Latest / Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner / The Buzz About: Mosquito Borne Illnesses, Polio, and HPV

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The Buzz About: Mosquito Borne Illnesses, Polio, and HPV · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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So and before I forget, I know you bring things for the group with Barbie souvenirs.
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Do you want to mention what you brought? I'm just curious.
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I'm going to forget if we dig into office. Well, I have a very cute pink shirt
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in Barbie letters that says vote. That's nice. Yep.
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And this year, the theme of the Barbie convention was kind of a mystery theme.
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It was a little bit like a clue game mystery theme. It was in Palm Springs where
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there's all of these like amazing mid-century modern houses.
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So it was kind of like a mystery at the Barbie dream house, you know, thing.
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And so the souvenirs that we brought home were actually like cardboard,
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a mid-century modern dream house backdrops and furniture.
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Welcome.
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Music.
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Pediatrics Now is brought to you by the Department of Pediatrics at the University
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of Texas Health Science Center at San Antonio and University Health's new Women's
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and Children's Hospital.
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Which is pretty swanky. Very nice. Yes.
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That sounds so fun. Do you feel like doing things like that,
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going to the Barbie convention, which you're passionate about,
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does that help you to do an even better job to be able to unplug and go do something like that?
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Yeah, I think everybody needs to have a work-life balance, right?
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Like it's, you know, if your job is stressful, regardless of what kind of job
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it is, it's, you know, you need to have an outlet.
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So shall we move on to West Nile virus? Sure.
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So this was also a major headline recently. Our former top U.S.
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Infectious disease expert, Anthony Fauci, was hospitalized with the mosquito-borne
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West Nile virus. So West Nile virus is a virus that we pick up by being bitten by a mosquito.
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And so we get West Nile virus pretty much every year since the early 2000s.
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So that virus sort of arrived in the United States in like 2003 or something like that.
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And since that time, it continues to circulate.
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It's seasonal, so it has a season of when mosquitoes are out and biting us.
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So we're actually currently in the season. We're actually just past the season.
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So as it cools off and the mosquitoes become less crazy, the West Nile season goes away.
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So it usually peaks in August every year.
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Nationwide, it peaks in August every year. And it is a virus that infects our
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nervous system, so it causes an encephalitis.
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Which is basically just means an infection of the brain tissue.
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And most people who are infected don't know that they are? That's right.
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So as with many viruses, we pick them up.
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Our immune system does its job. We get a brief illness, or maybe not even an illness at all.
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Maybe we're just asymptomatic, right? Maybe we don't have any symptoms because
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our immune system was on patrol.
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It found a virus. It killed it.
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And we never even knew it was there. So some people will just get a nothing.
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Some people will get a brief kind of, I don't feel well, I've got a headache
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and a fever for a few days, and then they get better.
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And some people will get the more serious, full-blown encephalitis.
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So what is your advice? I know we talked about it in summer safety,
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and we have listeners, practitioner listeners, especially around the world.
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So what is your advice in general for West Nile prevention? So for the individual person.
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West Nile is a mosquito-borne virus. The mosquito is the most dangerous animal in the world, right?
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Kills more people than any other animal in the whole world. Wow.
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When you put it that way, I'm worried.
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Right? More dangerous than lions, more dangerous than cobras, a mosquito.
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Because mosquitoes carry lots of different infections. So here in the United
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States, we mostly have West Nile
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as our mosquito-borne infection and a few other things here and there.
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But around the world, there's dengue, there's malaria, there's yellow fever,
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there's Japanese encephalitis.
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There's a lot of different viruses that are carried by mosquitoes.
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So the best thing that we can do to protect ourselves against mosquito-borne
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viruses is to protect ourselves against mosquitoes.
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And so that is all of the normal common sense things that we do,
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like when it is mosquito season, you know, wearing long sleeves and long pants,
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as much as you can tolerate that,
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and mosquito repellents, right?
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You know, when there's an outbreak of something, you know, addressing things
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like the, you know, like the potted plants in your yard that were there,
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or, you know, uncovered pools or.
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Puddles or, you know, water where mosquitoes breed, things like that.
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But really, it's just mosquito avoidance and all the normal things that we do to avoid mosquitoes.
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Is it on the rise since it's getting attention?
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It's actually not on the rise right now. So yeah, so I looked up some stats
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and it looks like this year we've had 65 cases in Texas, 880 cases in the United States as a whole.
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And those numbers are about normal for us.
