COVID-19 vaccination for people with cancer, with Steven Pergam, MD, MPH

It has been one year since the first cases of COVID-19 were seen in America and the country is in a race to vaccinate as many people as possible to end the pandemic. With more people getting the vaccine each day, it’s natural to want to know everything you can before you choose to get it, too.

Living Beyond Breast Cancer CEO Jean A. Sachs, MSS, MLSP, spoke to infectious disease expert and co-leader of the National Comprehensive Cancer Network COVID-19 Vaccine Committee Steven A. Pergam, MD, MPH, about the COVID-19 vaccines, focusing on how the vaccines work in and affect people in treatment for breast cancer. Dr. Pergam discusses what we know about the safety and side effects of the vaccines, how to plan for vaccines alongside current treatment, why you should continue social distancing and masking precautions after getting the vaccine, and why it’s important to get the vaccine when you have the chance.

Living Beyond Breast Cancer supports prioritizing people in active treatment and those with a history of cancer to receive the COVID-19 vaccine. To learn more about our support, read the letter to President Joseph R. Biden and the state health departments that we co-signed with more than 120 cancer organizations.

Steven A. Pergam, MD, MPH
Steven A. Pergam, MD, MPH, is an associate member in the clinical research and vaccine and infectious disease divisions at the Fred Hutchinson Cancer Research Center. Dr. Pergam serves as the medical director of infection prevention at the Seattle Cancer Care Alliance, where he and his staff have developed a robust program to protect cancer and transplant recipients against major healthcare-associated infections. Read more.

 

Jean A. Sachs, MSS, MLSP

Chief Executive Officer, Living Beyond Breast Cancer

Jean began her work with LBBC in 1996 when she became the organization’s first executive director; she was named CEO in 2008. Jean brings a lifetime of women’s advocacy experience to her role as CEO. She lives LBBC’s mission everyday by speaking with newly diagnosed women about their needs and gaps in support. Read more.

Jean A. Sachs, MSS, MLSP

Hi, everyone. I'm Jean Sachs I'm the CEO of Living Beyond Breast Cancer. I am very excited today we have an expert who is going to talk about the vaccine for COVID-19, which we know has been on everybody's mind for well over a year. Since the beginning of the COVID-19 pandemic, Living Beyond Breast Cancer has been bringing you information from various healthcare providers and experts to help you learn more about ways to protect yourself and to protect those living with a breast cancer diagnosis. Today, in February of 2021, we have two approved vaccines for COVID-19. And as of this conversation, more than 34 million Americans have received their first dose of the vaccine, with over 1.5 million people receiving it every day. We know members of our community have a lot of questions, which is why we have brought Dr. Pergam with us today to help answer them. First I'm going to let him introduce himself. Hi, it's good to have you with us.

Steven A. Pergam, MD, MPH

Well, thanks so much for having me. I'm always happy to join you guys. I'm Steve Pergam. I'm an infectious disease physician and I'm an associate professor at the Fred Hutchinson Cancer Research Center. I'm also the director of infection prevention at the Seattle Cancer Care Alliance. So I've been working really closely with COVID vaccines, as we've sort of rolled them out among our population. So I have a lot of familiarity with this and I'm excited to talk to you guys.

Jean A. Sachs, MSS, MLSP

Great. I'm sure there's a lot of demand on your time. We really appreciate your making time for us. So, let's get started. The National Comprehensive Cancer Network or NCCN has come out with guidelines to help healthcare facilities determine how to prioritize people with cancer, if they should get the vaccine, and when they should get the vaccine. As the co-leader of the NCCN COVID-19 vaccine committee, what are the guidance you provide that would affect people with breast cancer?

Steven A. Pergam, MD, MPH

Yeah, so the NCCN guideline, first of all, is this a great opportunity to work with a lot of different people, and I think one of the takeaways that we had during that discussion was we wanted to make getting COVID vaccines to patients, to cancer patients specifically, as easy as possible. And what we came up with was the idea that we wanted to not focus specifically on diseases, or specific treatments, but to focus more on who was undergoing active treatment as the primary reason to get people the vaccine. The thought being that they're at the highest risk for developing COVID-related complications. To get them the vaccine was our first priority. And then all of the other pieces played a role on the issues like comorbidities, things like heart disease or lung disease. Of course, age is also very important. All of these factors together play a role in terms of determining who should be getting the vaccine.

