 We'll wait, you know, two or three minutes. Good afternoon. I'm delighted to welcome you to today's lecture, which believe it or not, is the 25th lecture in the series on ethics in the COVID-19 pandemic, medical, social and political issues. It is a great honor for me to introduce my colleague. Many years, Laney Friedman Ross, MD PhD. Laney is the Carolyn and Matthew Bucks found professor of clinical medical ethics. There's also a professor of pediatrics, medicine, surgery, and of the college. Laney is the co-director of the Institute for translational medicine and associate director of the McLean Center for clinical medical ethics here at the university. Clinically, Laney Ross is a primary care pediatrician at the university's Comer Children's Hospital and provides inpatient care also of newborns in the mother baby unit. Dr. Ross earned her undergraduate degrees in public and international affairs from, I think it's pronounced Princeton University, her medical degree from the University of Pennsylvania, Perlman School of Medicine, and her doctorate in philosophy from Yale University. Laney trained in pediatrics at the Children's Hospital of Philadelphia shop and the New York Presbyterian Morgan Stanley Children's Hospital. Dr. Ross's research portfolio concentrates on ethical and policy issues in pediatrics, organ transplantation, genetics, and human subjects protection. Laney has published four books and more than 200 peer reviewed articles. Her fifth book, The Living Donor as Patient was funded by a Robert Wood Johnson Award in health policy and will be published by Oxford University Press this year in 2021. Currently, Laney is writing a sixth book examining the ethical issues related to siblings in health care that is funded by the National Library of Medicine. Laney is a frequent lecturer both nationally and internationally and actively involved in teaching ethics to trainees and staff here at the University of Chicago. Laney Ross was a 2014 recipient of a John Simon Guggenheim Memorial Foundation Fellowship and a 2015 recipient of the American Academy of Pediatrics William G. Bartholomew Award for ethical excellence. Laney was awarded the John D. Arnold M.D. Mentor Award for sustained excellence in mentoring medical students, which he has done spectacularly over the years, and was awarded that from the University of Chicago Pritzker School of Medicine in September of 2016, and was also awarded the Samuel Spector Award for mentorship here at the University of Chicago Department of Pediatrics in 2020. This year, Laney was selected as a senior faculty scholar in the Bucksbaum Institute for Clinical Excellence at the University. The title of Laney's talk today is the following, slightly different from what was listed in the program. It's going to be called COVID-19 Pandemic and Children, Equity, Ethics, and Policy Considerations. It's an honor to welcome Laney Ross to our program. Laney. Thank you very much, Mark. Appreciate the introduction. So as Mark said, I'm going to be talking about COVID-19 pandemic and children. And I just want to acknowledge two students who worked with me or two trainees who worked with me, Alice Lee, who is a second year medical student and Michael Harris, who's a second year pediatric resident for their work on reopening schools, as you'll see in the middle of my talk. I also just want to make two disclosures that Alice Lee received funding from the Pritzker School of Medicine summer research project and that my husband owns stock in Bristol, Myers, and GE, but I will not be discussing any well-labeled uses of any therapeutics. I should probably get it into screenplay. There we go. So my objectives are fourfold. First, I want to begin by familiarizing myself with the current data about children and COVID-19, then explore the rationale for K to 12 school closures and its impact on children, then examine equity issues surrounding K to 12 school closures and school reopening policies, and then finally consider the role of COVID-19 vaccines for the 21-22 academic K to 12 school year. And I just want to also make a disclaimer that this talk will only focus on children under the age of 18 in K to 12 schools. I will not discuss opening colleges and universities, but you'll have to invite me for another talk. So to begin, the current data about children. So these are the data as of April 22nd that there have been 3.6 million total child COVID-19 cases reported, which means that children represent about 13.6% of all cases reported, and the overall rate means that there's been about 4,800 cases per 100,000 children in the population. Changes in the child COVID cases, as you can see, in the last two weeks, there's been a real high number of cases in children, 73,000 from April 1st, April 8th, and then 88,000 last week from April 8th to April 15th. And in these last two weeks, children are now representing 20% of the new weekly cases, in part because of the successful rollout of the vaccines in adults. So over the total, over the two weeks, the total child COVID cases has increased 5% overall. It's been a pretty rapid increase. So one of the things about COVID-19 in children compared to adults is that many children are asymptomatic and that while children and adults express similar symptoms of COVID-19, the children's