Transcript

Department of Defense Leaders Update Reporters on DOD COVID-19 Efforts

April 21, 2021
Dr. Terry Adirim, Acting Assistant Secretary Of Defense For Health Affairs; Lieutenant General Ronald Place, Director, Defense Health Agency

STAFF:  Good afternoon, everyone.  Happy Wednesday.  Today we're going to focus on the coronavirus, COVID-19 and the Department's efforts to distribute and vaccinate our troops and to all other support issues that we are participating in.

And so with that, we have two special briefers today to join us.  I think many of you are familiar with them.  The Acting Assistant Secretary for Health Affairs, Dr. Terry Adirim and Lieutenant General Ron Place, the director of the Defense Health Agency. 

They're each going to kick off with a few opening remarks and then we're going to take questions; room, phone, room, phone.  And then closing remarks.

If you have any questions outside of COVID-19, feel free to reach out to us at OSDPA.  But for this briefing today we're going to focus primarily on the Department's COVID-19 efforts.  And with that I will kick it off to Terry Adirim.  Thank you.

ACTING ASSISTANT SECRETARY OF DEFENSE DR. TERRY ADIRIM:  Thank you.  Good afternoon.  Thank you for joining us here today and for the important work that you do communicating with our troops and their families.  General Place and I are going to brief you on DOD's efforts to defeat COVID-19.

The Department is committed to transparency about our activities and we intend to provide you with reliable and consistent data.  Since the start of the COVID-19 pandemic, DOD has had 282,166 cases, 3,942 hospitalizations and unfortunately 344 deaths.

And these numbers are total that include our military service members and their dependents, civilians and contractors.

DOD is continuing to play a key role supporting the whole of government approach to defeat COVID, including supporting vaccinations of our fellow Americans while insuring our own population is vaccinated.

This week, in line with the president's direction, all eligible DOD beneficiaries can now make an appointment to get vaccinated.  We are encouraging everyone to get vaccinated because these vaccines are very effective and safe and are a critical part of us getting back to normal.

With regards to the J&J vaccine last week, when the CDC and FDA announced they were recommending a pause in their use, DOD rapidly stopped administration and separated our J&J doses from our active vaccine supply.

We also communicated with those who recently received the J&J vaccine to advice that if they developed severe headaches, abdominal pain, leg pain, or shortness of breath that they should contact their healthcare provider.

This pause demonstrates the safety and transparency of our vaccine administration system- it's a success.  The vaccine-adverse event reporting system or VAERS sent up a concerning signal about a vaccine and the CDC and FDA quickly responded to it as we did.

This pause was to help insure healthcare providers are treating this issue correctly and, importantly, to determine if there were more cases that required investigation.  We know that these clots are incredibly rare but it's important that healthcare providers know how to treat them. 

DOD will follow CDC and FDA's guidance after the advisory committee on immunization practices or ACIP, the independent vaccine panel meets on Friday and makes its recommendations on the vaccine’s use. 

Because of the small number of J&J vaccine allocated to DOD, this pause has had just a small impact on DOD's vaccine administration rates.  We have great empathy for our service members and families deployed overseas because they do not have the same options as here in the United States to receive vaccines in their local communities.

So we're committed and working diligently to insure that they can get the vaccine if they choose it.  General Place will speak more specifically on what we're doing to address any shortfalls for our overseas location, so I turn it over to General Place.

LIEUTENANT GENERAL RONALD J. PLACE:  Yes, thanks, Dr. Adirim.  And for all of you, thanks for being.  First, I'll reiterate my appreciation for the men and women in military medicine who continue to serve their fellow members, their fellow citizens and in delivering this vaccine safely and effectively.  We continue to administer vaccine as fast as we receive it.

As of yesterday afternoon we've administered over 2.62 million doses to those eligible within the Department of Defense.  At least another 440,000 doses have been administered to our beneficiaries in our Tricare pharmacy and provider networks.

Beginning today, the department will be sharing our vaccine administration numbers with all of you on a regular basis, Monday, Wednesday, and Friday to include total doses received and administered DOD-wide.  This data is the same data that we're currently reporting to the CDC.  In addition, we'll share with you the number of individual Soldiers, Sailors, Airmen, Marines, And Guardians vaccinated.

The URL is https://www.defense.gov/explore/spotlight/coronavirus and we can make that available to all of you as you like it.  A few points regarding the national pause and administering the J&J vaccine.  First, as Dr. Adirim noted, we understood and agreed with the rationale for the pause.