Jean A. Sachs, MSS, MLSP

So, since you're prioritizing those in active treatment, is there a difference for someone who has early-stage breast cancer as opposed to someone who has metastatic disease, so is always in treatment?

Steven A. Pergam, MD, MPH

Yeah. So, first let's start by saying if you're a cancer patient and you're offered the vaccine, the answer should be yes. You should get it as soon as you can. This is more the guidelines to help if there's decisions to be made and you have to have to choose between individuals, so that we focus on those at highest risk. I think those that are primarily on hormone therapy, those are ones who are not necessarily at highest risk because they're not receiving treatment that's going to bring down their immune system as much as others who are receiving what we call cytotoxic chemotherapy. I think that's a slight difference, but otherwise, I think we want all of our patients to get vaccinated as soon as they can. So if they hear about a vaccine, they know there's a vaccine available to them, either at their cancer center or someplace locally, I would get it.

Jean A. Sachs, MSS, MLSP

Okay. What if you're you have a planned surgery? Is it appropriate to get vaccinated before that?

Steven A. Pergam, MD, MPH

Sure. One way to think about it is, if you're coming up emergently on that surgery, like in the next couple of days, you might want to hold off getting vaccinated, because we know that surgery itself is challenging and what we don't want to happen is for you to get a vaccine, have a reaction, even a slight reaction like a low grade fever, where they might delay your surgery because of that. What we’d really suggest is if it's a ways out – a couple of weeks before your surgery — go for it. Right after your surgery we usually don't give people vaccines. We'd wait about a week or so after your surgery to offer a vaccine to you then. So if you can time it somewhere around when your surgery is going to happen, then that's probably the best.

Jean A. Sachs, MSS, MLSP

Let's talk about safety. As we know, there have been a lot of questions and concerns that these vaccines were put through a very expedited process. How do these vaccines work and how do we know they're safe?

Steven A. Pergam, MD, MPH

These are vaccines that have been rigorously studied in phase III trials, where they've been given to 40,000 to 60,000 people to look at efficacy, and they've reviewed safety data as well. I think anyone who looks at the data now there's been, as you said earlier in the discussion, over 30 million people who've received the vaccine and we have not heard a large number of additional side effects or any things that were unexpected. The things that we know are associated with the vaccine are: you can get a little arm soreness from where your shot happened. You can certainly get a little bit of redness at the site where you've gotten the shot, and then some of the COVID-like symptoms might show up. You might have fatigue, you might have a fever, you might develop muscle aches all over.

Those are not atypical and sometimes not surprising. We've had some people that have developed more prominent symptoms after their second vaccine because you’ve boosted the immune system and had more of a response. A little bit different than some vaccines, we've had some people develop headaches as another side effect. That's not uncommon with COVID, too. So there's been a couple of different things that have happened during that, from the standard vaccine, are pretty common, related, symptoms.

The things that are rare, that have been described is something called Bell's palsy, where you get weakness on one side of your face, usually related to a reactivation of a virus called herpes zoster or herpes simplex. And interestingly enough, we know that immune responses in general can lead to reactivations to these viruses. So, it's not been a huge surprise. We haven't seen a large number of those to be concerned.

There also have been a couple of reports, and I think you have to be really careful of this, before you went into this, I'll just comment that I think, when you look in the news, you'll see a report that somebody got a vaccine and had some strange side effect and now everybody should be worried about it. Well, if you're giving it to 32 million people, people can develop all kinds of reactions, not necessarily always to the vaccine. Sometimes it may be, but the method by how this is being followed is really rigorous.

There are two systems in place that people are following really closely. One is called VAERS (Vaccine Adverse Event Reporting System). And, basically, that is on your vaccine card that you have. On the bottom of it, on the backside, it's got a place where you can report any strange symptoms you might develop. Additionally, any physician that sees you after one of those events can report that directly into VAERS. They collect those pieces of information and then review that over time, make sure there isn't a new side effect they need to warn people about. And then, secondarily, there's something called V-Safe, which is a way that you could respond. It's like 6 hours after your vaccine. And then a couple of times a day, they'll ask you if you've had any symptoms, and then once every day for a week, and then every week, and then certain months [learn more about V-Safe, including the schedule, from the CDC website].