symptoms tend to be more mild and cold-like, and most children recover within one to two weeks. So one question is who is a child? And as you'll see from this map, it varies depending on what state you live in and what age we consider you a child. And so the data, therefore, are also not fully consistent when I say zero to 18. If I'm only looking at Florida, the data are only going to go up to 14 and Utah only up to 14 as well. So, but some children do get very ill. And here is just to give you, as of April 15th, that we've had over 749,000 hospitalizations of children. And that represents about 2% of the total hospitalizations. And then, and then deaths, again, very small compared to adults, but, you know, a death of any child is considered a real tragedy and we've had close to 300 deaths from this pandemic so far to date. There is a unique severe presentation of COVID-19 in children. It's called Multisystem Inflammatory Syndrome in Children, or MISC. And here from the CDC, you can see what the case definition is. It includes children under individuals under the age of 21 presenting with fever, lab evidence of inflammation, and evidence of clinically severe illness requiring hospitalization with at least two organs involved. That there is no other plausible diagnosis and that the individual is positively the current or recent SARS-CoV-2 infection. So either by PCR serology or even by antibody exposure within the last four weeks. And so this is really important. When you use that definition, there's been over 3,000 such cases with 36 deaths. Most of the cases were in children and adolescents between the ages of one and 14 with a median age of nine. The cases have occurred in children and adolescents ranging from one to 20 years. Two-thirds of the cases have occurred in Hispanic or Latino children or Black, non-Hispanic. And 99% of the cases tested positive for SARS-CoV-2, the remaining 1% were around someone with COVID-19. And more than half of the cases reported were male. So again, the numbers are small when we compare it to over the 500,000 deaths in U.S. adults and yet pretty significant disease in childhood nonetheless. But even if children themselves do not get sick, one of the most tragic aspects of this illness is that a new model estimates that nearly 40,000 children have lost a parent to COVID-19 and that Black children have been disproportionately affected. So that's the update of how much COVID-19 has had a direct impact on children. And a lot of what I'll be talking about for the rest is the indirect. So not necessarily about COVID-19 as a medical problem, but all of the social and political issues that it raises. So my second objective is to discuss the rationale for K-12 school closure and its impact on children. So I just want to go back a year and look at the timeline. So on March 12th, the World Health Organization declared COVID-19 outbreak to be a pandemic. And on that date, 29 countries with national had national school closures. Less than a week later, UNESCO estimated that 107 countries had implemented national school closures related to COVID-19, affecting around 162 million children, roughly half the global student population. And then nine days later, it was noted that 1.5 billion children around the globe, that's 87% of Earth's student population, were affected by school closures because of COVID-19. So why did we close the schools? It was really based on evidence and assumptions from influenza outbreaks that closing schools reduces social contact between students and therefore interrupt the transmission. With influenza, children are known to be super spreaders, and that was at least a presumption at the time, although the emerging evidence continues to show that the school closures has had a conflicting but probably much less effect than many of the other mitigation strategies that we have used. So school closures in Asia, the data showed did not contribute substantially to control with minimal community transmission in Taiwan, even as schools remained open. Modeling work from the UK found school closures may avert fewer deaths and other non-pharmaceutical intervention, like keeping children separated by several feet as well as by masking. And that led some European countries to cautiously reopen schools while delaying the reopening of other sectors of the economy. And that's a really important point about the reopening of which sectors should come first and that not to reopen all sectors at the same time. There are other studies in France that found again limited evidence of secondary transmission. There was a big outbreak at middle and high schools in Israel where almost 200 students and staff were infected, but the reports of COVID-19 related deaths among teachers in Sweden where modifications to reduce class size and enhance social distancing were not made really was sort of the extreme end of the dangers of keeping schools open early on. But by the spring and fall, we had more data and we came to realize that schools overall were not super spreaders, particularly if other mitigation strategies were in place. And so that's one of the most important thing was the other mitigation strategy. So an article published in Jamon 2020 says that however made it possible that some of the reductions from closing schools