We expeditiously implemented the FDA and CDC recommendations with specifically tailored guidance given to every single vaccination location on specific adverse even reporting requirements when we received it last week.  Second, while the J&J vaccine was initially allocated to our overseas military communities, it is not the only vaccine that's been directed to them.

In fact, the Moderna version represents a huge majority of the vaccine that has been delivered overseas, and that will continue.  Third, we're sensitive to the fact that military hospitals and clinics represent the only source of FDA-approved vaccine among our population outside of the United States.

As Mr. Kirby mentioned on Monday, we're reallocating additional DOD Moderna doses from the United States to overseas locations for the next several weeks.  This reallocation means that 80 percent of our overseas population should be able to receive their first dose no later than the first of June.

Finally, the department is closely monitoring the FDA's review of the Pfizer vaccine to adolescence 12 to 15-years-old.  We're already developing plans to deliver this vaccine to our family member population both overseas and in the United States should it be approved for use in this age group.

We continue to see vaccine update rates increase with each passing week.  We're thankful for those who have taken this step protecting themselves, their teammates, their families, and those most vulnerable.  And Dr. Adirim mentioned with the opening of vaccine appointments to all eligible persons in the DOD, I truly expect this trend to continue.

Again, thanks for allowing us to update you on the department's progress and I look forward to answering your questions along with Dr. Adirim.

STAFF:  Thank you General Place and Dr. Adirim.  We're going to start with the phones.  Jeff Schogol, Task and Purpose?

Q:  Hi, question for both Dr. Adirim and General Place.  We've heard anecdotally that the Defense Department or that individual commands have been unable to offer incentives for service members to get vaccinated because the staff judge advocate folks are saying that would actually be tantamount to a punishment to those who aren't getting vaccinated.  Can you talk about that at all?

DR. ADIRIM:  Sure, absolutely.  The vaccine is voluntary, that's part of the EUA that the vaccine is voluntary so that is department policy.  And I think I'd like to quote Secretary Austin who said that the greatest incentive to getting vaccinated is that it saves your life and it saves the lives of the folks that mean a lot to you.  So, getting the vaccine in of itself should be an incentive and that's our stand in the department.

Q:  Well, if I could follow up, what I'm trying to get at is, are there legal reasons why the Defense Department can't offer other incentives to get vaccinated such as extra time off?

DR. ADIRIM:  Right now the policy is no additional incentives beyond getting vaccinated.  Now, there are other benefits to being vaccinated.  The CDC has updated their guidance with regard to travel so that those people who get vaccinated don't have to quarantine.

We've amended our force health protection guidance for travel in-line with CDC that those people who've been vaccinated do not need to do pre-travel quarantining.  So, that's an example of a benefit of getting vaccinated.

GEN. PLACE:  If I could add on just a little bit.  You spoke specifically to the office of general council, specifically talking about negative effects.  I'm not sure where that part of the question came from.  This is what I will tell you – that this is a voluntary vaccine.  Which means that commanders have to be very careful not to exert what we call undue command influence.

And so the right and left limits for them is informing their service members, informing their community information for people to make decision on their own.  But we're very careful as leaders in uniform, as commanders to not exert undue command influence on a thing that is voluntary.

And that's I think where the office of general council or staff judge advocate advice that you're hearing about is coming from. 

STAFF:  Thanks.  Meghann ?

Q:  The numbers on the screen, are these all three components, or are these active duty?

GEN. PLACE:  The numbers that you're seeing on the screen...

DR. ADIRIM:  Are they active duty or just service members including Reserves, that's your question?

Q:  Including reservists and National Guardsmen?

GEN. PLACE:  Well, these are all three components.

Q:  OK.

GEN. PLACE:  The numbers will be all three components for the foreseeable future.

Q:  OK.  And for now what's the difference between the vaccination rate overseas versus at home?  It's been more in the past few weeks, I just want to get an update.

GEN. PLACE:  Yes, it continues to be significantly more overseas.  The only geographical combatant command, so the AOR that we're talking about here, not the service members necessarily assigned to them.

Q:  Yes.

GEN. PLACE:  But the only geographical combatant command that doesn't have more than 50 percent of their assigned or family members, contractors, et cetera less than 50 percent is EUCOM.

Q:  Is there any particular reason for that?  Is that an availability thing or a personal choice thing?