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So we're not having some unusual West Nile outbreak, we're having kind of our
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usual flurry of West Niles.
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And, and so we're,
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This is actually where we really need public health authorities,
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like the health departments actually surveil for West Nile.
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So we have these things called sentinel chickens and sentinel horses.
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And these are like farm places where the health department goes and they test
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them to see if they've been exposed to West Nile.
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And that's how they know in advance, before we start seeing human cases,
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whether West Nile has kind of entered our regional community.
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And so, yeah. So people who are interested in that can actually pay attention
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to, I mean, the Texas Department of State Health Services has a whole website,
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whole webpage devoted to West Nile.
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And you can look at like the maps of like, where are the West Nile cases in Texas?
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How many cases, how many human cases, how many encephalitis cases?
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You can get all that information, you know, for free from the health department
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because that's, you know, an amazing part of our public health system.
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So most states would have that as well or every state. Yep.
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So that's so interesting. And I know you'd like to keep your eye on the wastewater. Yeah.
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Because that tells us a lot, too, from the health department.
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Yeah. So not all health departments do wastewater screenings.
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But wastewater is kind of a neat way that we can keep track of the things that
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are circulating in our communities.
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Shall we move on to something else mosquitoes carry? Sure.
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Eastern equine encephalitis, which sounds terrible and is terrible.
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Yes. And I mean, this can kill someone. In fact, it killed someone in New Hampshire recently.
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That's right. So Eastern equine encephalitis is also one of these viruses that
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is carried by mosquitoes.
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There's actually a bunch of them that we call arboviruses.
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And so there's Eastern equine, there's Western equine, there's St.
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Louis encephalitis, there's California equine encephalitis. So there's all sorts
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of encephalitis viruses.
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West Nile is one of those. So eastern equine is one of the more particularly
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severe ones that can lead to a very fulminant, life-threatening encephalitis.
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Although similar to West Nile, 95% of people who get eastern equine encephalitis
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have a mild disease or an asymptomatic infection.
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So it's really only 5% of cases of what some people call triple E,
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where you get that full-blown encephalitis.
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But yes, it can absolutely leave you paralyzed permanently or with,
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you know, brain damage from the inflammation that happens.
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So the risk is very small, though. However...
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What else do you want to say about this? And right now, what are you doing until
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we get that true first cold friend?
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Are you putting on mosquito repellent when you go out? Sure.
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So I would say in Texas, we really shouldn't have to worry about eastern equine encephalitis.
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Like we haven't had that.
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But I think it is something that health departments will be paying attention
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to because until a few years ago, we had actually gone for about 20 years in
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the United States without having any cases of Eastern equine encephalitis.
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So, you know, we know that once something begins to circulate and it is able
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to establish itself in the animal reservoir, it can then, you know,
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begin to recur and rise in humans as well. Does it come from horses?
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Originally, yeah. So originally I think it was maybe discovered in horses because
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it actually causes disease in horses, but it actually comes from birds.
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So most of these viruses, Japanese encephalitis does this too.
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Most of the viruses have a bird cycle and that's where they kind of stay,
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you know, year round is being harbored in birds. That's also how they migrate around.
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So that's how we got West Nile virus because we didn't have that in the United
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States, but migratory birds brought it from other places.
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Wow. And Tess, as an infectious disease doctor on the front lines,
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though, do you still put on mosquito spray every time you go out in your garden? Yep.
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With DEET? Yep.
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Yep, I do. I was gardening this weekend, and I sprayed myself with my DEET and
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went on about my business.
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So yes. And anywhere clothing isn't covering our skin because mosquitoes can't
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bite as well. That's right. Mosquitoes are not that strong.
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They have a hard time biting through your clothes.
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And so usually they'll bite you in the places that are exposed.
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So covering up as best as you can and then using some kind of repellent.
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I usually recommend DEET, but there are a lot of different alternatives.
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One of the ones, if people are looking for something more natural,
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is oil of lemon eucalyptus.
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Not quite as effective, though? Not quite as effective, although in a clinical
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trial, it was not significantly different than DEET.
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But you know that the DEET works, so that's what you use. And I know you love
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to travel. A lot of our listeners do, too.
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When you're traveling, do you bring or buy mosquito repellent? I do.
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I'm very vigilant about that, especially because, I mean, I like to travel to
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the tropics and to developing world places.
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And those are the places that have dengue and malaria and Japanese encephalitis. Yes.