may have been related to other concurrent non-pharmaceutical interventions. And at that time it was really about masking and about working from home. In Zimmerman did another study that was published in pediatrics looking at incidents and secondary transmissions of SARS-CoV-2 in schools and what they found that in the first nine weeks of in-person instruction in North Carolina, they found extremely limited within school secondary transmission as determined by contact tracing and again using other mitigation strategies. And finally another study looking at Florida also found that the resumption of in-person schools was not associated with the proportionate increase in COVID-19 among school-aged children. So most of the data, once mitigation strategies were in place, really showed that schools were not the dangerous place that they have been in historically in other pandemics like influenza. So in 2020 hindsight was the decision to close schools the right choice. And I would actually say that school closures were based on the best evidence we had and it was appropriate in March 2020. The question came how soon did we know that children weren't the super spreaders and that school closing was less effective and not necessary to slow down the spread, especially if mitigation strategies were employed? And this raises the question of what should have been reopened first? How quickly could we and did we know this and should we have changed course about school reopening sooner than we did? Because many other countries around the globe had much shorter school closures than we did here in the United States. And again, I'm going to emphasize this is not to suggest that schools should return to pre-pandemic policies and practices, they must have mitigation strategies in place. So here is just a global map of looking at different amount of time that different countries had for school closure. And you can see that we're sort of at the top of the peak for the amount of time we had school closure compared to the rest of the world. So early on what was the effect of switching to virtual learning? And the answer is most of the world, including the U.S., was totally unprepared to switch from in-person to virtual learning. There was a lack of universal access to technology, a lack of teacher prep and using the virtual technology, lack of plans of what the school day would look like. Many standardized testing, end of year testing programs were put on hold. Some schools created paper packets because they realized that many of their students did not necessarily have access to the Internet. And some countries, in fact, with nationalized standardized curriculum actually use television. So for example, in Mexico. And finally, some countries just conceded that the year was over. And this was back in March. And so a UNESCO UNICEF report coming out in 2020, asked what have we learned, an overview of findings from a survey of ministries of education on national responses to COVID-19. And what they learned is that online learning has been provided as the solution for at least a proportion of students in all high-income countries, but not as uniformly among countries and other income groups. So one of the things we know about pandemics is that they exacerbated disparities here in the U.S. but even more so globally. Approximately three quarters of countries reported that remote learning days count as official school days. However, this was the case among other countries. And one of the things we know about online learning, specifically the use of the Internet was really an high-income country solution. There were policies to boost access to online learning. Most countries responded to this UNESCO reports, 89% saying they've been introduced at least one measure to increase access to the devices and connectivity needed for online learning. But most countries have also taken measures to support populations at risk of being excluded from distance learning platforms, most commonly learners with disabilities and learners who don't speak the language of instruction. However, over 30% of low-income countries were not introducing any measures to support access or inclusion. So again, just the problems that we saw in this country just magnified when we look over the global platform. So what have we learned? First opportunity for learning. Overall 108 countries reported missing an average of 47 days of in-person instruction due to school closures equivalent to about a quarter of a regular school year. Learning assessments, while most countries reported that student learning is being monitored by teachers, there are big differences again across income gaps. And of course, and only 3% reported that student learning progress is being tracked, is not reported. So we have a number of programs that have been implemented in the last quarter in low- and middle-income countries, meaning that it will be even harder to figure out exactly what type of learning loss to death we have experienced. And the reopening support to remediate learning loss, most countries again who responded to the survey introduced additional support programs to remediate learning loss as schools were reopening across all income states. But meanwhile, one in four high income countries were not introducing any