You can do that on your cell phone. It's really easy text messages that say “tell us how you're doing,” and easy to follow. They're really being careful about following for side effects, but there are some odd ones that have been reported. You've heard people report ITP or idiopathic thrombocytopenic purpura, and a few others that have been described, but no real association yet that we can link directly to the vaccine in any of these cases. But they're currently being investigated. These are super rare.

And then finally, the biggest one you probably hear the most about is the allergic responses. There was some concern early on that people would develop anaphylaxis, which is a really severe allergy response. Those have been very uncommon. There's been a couple of papers published recently that this is really rare and along the lines of other vaccines that are given to people. So not something that's unexpected.

Jean A. Sachs, MSS, MLSP

Right. And I think we just read about this this morning, that sometimes your lymph nodes are enlarged. Can you talk a little bit about that? Especially for people that might be going for a mammogram or other kinds of screenings?

Steven A. Pergam, MD, MPH

Yeah, that's a good one. One of my colleagues, actually, after the vaccine had a pretty large, full lymph node under his arm. One of the ways that that vaccines work is after you get your shot in your arm, those cells in that area will then migrate back to central locations and then replicate. So one of the places where they will migrate is to your lymph nodes. A good immune response might be that your lymph node gets a little bit enlarged, and that can be scary for some patients. I wouldn't say common, but it is a reaction to the vaccine. For breast cancer patients, one consideration that we have talked about a little bit is if you have a lymph node dissection on one side of your [body], it may be ideal to think about getting your vaccine on the opposite side, where your lymph nodes are normal, because that may help with your immune response. Particularly people who have lymphedema on one side of their [body]. I would definitely choose the alternate arm to get your vaccine.

Jean A. Sachs, MSS, MLSP

That's a good point. And then in terms of imaging, or if you're going in for follow-up testing, make sure you…

Steven A. Pergam, MD, MPH

Yes, yes. Make sure to tell your physician you got your vaccine if they're worried that they feel a new lymph node, because you don't want to go under surgery right after something like that. It usually goes away after 48 hours.

Jean A. Sachs, MSS, MLSP

That's really helpful. We've had a lot of questions because we know in the initial trials for the vaccine people with cancer were not included. Typically, when approving a vaccine, are you testing them on cancer patients?

Steven A. Pergam, MD, MPH

Pretty infrequently. So there's one small clarification. In the Pfizer trial, about 3.7 percent of those enrolled in the trial actually were cancer patients. They just described them as “a history of cancer.” What we think is they were probably people who had survived cancer, and were maybe a prostate cancer or a form of breast cancer patient who no longer had disease. We don't really know because they don't give us that data other than saying that.

We do know that both of the trials excluded people that were on active treatment and active chemotherapy. So it wouldn't be a lot of the patients that are currently asking these questions now. The way that I think about this from the standpoint of other trials, and when we do vaccine trials in general, we don't typically include cancer patients in the first few phases of the trials, because if you have an altered immune response and you're trying to figure out if a vaccine works, you want to give it to people that you know are going to have normal response.

So in typical clinical trials for vaccines, in phase III trials, we don't usually enroll a lot of cancer patients. It's pretty uncommon. We also don't enroll a lot of people over 65 because we often know that they don't respond as well, either. So what happens is there's what's called a phase IV trial, which are these post-licensure trials that are often done in populations of interest. Right now there's a bunch of places around the country and they're looking at immune responses in cancer patients, people with solid organ transplants, and other high-risk conditions to see how they respond to the vaccine. And that data, the NCCN will be looking at as they become available to help us rethink the guidelines and maybe target specific groups that maybe are not going to respond as well during their treatment. That's the piece we just don't know right now.

Jean A. Sachs, MSS, MLSP

It sounds like we know a lot. So I think what I'm really learning from you is that a lot was done before these vaccines were approved. And even though it went quickly, there were a lot of people and a lot of data studied.

Steven A. Pergam, MD, MPH

Yeah. These vaccines were reviewed in many different ways through the process. A lot of people were studied, obviously, and there's a lot of data that went into this. There was also a committee that reviewed the outcomes of these trials, independent from the companies that did these trials, to make sure that they were, that they look safe. There's something that happens during a large clinical trial: We have an independent body that reviews the data to make sure that it looks good and that there's no associated side effects that are dangerous. And then the FDA reviewed this, the committee that reviewed it, and voted to approve these vaccines. And then the ACIP (Advisory Committee on Immunization Practices), which is through the CDC, decided guidelines for allocation and who should get the vaccine. So there's massive review process and it's continually being reviewed as these are continually being given to patients and others in the community.