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And, you know, and I don't, there is a vaccine for dengue that's not available
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to us, but. Because we don't need it in the United States?
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It's available in Puerto Rico, which is the United States, but that's it.
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So it's available for endemic areas for complicated reasons.
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And similarly, there's a malaria vaccine that is not licensed in the U.S.,
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but can be used in malaria endemic areas. Wow.
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And then if you're going somewhere where it's cold, though, you don't worry about that.
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No, no. Then I don't worry about mosquitoes if it's cold. Bed bugs? Yes.
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And respiratory viruses, right? Because the winter is winter virus season.
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And for our practitioner listeners, we will have an episode on everything we're
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talking about for parents on our sister podcast, Pediatrics Now for Parents,
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that can also be found wherever you get your podcasts.
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And the website for that is pediatricsnowforparents.com.
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Our last topic, unless you want to say anything else about equine encephalitis,
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is there anything, COVID, flu, anything you want to say? No.
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Okay, so speaking of paralysis, as we know, this is another recent article.
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The poliovirus that paralyzed a child in Gaza, the first case in the region
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in 25 years, has traveled a long path.
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It says, according to the New York Times, it most likely arose in Nigeria and
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made its way to Chad, where it was first detected in 2019, according to the genetic data.
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Analysis. Poliovirus is a virus that, you know, we had a ton of up until the
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early part of the 20th century.
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My grandfather actually had polio when he was a baby.
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Did he have long-term effects? He did. Yeah, he did. He had a very abnormal gait.
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And then, of course, you know, by
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the time he was middle-aged he really had to use a wheelchair
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but he he actually didn't mind because
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because ultimately because he couldn't walk properly he
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couldn't enroll in the military when he was a young man
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and so then world war ii he got to stay at home in his small texas town and
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he says he married the prettiest girl in town because all the other boys were
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gone and she was pretty my grandma was the best girl in town.
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So yeah, so polio, you know, most of us have never seen polio.
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But if we are now of an old age, like I am, you know, we had grandparents and
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older family members who may have had polio.
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And polio is no joke. Like polio paralyzes you and leaves you usually with a permanent disability.
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So scary. If you survive it.
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So, and, and so we, we have had very, very effective vaccines for polio.
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And traditionally there have been two types of vaccines for polio.
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One is the, an oral live polio vaccine, which contains live polio viruses and you swallow them.
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Polio is a virus that we ingest. So it's fecal oral. So we get it from contaminated food or water.
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And then it...
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Circulates, it grows in our intestines and can infect our spinal cord.
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And then, and we poop it out. And when we poop it out, then it gets into the
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soil or the water and other people become exposed. And that's how polio spreads.
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And, and, and so we had the first vaccine for polio was an alive oral polio
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vaccine where the virus had been altered so that it couldn't make you sick,
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but that it could still grow in your intestines and you pooped it out.
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And the advantage of that is
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you could give a certain number of people in your village polio vaccine,
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and then everybody would get kind of vaccinated because everybody would get
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exposed to each other's poop in their contaminated water or through poor hand
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hygiene or whatever, right? Like all the things.
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And so you would get what's called herd immunity. That's actually what herd
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immunity is, is where you've vaccinated a few members of the community,
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but then everybody gets immunity because they all actually get exposed to the virus.
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And so we don't use the oral polio vaccine in the US. We haven't used it for decades.
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And then there's an injectable polio vaccine, which is not live. It's killed viruses.
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So it's viruses that have been killed.
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And then And we put their pieces into us to teach our immune system what polio looks like.
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And both of those vaccines are very effective.
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The oral polio vaccine may be a little bit more effective than the injectable one,
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but obviously has its initial intended effect of giving herd immunity,
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which is an unfortunate unintended effect of spreading polio.
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Right, of having polio then circulating in a water system.
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Or a sewage system that is capable of infecting people.
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And so then if you, so for instance, a couple of years ago, there was a case
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of polio in a man in New York, and not in New York City, but in one of the other
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cities and other towns in New York.
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And he was unvaccinated, so he didn't have any of his own protection against
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polio because he himself had not been vaccinated, but he was exposed to this
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vaccine strain of polio.
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So somebody in the community that he was in contact with had had the oral vaccine
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and was pooping out vaccine polio, and he ingested that.
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And because he didn't have any immunity, he got polio from the vaccine polio.
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So all of the polio that we have had in the United States since, I mean, a long...
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A long time, decades and decades, has been what's called vaccine-associated paralytic polio or VAP.