additional supports, while high-income countries are also more likely to consider remote learning a substitute, school closures can lead to learning losses and why did the achievement gap even in these high-income settings. But pedagogy is only part of the issue. In the U.S. and globally, schools serve many other functions as they see as teachers and staff from mandatory reporters, they're a source of mental health promotion with the role of teachers, staff and counselors, they're a source for exercise and physical well-being. And finally, for many children in Title I schools, they're a source of medical and dental care as well. So when we close the schools, we lose a lot of these other services unless we have a plan in place and again, most countries including the U.S. were not prepared for what happened early on. First, let's look at food insecurity. In the U.S., 22 million children get free or reduced-price lunch during the school year. These school lunch programs are an important source of food for many of the children. And in fact, during summer vacation, only 16% of the children who need the USDA-funded summer meals are able to access them. And this makes summer the hungriest time of the year for lots of children and it can have long-term consequences. So the first one is the issue of increased child abuse and neglect. And here was a study from the CDC MMWR and it showed that the heightened stress, school closure, loss of income and social isolation resulting from the COVID-19 pandemic have increased the risk for child abuse and neglect. And what they did was they looked at the number of ED visits and then also looked at the proportion of these visits compared for child abuse and neglect compared to the baseline. And what they found was that despite decreases in the weekly number of emergency department visits related to child abuse and neglect, the weekly number of these visits resulting in hospitalization remains stable in 2020. However, the yearly percentage of emergency department visits related to child abuse and neglect increased significantly. Meaning that while parents were avoiding the emergency rooms, they were still coming in for child abuse and neglect health problems and although the increased proportion of ED visits related to child abuse and neglect might be associated with a decrease in the overall number of ED visits, these findings also suggest that healthcare seeking pattern shifted during the pandemic. So food insecurity, increase in child abuse and neglect, how is COVID-19 impacting the mental health of children? Here was an article from December 2020 that looked at all the articles that had been published up until that time with 77 articles that they were able to find and basically their finding was children respond to stress differently depending on the developmental stage but high rates of anxiety, depression and post-traumatic symptoms identified among children in all of these studies which really were from around the world with only two articles coming from the US. So as time passed, it was obvious that the pandemic was not going to end anytime soon and that we needed to have plans for the 2021 pandemic year and so there were three thoughts last summer, do we remain virtual, do we go hybrid or do we go full back in person? And so my third objective is to look at equity issues surrounding K-12 school closure and school reopening policies and this is a project that I did with Alice Lee and Michael Harris. So schools were closed, one of the points I want to emphasize is that the schools were closed during the COVID-19 pandemic to protect particularly the elderly. And that contrast with the polio pandemic when schools were being closed to protect the children themselves, not another population and so early in the COVID-19 when school closure was enacted, it made sense since we didn't know who was going to be most at risk but as we came to realize that the children were not the super spreaders and were not really getting sick, the whole issue of whether the schools should have been reopened versus restaurants, businesses is an important question and was done differently in the U.S. and in fact in each state versus what was done around the world. Why treating social policies that are likely to have a broad range of unintended consequences have to be taken with great caution and that an intervention on one vulnerable group to help another should be done only in the setting of strong evidence. So in other words, keeping the schools closed to protect the elderly makes sense if it truly protects the elderly or the elderly, data which we were not going to find. So here was this study that I said that Alice Lee, Michael Harris and I did. What we did was we looked at state level guidance addressing equity concerns. Now this was a every few days many states revised their policies and so we looked at policies as of the date of July 15 for school reopening remembering that some schools in the U.S. start in early July. So that was our date for looking at all of these different state level guidance. And so we did a Google search to identify all of the documents from the 50 states in the District of Columbia. We used the most recent guidelines as they said from July 15. And what we collected was whether the document about school