GEN. PLACE:  I don't want to speculate what it means or reasons why.

DR. ADIRIM:  Well, you have to understand that with regard to prior to this week, most of the service members who are young and healthy and dependents who are young and healthy were in tier 2.  So, we weren't opening it up to tier 2 until this week.  So, that may have some impact.

STAFF:  Let's go back to the phones.  Ellen Milhiser, Synopsis.

Q:  Hi.  Thank you all so much for doing this, I very much appreciate it.  I'm going to ask about the mass vaccination sites with FEMA.  Could you tell me with the country reaching the point of meeting all demand are you all in discussion with FEMA for closing down the military's participation in those sites?

DR. ADIRIM:  We are currently -- have -- I'm going to -- how can I answer this?  As long as FEMA has determined that keeping these vaccination sites open and that they need our support we will continue to staff them.  There's always discussions between NORTHCOM which has the lead on this and FEMA about where the needs are.

So, if there are any changes, you know, those are things that our NORTHCOM commander can, you know, announce.  

Q:  If I could ask a follow-up.  Do you all have any UAMTFs still working in civilian hospitals? 

GEN. PLACE:  Yes, that's a great question.  We'll take that one for the record.  I'm not personally aware of any but we can take it for the record and get you the exact answer. 

Q:  Thank you all so much. 

STAFF:  Thanks, Ellen.  Oren? 

Q:  About a month, month-and-a-half ago, the utilization rate was 88, 89 percent.  On Monday, John Kirby said it was 83 percent and now it's below 81 percent.  To what do you attribute what appears to be a declining trend?  And have you had to discard any doses of any vaccines? 

GEN. PLACE:  Sure, so one of the interesting situations is as you go from a supply-constrained environment to, in some locations perhaps, a supply-unconstrained environment.  More ends up sitting on the shelf as people aren't coming in. 

Remember that we still think this is a pretty valuable commodity, so we don't open them, we don't freeze them until they are going to be used.  And so if it turns out that we're not having the same number of people come in then we don't take it out of the freezer, which means that -- or the refrigerator in the case of Johnson & Johnson when we're using it.  But it's in there.  So that's why the numbers perhaps are going up. 

I forget the second part of your question? 

Q:  Have you had to discard doses? 

GEN. PLACE:  Oh.  The answer is yes.  I mean, that's -- we call that the ‘slop of business’ though.  If you look at any immunization program that we have, you're trying to stick a needle in, the needle goes in wrong, and some comes squirting out, so OK, you've lost it, or you're a human being, you're dealing with it, and you're distracted, and it falls to the floor. 

If you look at, though, the waste that we've had with this particular vaccine, it is by far and away less waste than we've had in any other mass vaccination program in our history.  So we're talking at the ranges of 0.04 to 0.06 percent wastage.  So yes, we have it, but it's minimal. 

Q:  And that's across the three different vaccines, Moderna, Pfizer...

(CROSSTALK)

GEN. PLACE:  It's across everything across the military and health system.  The numbers that you see up there that we've been -- that have been shipped to us, I think the number today was 0.06 or 0.07 percent that we've had of loss. 

STAFF:  Stay in the room here.  Caitlin?

Q:  Yes, so now that everyone is eligible overseas, are there any special indicators or anything that can allow someone to be prioritized above another person, say, for example, if they're PCSing? 

GEN. PLACE:  Yes, so the services, as they handle their PCS rules, as you recall, or maybe you didn't if you didn't hear what we talked about two weeks ago.  Each of the services have a little bit different way of approaching that.  And in particular, one of the services...

(CROSSTALK)

GEN. PLACE:  Yes, OK, one of the services, at least, is specifically vaccinating their service members before they PCS OCONUS, as an example.  But there is no departmental requirement for that to happen.  So they are each evaluating their situation.  And, quite frankly, as we get more and more vaccine overseas, it will be more prevalent overseas.  So then we will be having to vaccinate people here before they go just to try to achieve some sort of equity. 

But there is no departmental policy.  The services are addressing it individually. 

Q:  OK. 

STAFF:  Thank you. 

Jenny? 

Q:  Thanks.  I was just wondering about safeguards of vaccinations.  Is it safe with just the two vaccinations or do you think a third vaccination is necessary or what? 

DR. ADIRIM:  Are you talking about a booster? 

Q:  Yes. 