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And so that's why we stopped using the oral polio vaccine, because we just don't
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have enough circulating polio anymore.
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We've basically eradicated it from the United States. So we didn't need to use
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that version of the vaccine anymore. We could use the other version.
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But in the rest of the world, they have used the oral polio vaccine.
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But the problem is, is that in most places, there are only places,
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there've only been a tiny number of wild type polio infections left in the world
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in, and I don't remember all, it's like Nigeria and Pakistan and a few other places.
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Every other polio case in the world has been vaccine-associated polio.
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So there has been a large push to move away from the oral polio vaccine,
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because why would we keep allowing people to be exposed to the live poliovirus
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if there's enough immunity that we can prevent it from happening using the killed poliovirus vaccine?
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But the problem is you have wars
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and other things that disrupt vaccination campaigns and people lose it,
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whole entire communities lose immunity to diseases because in the middle of
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a war, you can't, you can't do your vaccine campaigns.
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And so that's when we see measles come back. You know,
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we see measles running rampant in, in Syrian refugee camps and you see chicken
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pox running rampant in our southern border, you know, immigration centers.
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And you see polio popping up in Syria and in Gaza and places like that.
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So and then the race is on now to vaccinate as many children as possible in Gaza.
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How worried are you about this? I mean, I'm worried about it.
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For those people. I'm not worried about it for the United States,
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except that we have less and less and less coverage of polio vaccine.
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We have more and more people who decline getting their children vaccinated.
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And so, you know, with eventually somebody, you know, people are going to travel
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around and are going to pick up, you know, a wild type polio strain and bring it back.
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And the solution to that is not preventing people from moving around, right?
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Preventing UN peacekeepers from going to a country and then going back to their
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home country or preventing refugees from coming from one place to another place or preventing,
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you know christian missionaries from going to
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a place and then coming home right like the the
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key is let's keep everybody at home and as immune as possible so that way when
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these diseases get accidentally imported back into our community we don't really
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have to worry about them because there's enough enough widespread immune protection
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that they don't even have a chance to circulate,
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which goes back to the vaccines.
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Yeah, yeah. So, you know, and killed polio vaccine, the IPV or the inactivated
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polio vaccine, that's the injectable one, is super safe. You can't get polio from that vaccine.
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All you can get is immunity to polio from that vaccine.
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So, you know, that should be a no-brainer.
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Anybody who's going to be traveling, you know, to do any kind of medical work
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or missionary work or military work or peacekeeping work should be vaccinated for polio.
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Say if there was more of an outbreak, would we be able to get the vaccines in
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mass quantities in the United States? We should be.
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I mean, we should be. I mean, as far as I know, I don't know that there's a
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shortage of polio vaccine.
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You know, the polio vaccine is part of our routine childhood vaccination series. And for the...
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The parents who choose not to get their kids vaccinated, though,
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they could be opened up to getting polio at some point?
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They could be. I mean, the good thing is because we are not using the oral polio
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vaccine, if a parent has chosen to not vaccinate their child,
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their child has an extremely low risk of coming in contact with the vaccine-associated
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polio virus because we don't have that circulating in our community.
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The exception becomes when that child travels, right, or the parents have traveled
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and then they come home with that and their child's not protected.
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The pediatric practitioners say some parents are saying, I don't want so many
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vaccines where they're lumped together.
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Is there any concern about the current recommendations, a child or baby getting
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too many vaccines at once?
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No. So, I mean, this is an issue that often gets raised, that this idea that
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we're exposing them to too many antigens at the same time and that that will
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overwhelm the immune system or be too much for the immune system to handle.
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And while that might make sense logically, I think that we have to remember
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that every single thing, every time we breathe...
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Every time we eat or drink, we actually expose our body to a bunch of different pathogens.
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Like there are things that we don't see them, but they live in like the dust and the houseplants.
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None of our food is actually sterile. Our water is not sterile.
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And so we put antigens inside our body on a second by second basis.
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And so we're constantly being exposed to antigens.
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And honestly, those few microliters of an antigen that is in a vaccine is like
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pennies to the daily onslaught of things that our immune systems are dealing.
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So an antigen is basically a piece, like a protein or some piece of a germ that
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is the thing that we react to, right?
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So lots of different things can be an antigen.
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You know, if you think about a virus, I think everybody's kind of gotten familiar with COVID.
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If you think about like all those little spike proteins on the outside and the
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membrane that the virus is made of, and all the little bits and pieces.