reopening even mentioned equity as a guiding principle and whether the state offered any specific guidance regarding the following 11 equity concerns about security and nutrition about homelessness and temporary housing about lack of access to Internet and technology. We specifically wanted to look at students with disabilities, English language learners, students involved with or on the verge of involvement with child protective services, mental health support, students at greater risk of severe COVID infections, staff at greater risk of COVID infections, students living with someone at greater risk of infection. And what we found was that 44 of 51 states explicitly mentioned equity as a concern for guiding principle. So the ones in the seven states that did not mention it. And they as you can see came from the West Midwest and Southeast regions. And although six of the seven states that did not explicitly mention equity as a guiding principle have Republican Governors, there was no significant difference and we looked at the 11 specific equity concerns by political party. And so as you can see here, we looked at the 11 specific concerns and you can see that basically virtually all address students with disabilities or special needs or 51 states if you count the District of Columbia. And then the least frequent issues that were covered were, for example, students living with someone at higher risk of severe illness and staff living with someone at higher risk of severe illness, which is particularly important in our Black and Brown communities. The state level measures of inequity and equity issues. So we were unable to find any factor that strongly correlated with the total number of equity issues that a state's guidelines addressed. So we looked at everything. So we looked at did it matter whether percent urbanization? Did it matter what the Gini coefficient was? Did it matter the poverty level in the state? Did it matter the education level of the parents in the state? Did it matter the overall health status in the state? And as you can see, they're all just all over the place. There were no factors that we could find that would associate with the policies at the state guidance equity level. The need to reopen schools by fall 2020. I was supporting in-person schooling, especially for primary schools, but also supported parent and teacher vaccines were going to be widely available for the adults. I wasn't willing to wait for the vaccines to be approved in children, given that they are at low risk for serious disease, particularly not willing to wait to reopen schools in the primary schools where young children are not only at low risk for serious disease, but are also at low risk for being super spreaders. So why did I support in-person schooling? The number one was that the learning gap is exacerbated by being disrupted or at risk of disruption from food, from security, from mental health, and other health services. And so we need though, obviously not just to open schools as we did pre-pandemic, but we had to have risk mitigation strategies. And these were some of the ones that were being proposed or used by some schools. Some were doing infrared temperature taking. Some were doing COVID-19 saliva testing on a weekly or bi-weekly basis. Some were then doing contact tracing. Many were requiring masks and other PPE, depending on the activities. Some were requiring flu shots in part to make sure that we wouldn't overwhelm our healthcare systems. And then the whole issue of COVID-19 vaccines for when school personnel became available. And I think looking back again, 2020 hindsight is always the best vision. I think all of these were useful except for the infrared temperature taking, just because the way schools open was led to the children crowding even more. And we have that famous picture from the New York Times of just piles of children waiting to have their temperature being taken. And my position was, whether it's based on our obligations of solidarity, civic responsibility or moral responsibility, unless there's a medical reason all should accept these pandemic risk mitigation strategies. And that there would be very, very few medical exemptions from mask wearing. Some children with disabilities really would not be able to wear masks at any time, but otherwise virtually all children should be able to wear masks. I'm going to have to say at the University of Chicago, some of my colleagues were being approached by parents to ask for exemptions for wearing masks because their children would just quote uncomfortable and we were not supplying those. So the need to reopen society, what was the Illinois approach? So we had this complicated five tier three in the guidelines for tier three. Most things were suspended, although there was some limited capacity for bars and restaurants even limited for hotels. And then in tier three, when you got to tier one, there was more reopening of bars and restaurants and hotels and even gaming and casinos. And yet the schools were still being kept closed. In fact, the schools aren't getting reopened until phase four, which is the fourth stage of reopening. Whereas in other parts of the world, schools were the first to reopen and the last to close. And I would have argued to do just that and to have opened