DR. ADIRIM:  Well, the science isn't settled yet about whether or not we're going to need a booster.  We anticipate that will likely will.  But we look to the FDA and CDC to make those determinations about whether or not we need a booster.  But we'll be prepared to administer that to our beneficiaries and our service members if that comes to pass. 

Q:  Dr. Fauci yesterday, he gave a briefing at the White House, he mentioned about maybe a third may be necessary.

DR. ADIRIM:  I think we can expect that you're going to need a booster.  But, again, for us, we look to the CDC and the FDA to make those recommendations and we implement it, so whatever Dr. Fauci says. 

STAFF:  Abraham? 

Q:  Thank you.  Thanks for doing this.  So two questions.  One, how do you circle back, now that you've opened it to everybody who's -- to the eligible, how do you circle back to tier 1A and tier 1B?  Like, what's the process for going back to folks who have turned it down before?  Are you doing a different approach to that to kind of pick up -- tie up loose ends? 

And also, you mentioned the word "normalcy." What is normalcy going to look like in DoD?  When is that going to happen? 

DR. ADIRIM:  Right.  I'll start with the first one.  That's a really good question.  And we do continue to notify our service members and others who are in the different tiers, giving them opportunities to come in to get vaccinated.  We use all communication channels at our disposal to not only communicate with our DoD family, but also to educate them about the vaccine. 

So we use social media.  We use our website.  We've sent out and emails.  All across the board to make sure that everybody has the information that they could come in and get vaccinated if they so choose. 

What was the second question? 

Q:  Normalcy. 

DR. ADIRIM:  Normalcy.  Yes, you know, I wish we could predict exactly what that would be.  Certainly if more people get vaccinated and lower the transmission within the United States, it wouldn't be just within DoD because we're all part of the same community.  So if at some point in time the virus is not transmittable, then we could get much closer to normal.  I know you've probably seen the news reports about Israel, it's pretty amazing that their vaccination rates and their ability to get out more. 

But we're not there yet.  We still need to remain vigilant.  We still need to use public health interventions.  We still need to mask, socially distance, and do our best to stay out of crowded indoor venues. 

Q:  And let me just follow up.  Nothing specific, no specific tactics for going back to those high priority tier 1A, tier 1B folks, it's just they get the same messaging that everybody else gets, they just get it again. 

GEN. PLACE:  Let me re-adjust that just a little bit.  There's no specific guidance from the department indicating to each of the individual 350 sites exactly how to do it.  That's an accurate statement.  But each of the locations have their own techniques and tactics on how they're approaching it.  So tier 1-Alpha, as you likely recall, at least in the department, is our emergency department staff, it's our first responders, it's the fire departments, it's the police forces, security forces, emergency medicine crews, ambulance crews, that sort of thing. 

We know who is vaccinated and we know who is not.  And so the individual leaders of those locations can go back and say, hey, look, you know, we still have some opportunities over there.  Are you interested yet or not?  Or, if a particularly large percentage (gain, feedback does come back to me) as  in when large groups have said collectively "we didn't want to do it then," they will bring even large groups together and said, ‘OK, now that we have 2.5 million doses across the department and you see just how safe and effective it is, does that change your mind at all?  Is there any information I can help you with as a group that perhaps might change your mind?’ 

And in some cases we've see entire organizations say, ‘yes, you're right, I was worried about it before now I'm not so worried about it’ and en masse.  So an ambulance crew or, you know, a shift in the emergency department that perhaps was worried about it before, now they're not. 

So yes, the answer is there's no departmental position about it but that doesn't mean that leaders aren't engaged locally with those they are responsible for to have that interaction, and it's happening and we're seeing it happen as the data continue to come in.

Q:  And that -- those best practices are being sent up the chains and ...

GEN. PLACE:  Absolutely, and -- and I continue to have telephone calls every single week with the directors of each one of these vaccination sites on the best practices that we're seeing.  We have internal products, communication products, information - products, educational products, et cetera that are made available to everyone that want them.  So, you know, you have to actually go to get it but it's on an internal, you know, share point site so that they can go get it.  Does that help?

Q:  OK, thank you.

GEN. PLACE:  You're welcome.

Q:  So I'm wondering, as -- since the population does tend to skew young, are you anticipating a difference in the hesitancy rate among the younger population of active duty?  And then I have a follow up question about these so-called "double variants."

DR. ADIRIM:  Yeah, no, both great topics.  You're exactly right, our population tends to be younger.  Their reasons to, perhaps, avoiding vaccination, or at least avoiding vaccination at this time, mirror that in the civilian sector.