Jean A. Sachs, MSS, MLSP

That's good to know. When do you expect some of the other vaccines to be approved?

Steven A. Pergam, MD, MPH

The Johnson & Johnson vaccine, which is the next up, is going to be reviewed on the 26th of February. That was announced. That's the next one we expect will be reviewed. I don't know whether it'll be approved or not, but that one is definitely a next stop. And then the AstraZeneca vaccine, supposedly is close to submitting their paperwork to the FDA, but I've not heard when that is going to be reviewed.

And then probably the next, my guess would be the next would be a new type of vaccine. So to be clear, the Johnson & Johnson and AstraZeneca are different vaccines. The ones we have right now are what are called the mRNA vaccines, and the next ones that are coming are adenovirus vaccines. So these are adenovirus vectors that deliver, similar to the mRNA that's given to patients that allows that replication and of the spike protein, similar to the mRNA vaccines. The next would be a protein-based vaccine which a company called Novavax is making. It would probably be the next I would think would be coming. So they're all slightly different in terms of how they work and how they produce an immune response.

Jean A. Sachs, MSS, MLSP

Right. And we don't have to get into the details, but it's important for people to know they can't select which vaccine they're going to get, right?

Steven A. Pergam, MD, MPH

Yeah. If you're offered a vaccine, like you go to a place and you say, “I really want Moderna. I've read a lot about the company. I really like it.” The answer is no. The answer should be, you get what you get. So if you have a chance to get Moderna, if you have a chance to get Pfizer, if you have a chance to get on Johnson & Johnson, if you have a chance to get AstraZeneca, if you have a chance to get Novavax – get it. I really think at this point in time, any vaccine is really ideal. And what's nice is, if you look at Johnson & Johnson, Moderna, Pfizer, the ones that you've been able to see the data on have really decreased the risk of hospitalizations and major complications like that. So any of these vaccines we want to get to our patients to prevent those kinds of complications.

Jean A. Sachs, MSS, MLSP

Right. And the Johnson & Johnson is one shot. Is that correct?

Steven A. Pergam, MD, MPH

Correct. They're doing studies looking at two shots to see if it might be better, but the advantage of it is you get one shot. I think it'll be a workhorse in some of the lower risk communities in particular, um, where it might be something that allows us to get more vaccine to more people.

Jean A. Sachs, MSS, MLSP

Let's talk about effectiveness. I have friends now that have been vaccinated and my 91-year-old father is on his way to getting his second dose. So once you're vaccinated, what's different in how you live your life and what are your thoughts on that?

Steven A. Pergam, MD, MPH

The way that I look at it and the way that I've done this – because as a healthcare worker, I was vaccinated in phase one – I haven't changed anything. I'm still doing the same thing. I'm still wearing masks. I'm still avoiding going into crowded places. I have not been to a restaurant since the outbreak started. None of the things that I would normally do. The places where I spend my time are at home and at work. The way that I  talked to people about this is that, certainly we've seen people get infected between the first dose of vaccine and their second because they think “I'm vaccinated, I’m safe,” and I would not do that. I think you want to continue to mask. I think you want to continue to socially distance.

And I think you want to do the things that you're normally doing. Because right now, when you think about the percentage of people in the United States who've been vaccinated, if it's 30 million, it's 10 percent, maybe, at most, of the United States. So there's still a ton of people that are not vaccinated. The other thing that's hard to know when you're out in the community is who is vaccinated and who's not, even when there's a lot of vaccine that's been given, even if your community's pretty well vaccinated, there's some people who are not getting vaccinated because they make that personal choice not to. So not everyone who has the offer to get vaccinated says yes. So you don't know if you're going to be in contact with somebody who's not vaccinated. What you need is more of the population overall vaccinated to decrease the risk of COVID spread.

I think the other piece that's really important, that's becoming a bigger issue in the United States, are the COVID variants, the SARS-CoV-2 variants. And the B.1.1.7 variant, which was originally described in the UK, is one that does spread more easily, um, has better connection to the surface mark group that is used for the virus to enter into cells and can be associated with higher risk of complications. We know that these vaccines work against some of these variants, but there is concern that new variants could develop that are more resistant to the vaccine. And there is one in South Africa, that was where it was originally described, that seems a little concerning for that particular reason.