schools before bars here in Illinois. But will the K-12 school reopening in the 2020-2021 academic year achieve equity? And what we know is that Biden has a hope to make reopening schools a national emergency on January 21st, 2021. And he said he wants to see most K-12 schools open during his first hundred days in office, which would be between now and April. And his plans were more PPE, more testing, vaccines for teachers, and better data. But where are we in April, 2021? It turns out that two states have ordered state-ordered regional school closures continued. Ten states have state-ordered in-person instruction. Two states have state-ordered in-person instruction only for certain grades, and 36 states, the vast majority accounting for 70% of our children, have left this decision to schools or districts. Meaning that everybody's doing something different. To hear more, tune in tonight to Biden's speech to Congress, where we might hear his further plans for schools reopening, and particularly for the next year, 2021-22. One question is, as we reopened early in this year, 2021, reopened for whom? So the Chicago public school system only expects about 37% of eligible students to return to in-person officials when queried in December of 2020. And the CPS data show a disproportionate number of students expected to return are white. So here is the overall enrollment of children in our Chicago public schools. You can see that 11% are white, about 36% black, about 47% Latino, and about 4% Asian. And students planning to return more than double the number of white children were planning to return, slightly less black children, slightly less Latino children. And Chicago is not alone. A Biden administration survey found that about half of US elementary schools are open for full-time classroom learning as of last month, with great variability by region and by race, so that white students taught entirely online. And it actually was also regionally dependent in the south and midwest, where schools were the quickest to reopen, just under 40% of eighth grade students were enrolled full-time in classroom instruction in January, versus 10% in the west and northeast. And the survey also found striking differences based on the student's race. White students, about half were learning fully in-person and only about a quarter exclusively online, while white students nearly 60% were learning entirely remotely. Asian students were about to third remote and just 15% attending fully in-person. So, this is a real challenge about reopening schools. From an equity perspective, we know that virtual learning exacerbates our learning gap, as well as the unintended adverse impact of food insecurity, lack of child care, mental health issues, et cetera. And these access issues must be addressed. And yet, black and Latinx parents may prefer to remain virtual for now, due to lack of trust and safety of the school, lack of trust in the value of the school, and they live with family members who are at higher risk, which therefore raises ethics questions. Is it adequate to say parental choice preference should prevail if we think it's actually going to further exacerbate equity? We're not going to say to close schools to reduce the equity, because we know that reopening schools is the only way to get back to a real healthy learning environment. And so, one real ethics question for both all of us, but also for the parents is how to determine risks and benefits under uncertainty, given that COVID-19 is a novel disease. So, in retrospect, our policies, we should have closed schools given the uncertainty of its impact on reducing spread, probably. But we also, having implemented a stay-at-home order, watch it we have reopened first, and as I've been arguing all along, we should have started with reopening our schools. It would have actually facilitated the reopening of many other things, because, again, school is a form of child care. And then we have to get into the issues of voluntary versus mandatory mitigation strategies. So, should masks be mandatory? It took quite a while for that to become mandatory in most parts of this country. The COVID-19 vaccine, currently under an EUA, so it's going to be voluntary, will it ever become mandatory? Remains to be seen. The issues we had initially were who to get priority, and we chose healthcare providers and then the elderly before we then went to our essential workers, including our teachers. And then the last policy question is, for how long are we going to accommodate school personnel who do not want to return physically, and how long are we going to accommodate parents who do not want their children to return physically, and for how long are we going to require masks and other mitigation strategies? All of these are issues we're going to begin to prepare for the 21-22 K-12 academic year. And so what I want to consider is the role of vaccines for the next academic school year. So let's assume that all schools will be in person in fall 2021. Question, should the COVID-19 vaccine be mandatory for K-12 school entry, and if so, for whom? And our options are going to be for school personnel, students, or both. And what are the ethics behind this in general, we think that we want to use the least restrictive alternative. If we can get