We have heard anecdotally that -- and also through surveys, such as Blue Star Family surveys, that younger people may feel that they're not as vulnerable to COVID and that perhaps the risk of getting vaccination is higher than getting the disease, which of course we know not to be true.  We've also heard that people want to allow those who may be more at risk to get vaccinated. 

So there's all kinds of reasons and it's similar to what we see in the civilian sector, and this is an area where I think we could focus and we could do a lot better in focusing on that population, to help them get educated because the message really is that you're doing it not only to protect yourself but also your colleagues and teammates, your family and your community.

So that's the message that we're trying to get out to -- to those individuals, so -- and variants, right?

Q:  Yeah, on the double variants that are emerging in India and the -- have recently been reported, is there any thinking or worry about that, or ...?

DR. ADIRIM:  Yeah, no, absolutely, and we do worry about the variants and the impact of the variants on transmission.  As you know, the most common variant right now in the United States is the B117 variant, which is a highly transmissible virus.  We test for variants.  We do whole genome sequencing. 

We are -- you know, now that we're in a phase where a lot more of our people are getting vaccinated, we are looking at various testing strategies for post-vaccination, and whole genome sequencing is one of them -- one of the strategies.

STAFF:  Mike?

Q:  I just want to confirm, has there been no cases within DOD of any blood clotting problems related to the J&J vaccine?  You haven't -- have you -- I -- I know there's only, like, a handful, anyway.  Has there been -- I just want to confirm, there's none within DOD?

GEN. PLACE:  That's correct.  We are not aware of any clotting disorders or -- or challenges related to the J&J vaccine, Janssen vaccine, currently within our system.  That said, based on that guidance that I published, you know, it's very specifically tailored guidance, I will tell you that we're getting all kinds of people writing into our own internal vaccine adverse event reporting system with things that they're seeing.

But at present, we've not yet seen a case, we're not anticipating seeing a case.  That's just the information I have so far.

Q:  What are some of the -- some -- since you brought it up, what are some of the things that -- that you've received from these?

GEN. PLACE:  Well, remember that the guidance that came from J&J specifically, or from the FDA specifically, looked at pain.  It's headache, right, it's dizziness, it's seizure disorder, it's chest pain, it's shortness of breath, it's abdominal pain, it's extremity pain.  There's lots of reasons for having pain.  I mean, we're Americans, haven't you all had pain at some point or another?

 And so if temporarily-related you have pain and you've got a vaccine, then we're getting all kinds of that.  So the very generic guidance that went out with it has an incredible amount now of reports, among other things, related to pain for those who have had the J&J vaccine.

Q:  (inaudible) Thank you for doing this.  I don't know if this is in your area of responsibility.  Can you speak on the vaccination effort at the Guantanamo Bay, Cuba Prison?  The New York Times reported that maybe 90 percent of the prisoners have been vaccinated today.  Which vaccine are they getting and has there been any issues with this vaccination program at the Guantanamo Bay Prison?  Thank you.

DR. ADIRIM:  Sure.  Yeah, are you speaking specifically about the detainees?  Because yes, they did.  They were offered the vaccine this week and I think 32 out of the 40 accepted vaccination.

GEN. PLACE:  Yeah, the specific vaccine is Moderna, just like it is for all of our OCONUS locations.

DR. ADIRIM:  That (one ?).

STAFF:  Moshe?

Q:  Hey, thank you for doing this.  Last week, General Wolters, on Capitol Hill, said that the pause in Johnson & Johnson would impact the ability to ramp up vaccine distribution by about 20 percent.  So I'm just wondering what effect does the pause have on vaccine distribution at other overseas bases, or even here in the U.S., even if it's just in the short term?

DR. ADIRIM:  Well, we didn't distribute the J&J vaccine here in the United States.  I'll let General Place answer the question about the impacts, cause ...

(CROSSTALK)

GEN. PLACE:  In general numbers, I mean, you can see the numbers that we've had delivered -- 3.2 and a quarter million.  Of those 3.2 and a quarter million, it's about 150,000 that are J&J.  That's it.  We've administered just north of 60,000.  I'm not going to say the exact number, cause I don't remember it, but 63,000, 62,000, somewhere in that neighborhood, and another 99,000 I think we have under quarantine.  So we have it, it's in our refrigerators, but quarantined off away from the rest of it.