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Every single one of those pieces is an antigen.
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If you think about your food, like the number of different proteins that are
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on your food particles is, you know,
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hundreds, thousands of different shaped components that we can react to, right?
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So if you have a peanut allergy, you react to peanut antigens,
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right? If you have a soy allergy, you react to soy antigens.
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So an antigen is basically just a component that makes up a whole.
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And if it's something that our immune systems react to, then we call it an antigen.
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Tess, this has been so insightful. It's such an honor to be here with you today.
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Is there anything we didn't cover that you want to mention before we go?
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I know we've covered a lot. It's all so important. I guess the only other thing
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I would like to mention just about polio is about the wastewater surveillance.
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So, you know, one of the, like I mentioned, I mentioned that there was the man
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in New York in 2022 who had polio.
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And so after that case, that town in New York, and of course,
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the state in general in multiple places started surveilling the wastewater for
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polio virus, because it's a virus that lives in the intestines and you poop it out.
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So it's actually one of the easier things to find in wastewater.
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And so there has been pretty active surveillance for polio in the wastewater.
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And as of March of this year, that town, which is called Rockland,
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New York, has not detected any more polio in its wastewater.
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So they did a big vaccination campaign to try to be sure that the town was adequately
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immunized against polio in case there were circulating, you know,
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people who were circulating that viral strain around.
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And that seems to have been successful because there's no more polio circulating in that wastewater.
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Wow. So a success story. Yes. People can change.
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I'm a believer in that. And so say if a parent's listening who their kids did
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not get the regular vaccines, they haven't gotten the regular vaccines,
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should they, and now they're teenagers, should they go out and get their kids vaccinated?
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As an infectious disease doctor, I say yes. There are actually some vaccines
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that by the time you're a teenager, they don't need those vaccines anymore because
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the time that they would have been susceptible to those infections has passed.
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But there may be new ones that they get because we have teenager vaccines too,
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things that we don't give to the little babies.
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HPV. Like HPV vaccine, an endococcal vaccine.
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And so what I would say is if a parent has been not wanting to vaccinate their
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child for a variety of reasons, I would recommend that they literally like write down their concerns.
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Like really make a list.
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Like here, here is the thing that is my concern and talk about it with your pediatrician, right?
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Because, because it's easy to see a lot of misinformation on the internet.
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And, and I can guarantee that the vast majority of pediatricians are not like
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in the pocket of big pharma or something like that.
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They really just want to keep your child healthy.
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And that that is their goal is to keep your child healthy. And they're not going
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to be recommending things that they think are going to hurt your child.
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And, and so if, if there may be valid concerns that you have,
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and I think it's important to raise those to truly understand like what,
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you know, what is the issue?
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And I'll give you an example that I recently had an encounter with some patients
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in the hospital and they hadn't vaccinated their child.
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And I just asked why, like, what was, you know, what was the reason?
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And they were like, well, it was a religious exemption. And I was like,
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well, what was the religion?
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Right? Like, what was that? And they were like, well, we're Muslim.
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And I was like, okay, so is the concern, because there's,
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In Islam, there's no religious exemption against giving vaccines in Islam.
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And I mean, I knew that. It wasn't, you didn't confront them with that.
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But like, really, what was the concern?
29:59
And the concern was pork products, right? So gelatin is a pork product.
30:05
So, you know, which vaccines contain gelatin and which ones don't.
30:08
So then that really came back to me to be like, well, okay, maybe I should go
30:13
look up and see which vaccines contain gelatin so I can at least let this family
30:17
know these are the vaccines that you,
30:20
you know, from that standpoint, if it's truly an issue of religion and pork,
30:24
these are the vaccines you don't have to worry about because they don't contain that.
30:28
These are the vaccines that you may want to avoid because they do contain that.
30:32
And they may choose or, you know, and if that was truly their reasoning for
30:37
not doing that, then at least I've given them some information about it.
30:43
But I think, you know, from a parent standpoint, just being like,
30:47
oh, we just don't do any vaccines because it's against our religion or whatever the reason is,
30:52
like, I think it's important to really pin that down because there may be things that,
30:59
you know, you could protect your child against,
31:01
but still not violate your religious belief, right and maybe it wouldn't be
31:06
a hundred percent of things but but I think that we all want to,
31:10
keep children healthy and keep them protected and.
31:14
And I think that that's where the pediatrician and the parent can kind of work
31:19
together to come up with a solution.