And then finally, if you're 95 percent, that means 5 percent of people don't respond. With cancer patients, I think we're optimistic if we think the responses are going to be 95 percent. I think at best, there might be 50 percent, it might be 60 percent, that you might prevent you from developing the disease. I hope that what it does is it helps prevent you from developing severe disease. If that's true and you still have a risk, you still need to be thoughtful about how you do it. It's kind of the way to think about flu and flu in the winter. I tell people to be cautious when they're out walking, and to wash your hands frequently. And now we'll be telling people to mask all the time. I think those are really important steps you can take to help prevent you from getting infected. So it's not life changing yet, but I do think it's coming. I think the more vaccine that gets out to people, the more you're going to see less transmission in our communities.

Jean A. Sachs, MSS, MLSP

I think we're all wondering though, if you trust all your friends and if they've all been vaccinated, could you have a dinner party and not wear masks? I think these are all things we have to slowly figure out.

Before we close, I do want to have you talk a little bit about the distrust that there is in a lot of communities about taking this vaccine and what you think physicians and organizations like LBBC can do to help people feel more comfortable? I know we need to get to herd immunity and that's a lot of people.

Steven A. Pergam, MD, MPH

Yeah. It's hard. The anti-vaccine community and those who really are against vaccines in general have targeted this vaccine pretty heavily and are doing what they can to assure that Americans don't pursue this. And that's unfortunate. I think it’s a small community in general, but they are really spending a lot of time trying to get people to not get vaccinated, similar to the group that says “don't mask while they’re in public. It's fine. COVID, it's a hoax.” There's always going to be people who are going to talk if I take an alternate stance.

What I think is really important is if you're on the fence about getting vaccinated, is to talk to people who are experts. Don't go to the web and look this up. Talk to your physician, talk to your treatment team, and find out the real details, because their goal is to protect you and your family. And they're going to give you what they know is this the truth. And no treatment’s perfect, no medicine we give to patients is perfect. But these are incredibly critical to decreasing the risk of you and your family developing COVID.

I think the best example right now is in Israel where they've vaccinated a large proportion of people, 65 and older, and they've seen really large declines in the number of people [in that age group] who are developing disease in that country, more than those who are under the age were getting vaccinated, which is continuing to go up. So it suggests that there is a major benefit. I think it's really important that the CDC, the National Institutes of Health, the American Cancer Society, the NCCN, all these organizations that are really focused on patients, are very supportive of vaccines.

What I do with people who are on the fence is I review what their issues are and their concerns. And I validate those concerns, first of all, and say, “I understand you're nervous. This is a vaccine that was brought up really quickly.” And then I give them a counter-argument that says, “Well, let me tell you why that's not atypical.” Obviously things moved faster and there was more money put behind these trials than ever before to make sure they went quickly. When you have a pandemic on hand, there's lots of people who want to sign up for clinical trials, where a normal study would take a lot longer.

So I walk through some of the basics of that to make sure that they understand and to let them know there's lots of safety levels where this has been studied before they worry too much. I also remind them as you said earlier Jean, that more than 30 million people have received this vaccine. That's a lot of people, a lot of safety data, that really helps us to feel much better about where we are now. That's a hundred times the size of the trial. So, important to keep in mind that, there's a lot of safety data out there, too.

Jean A. Sachs, MSS, MLSP

We know that in some of the racial and ethnically diverse communities, particularly the Black community, there is hesitancy to take this vaccine. And there certainly has been a long history of discrimination and understanding why they might not be open. So what do you recommend to get the message out?

Steven A. Pergam, MD, MPH

Yeah, it's really important. I work closely with an organization at Fred Hutch that has run a lot of the COVID vaccine trials, the COVID Vaccine Prevention Network, or coVPN. One of the things they've done is they've really focused messaging on these high-risk communities. One of the things that is really important for people in these groups to understand is that they are currently some of the highest risk for getting COVID-19. And that is not because of who they are. It's not the genetics, it's not even like that. It probably is because they're essential workers. They have higher exposure. They often live together in families, and so exposure can happen through that mechanism, too.

