data. How do you analyze it really quickly in order to be able to understand what is kind of the optimal response, immune response we are thinking to kind of we're looking for to hone in on what would be an effective or efficacious vaccine? AI can help do that, can kind of lead that process. Same with we were talking about sort of the messaging, what messages to develop to an individual who is vaccine, anti-vaccines, who is just concerned about vaccines or sort of pre-contemplative. You can sort of think about using AI to monitor kind of what the public attitudes are at a particular time in a particular area and then help distill that into some sort of trusted messages to be delivered by, I would say, a person, though I think that trusted kind of individual. I think there is a lot of excitement about that. I think one kind of sense just always, as I always sort of when we talk about AI, because we do a lot of that work with our patients that are trying to understand from them what are their attitudes towards AI, how do they see that fit into their care and into healthcare, is I think there needs to be a lot of transparency in how AI is used in the process, kind of ethical communication around it, and sort of to make sure that kind of the data that are put in are not sort of all accurate in the sort of data sharing agreements, et cetera. I think I agree with you. There's a lot of excitement about that and worthwhile investment. Right. I think we've got time for one last question from the audience. In the back. Okay. Hello. I have a question for the vaccine. It used to be a very preventive method for infectious disease, but nowadays, for example, like the HCV, HIV, already have a very good treatment. For example, the PEP treatment have an effectiveness of over 99%, make the development of HIV vaccine less urgent. So I am wondering what is the next growing point of the vaccine industry since the traditional infectious disease already have a very low profit margin. There are so many manufacturers there. Is that would be like, for example, the cancer vaccine or a vaccine platform can be quick response or are there any focused area? Thank you. I can, if I understand the question correctly, you're sort of highlighting how there are lots of wonderful therapeutics for many infectious diseases. You use the example of HIV and other kind of viral as one example. Why would you need a vaccine? How does that fit into kind of the niche of the sort of kind of preventive and therapeutic sort of armamentarium? I would just sort of say that a lot of it comes down to choices, having a choice of what modality you're going to use to prevent a particular illness. Maybe it's an antiviral that you want to take that has indeed, like lenacapavir for HIV, has incredible efficacy in clinical trials and now sort of as it's being rolled out. Some individuals, for example, don't either have access to it, it's prohibitively expensive, or they don't like the side effect profile. Then having an option of a vaccine is actually attractive because you have choices, right? I think people kind of want to have a toolbox, a prevention or a therapeutic toolbox that they can reach for, and they can make a decision with their providers as to what is the best thing for them at that particular time in life. I think there is always sort of a platform for developing vaccines, even for infections for which we have really good treatments. I'm not sure if I'm answering your question. I think that, yeah. Great. That concludes our vaccine panel. Thank you. Thank you. Thank you. If everyone will stick around for just two more minutes. I just want to thank everyone for coming. Thank you to all of our panelists, Carrie Chan, of course, all the teammates here, Eric Cabelli, and everyone from Columbia, and of course, all of the attendees for coming. We at Gabelli, we care about your physical health. We also care about your financial health. Feel free to scan that QR code here, talk to one of the teammates. There is another one out on the posters out in front. We look forward to seeing you next year and around the same time as well. Just to put a little plug for our other conferences, we host 11. The next one coming up will be one about our pump valve and water system symposium, February 26th, right here in New York. Thank you, everybody. If I could just ask Carrie if you could join the moderators for a final photo as well.