31:22
It doesn't have to be all or nothing if your religious belief is preventing
31:27
you from getting a certain type of vaccine. Right. It's a great point.
31:32
What about as adults? If adults weren't vaccinated as children,
31:36
do you have any advice for the listeners then?
31:40
Yeah. So I'll tell you, usually what I do with people who have been unvaccinated
31:44
and are now older, they're either teenagers or adults, is really to kind of
31:48
be practical about it and like
31:49
which of the things that you're actually going to be exposed to, right?
31:52
So like am I, you know, I may not need to vaccinate you against polio if there's
31:59
no circulating polio and you're not traveling anywhere or whatever.
32:03
Maybe that's one that I could spare you.
32:05
But I know that if you are, you know, you like to go out camping or hiking or
32:10
whatever, you probably need your tetanus vaccine if you've never had a tetanus
32:14
vaccine, because tetanus is actually ubiquitous in our environment.
32:17
We just don't see tetanus because we vaccinate people, right?
32:21
But there are cases of tetanus that pop up every now and then.
32:26
And, you know, or hepatitis A, such a common foodborne virus,
32:31
that super effective vaccine that is something you might realistically in San
32:36
Antonio be getting exposed to.
32:38
And if you got the vaccines as a child, you got that?
32:42
It depends on how old you were. So how old about?
32:46
I don't know the year off the top of my head, but I know that we started,
32:53
it became part of the routine childhood vaccine series series.
32:59
In the late 90s, early 2000s, sometime around then, prior to that,
33:07
hep A vaccine was only for high-risk areas or high-risk people.
33:12
And so people who were born in 2000-ish or something like that or later probably had it as a child,
33:23
but people who are older than that maybe didn't have it. So you recommend going out and getting it?
33:28
Yeah, yeah. What about the Hep B vaccine? I'm a volunteer in the NICU at the
33:33
University Health's new Women and Children's Hospital.
33:36
So I just got it. But if you're not working in a health care setting.
33:40
Yeah, so Hep B is a virus that you get through blood or sexual exposures.
33:45
And so, yeah, so people who are doing health care work are at a particularly high risk for Hep B.
33:51
People who are using needles for either drug needles or tattoo needles have
34:03
a higher risk of getting hep B.
34:04
And people who have some higher risk sexual activities are at a higher risk for getting hep B.
34:11
So yeah, so if that applies to somebody, they should consider getting protected against hep B.
34:19
And the HPV vaccine, is it still, you have to be, it's, if you're older than 44, you can't get that?
34:26
Yeah. So I, so I.
34:29
Yeah. I don't, I don't know the upper cutoff since I'm a pediatrician and it
34:33
used to be, it used to be 26, but then I know that they loosened up those guidelines
34:38
and I don't, and you know,
34:41
the, the rationale was really just that like by, by that time you've already
34:44
had so much HPV that, that the horse is out of the barn.
34:48
But I think that there are some more recent data suggesting that, you know,
34:54
HPV vaccine actually enhances your natural immune system dealing with a virus
35:03
you already have as well.
35:05
So I don't know what the upper age limit for HPV vaccine.
35:09
Again as with all other things if you can prevent the
35:12
thing from getting into you sticking to you
35:15
when you get exposed to it in the first place
35:18
it's better than trying to deal with it afterwards so
35:21
for our parent listeners our pediatrician listeners if you haven't had the hpv
35:25
vaccine that might be something to look into yeah absolutely and and you definitely
35:31
for your for your children like no don't wait until they're sexually active
35:36
to get their hpv vaccine because it's one of the first STDs that comes along.
35:41
Like get them protected against it before they become sexually active.
35:45
And that way, it's like one less thing that you have to worry about. Exactly.
35:50
That's great advice. Anything that we didn't talk about? No, I think that's it.
35:55
I think my daughter got, it started at age 11, the HPV vaccine.
35:59
I think now we give it at nine. Wow.
36:02
If you can convince somebody to take it at nine.
36:06
Nine-year-olds don't like it. Dr. Tess Barton with University Health and the
36:12
University of Texas Health Science Center at San Antonio, infectious disease expert.
36:16
Thank you so much for being here today again on Pediatrics Now. Great. Thanks.
36:21
We hope you've enjoyed this episode of Pediatrics Now. Click on the link for.
36:23
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36:28
You can also email us with questions or episode ideas.
36:31
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36:41
I'm Holly Wayment. I hope you can join us for our next episode.