In general, there's been long-term concerns with how medicine treats these populations. W need to move beyond that. One is we need to get the vaccine to those communities. And one way to do that is to come with education and providers and those who provide the vaccine to them that look like them. What we need are more images of African-American and Latino physicians and nurses and others who are getting the vaccine and saying, “I'm excited about this.” We need to be getting the message out that's directly to them. We tried to work with communities directly by going to them and asking them what they want, asking them what their concerns are and walking through what we know about this. I think you have to address the hesitancy and the concerns of these communities head on.

And then I think, as I said, you need to bring the vaccine to them. They may be groups that may not be as interested in going to a large vaccine site in a community. And you may have to figure out ways to address that population differently because they are concerned. They've been mistreated for years. And so, we need to really take this on as an opportunity to build that trust by bringing the vaccine to them and working directly with those communities. That's at least what we've been trying locally. I think it's going to be important as that messaging has to be targeted to them. And it has to be targeted with images of people that look like they do so they feel that they can trust them.

Jean A. Sachs, MSS, MLSP

In terms of the rollout, we know it's been a little bumpy in the United States and it's state-by-state and county-by-county. And a lot of people, maybe everybody, are having to sign up online. I know it can be harder for people who are less comfortable refreshing their browser every minute to see if you can get an appointment. Do you see that over time that will change and it'll be easier to access?

Steven A. Pergam, MD, MPH

I do. It's going to take a little bit of time. I think probably, end of March early April. It gets hard. They can only produce a certain number of vaccines at a time. And there's lots of people who want to get the vaccine. I think what many of us in the cancer community have really been advocating for is more access to cancer patients. And that cancer patients should be given more freedom to get vaccinated. But that's true for a lot of groups that feel the same. It's been hard for a lot of people and I really feel for the cancer patients who are on active treatment who are going into their appointments on a regular basis, asking their providers, when can I get the vaccine? And they say, “go to the website and sign up,” and they're getting [cancer] treatment when everyone else is sitting at home and can refresh and refresh and refresh until they can get an appointment. I think that can be really difficult. I think it'll get better particularly having a third candidate out. The Johnson & Johnson vaccine, if and when that gets approved, I think that could be a great opportunity to exceed our vaccine availability. But right now it's hard.

Jean A. Sachs, MSS, MLSP

We’ve been, since the beginning of this pandemic, talking about how cancer patients can't quarantine and it has been really different, including for their caregivers who I hope can get prioritized as well. It's not that fun to be home all the time, but you know, it is really a luxury.

So is there anything I missed or anything that you wanted to add?

Steven A. Pergam, MD, MPH

I would just like to follow up on that last comment you made about caregivers. I think it's really important for caregivers and family. It's a great opportunity for cancer patients in general to have this conversation with their families about this. If they've got people that are a little bit hesitant, they're not sure, to tell them why it's so important for you that they get vaccinated. Because even if you get the vaccine, if your response is somewhat tempered, it's not quite as good. One of the best ways to protect yourself is to get everyone in your household vaccinated. That may not be easy right away, but definitely tell them when their time comes up to do it because one of the best ways to get COVID is to get it from family because you're sitting in your household all the time, you're not masking and you're in very close contact, and you can't avoid that. We do know that households are one of the primary ways that we see spread, that it really can be important for your family to get in to get their vaccine, too. I think that's a really good point that you made at the end that I want to make sure people take home. If a patient can't get it, make sure the family members do right away.

Jean A. Sachs, MSS, MLSP

I think that's a great point. We talked a lot, earlier in the pandemic, about the pressure when you're in treatment, before the vaccine, that your family had to be as isolated as you were. We have people who have kids, young kids, teenagers, young adults. It's not always easy.

Well, I just want to thank you so much. I'm hoping the next time we talk we'll be in a really different place. But I know we have made progress, so we have to all feel that – feel hopeful.

Steven A. Pergam, MD, MPH

Agreed. I think we're in a different part of the pandemic phase now where treatments are improving outcomes and we're seeing new vaccines come out that I think are game changers for how we're going to approach this in the future. So, exciting times.

Jean A. Sachs, MSS, MLSP

Thank you.

Well, I want to thank everyone for watching and remember Living Beyond Breast Cancer is always available. We have closed Facebook pages. If you are interested in real-time support, just go to our website and we'll connect you and we will continue to bring you updates on the vaccine. If you have questions, send us an email, let us know what else you want us to cover.