So we're talking about 150,000 total against 3.2 million doses.  So the total percentage in our inventory that we've received is relatively minimal.  Now, we did intend, as General Wolters mentioned, we did intend for a significant amount of that to be used in the European theater, and now we've had to go to Plan B, and that's what I tried to get to in my opening comments, that we've substituted an additional Moderna vaccine for what we thought we were going to be able to use Johnson & Johnson vaccine.

And as I indicated, we still believe that every single person, even up to 80 percent, accept the call to get a vaccine by the 1st of June.  We'll have enough vaccine there so that by the 1st of June, up to 80 percent of people who live in EUCOM, his specific area of responsibility, or any of the COCOMs will have a vaccine by substituting Moderna for what we thought we were going to have for J&J.

Q:  Thank you.

STAFF:  Oren ?

Q:  Just looking back at the numbers real quick, the -- there's about 620,000 un-administered doses.  Are you seeing or anticipating surpluses build up in places?

GEN. PLACE:  A little bit, yeah.  So as I had already indicated, 100,000 of those -- 99,000 and change is J&J.  So just take that into account.  But yeah, there's some locations that we are seeing some surplus.  Some of it is, as I think all of you know, the way the Pfizer and the Moderna doses work, it's you get both doses.  So here's the first dose, 21 days from now for the Pfizer, you get your second dose.  Moderna, here's first dose, 28 days, you get your second dose.  Well, lo and behold, some people don't come in for their second dose.  I'm sure that shocks all of you but so then, what do you do with it?

Now, according to the phase three clinical trial, it's actually 21 to 42 days for Pfizer or 28 to 42 days so certainly they have to keep it for several weeks just in case the person says ‘well I didn't come in on exactly the day but I can still come in with that amount of time it'll still be effective for me.’  So in some cases we're keeping it around because people still may come in. 

And other cases it's in a location, just as someone mentioned before, perhaps that particularly part of the country isn't as interested in becoming vaccinated as another part of the country.  And even though we're trying to distribute it across all 350 vaccination sites equally the acceptance rates at all locations isn't necessarily equal.  And so all those are variables that we have to work through as we deal with the allocations that we get.

We are very close, or perhaps we're there already, from a tipping point to this being a supply limited environment to some other factor whether it's acceptance rates or we think that we still need to vaccinate people.  But as I mentioned in my opening comments fully 444,000 that we know of, DOD beneficiaries have gotten a vaccination somewhere else.  Maybe it's higher than that and they just haven't told us because they didn't bring the information in, so all these are variables that we're trying to sort through. 

So the answer to your question is I don't know.  But those are all the things that I think about as we work the program at least as we know it today. 

Q:  Thank you.

STAFF:  Do we have any further questions in the room?  All right, well with that I will hand it back over to General Place and Dr. Adirim for final comments. 

DR. ADIRIM:  Sure, well I want to thank all of our DOD family who have accepted vaccine.  They really are helping us to reduce the transmission and helping us get closer to normal.  I also want to thank our hard working military medical personnel who are doing the hard work and getting our people vaccinated as well as our fellow Americans. 

GEN. PLACE:  I’ll echo that as well and it there was a comment already about the FEMA teams but there wasn't a comment about the National Guard and I think all of you know but in each of the states and territories the National Guard is working hard to support the citizens of those states or territories.  So between the active duty support to the FEMA teams and the National Guard support I could tell you that, in addition to what we're doing inside of our vaccination sites, that's led to more than 11 million more vaccinations across America. 

So from a whole of government, a whole of DOD support if you add all that stuff up together it's almost 14 million doses gone into Americans at the hands of someone wearing the uniform of the United States.  And we're really proud of that. 

That said, again to the question about the normalcy,  I don't know what the new normal is going to look like but we live in a changing environment all the time.  That's just the world we live in, it's always changing.  So I don't  know what normal's going to look like but I do know this- that as long as we're aware of the requirements -- the requirements from a public health perspective of stay home when you're sick, wash your hands, all right be nice to other people, get tested when it's appropriate and if OK for you based on the feedback the you get from your healthcare provider get vaccinated.

Whatever that new normal is going to look like we're going to get there faster and that's if we do it together.

So thanks for the great questions.  Thanks for you continued involvement with these iterative press gatherings that we have and we thank you for the questions. 

DR. ADIRIM:  Thank you.

STAFF:  Thank you all and thank you to our special guests, General Place and Dr. Adirim.  Thank you.