herd immunity voluntarily, that would be ideal. And only to think about mandatory if we cannot achieve that. And so the question is, can we get herd immunity voluntarily? And here, looking at the adult level of herd immunity, as of April 24th, 137 million or 53% of adults have at least one dose of a COVID-19 vaccine. And in fact, approximately 2 million adolescents, 16 to 17. Because if you remember, the Pfizer and the Moderna were approved down to the age of 16. So already 25% of adolescents have received at least one dose. And that's even before they get priority and it's only been open basically for about since the beginning of April for that age group. Natural immunity, we have over 30 million cases in the U.S. and an additional 3.6 million cases in children. The CDC estimates that actual number of cases is four-fold that number because of the reduced testing early on in the pandemic and the fact that even today, only people who have symptoms are really getting tested and we know that many people who get COVID-19, particularly the young and healthy, maybe mildly or asymptomatic. But if we use that four-fold multiplier, we have about 120 million adult cases already in this pandemic and about 14.4 million children. Now, the vaccinated and the previously infected are not mutually exclusive groups. So if we need 80% of adults to have immunity, we need about 206 million adults. We have 137 million already with vaccines and 120 million who have natural immunity although we don't know how long either of those will last. So my guess would be to achieve some degree of herd immunity, we're going to need to vaccinate at least another 40 million or so. We still have to address the children who make up another 70 million members of our society or at least the older adolescents about getting them vaccinated to achieve this herd immunity. The polls show evolving interest in vaccine intention among adults. In the figure one you can see from September 2020 to December 2020 we're starting to see an increase in those who are definitely and probably going to get the vaccine. And on figure two you can see that half of Americans intend to get a COVID-19 looking at it from May 2020 up until February 2021. So again as we get greater experience with the vaccine people see that it's safe and that it's becoming effective and that it has been proven to be effective and more people are becoming willing to get the vaccine. But we're still going to have a large number who are going to refuse to get vaccinated. So what would be the arguments for and against mandating vaccines for school personnel? So the vaccine mandates would be unjustified right now because they're only on an emergency use authorization which require less safety and efficacy data than full biologic license application approval. And the BLA approval should be coming in either May or June for probably Pfizer and Moderna. But once the FDA then gives the BLA then it's ethically possible to make this vaccine mandatory. And we've actually had policies like that in this country for over 100 years. We had the legal case of Jacobson versus Massachusetts where an individual named Jacobson was refusing the smallpox vaccine and it was decided that the states do have the right to uphold vaccination mandates. But adult vaccine mandates are really rare. Although at least 16 states do require influenza or happy vaccines for post-secondary education students. But outside of the student environment adult vaccine mandates are even rarer. I mean I'm not even sure I know of any. Except in particular workplaces. So we're unlikely to mandate in adults whether students or school personnel without greater safety data. And that of course will be coming within the next few months. It's also a concern that the teachers unions may balk at mandated vaccines. Just like some healthcare groups have balked at that. The early results of vaccinating children can we do it? Well the early results from clinical trials show that the Pfizer vaccine is safe and effective in children age 12 and up. The Pfizer COVID-19 vaccine is currently approved for children 16 and up under the EUA. Pfizer studies in younger children have begun. They're actually also considering lower doses because the children's immune system is so strong. Other vaccine manufacturers are following suit. And so once the EUA for school is approved for children, parents can be able to voluntarily choose to have their children vaccinated. But again, while under an EUA it's always going to have to be voluntary. But once the FDA gives BLA approval should we mandate it for children. And this was a piece that I wrote with Doug Opel and Doug Deakamout looking at what would we need to be what factors do we need to have in order to justify mandating a COVID-19 vaccine for children. So in the box there are vaccine related issues. There are disease related issues and there are implementation related issues. Of course, the number one concern is that we achieve safety. Once we've achieved safety, then we want to know that it's effective and that we also want to know that it's actually cost effective from a societal perspective as other vaccines use to prevent disease. We're obviously going to need to know that the vaccine containing the Santogen should bear some relationship to increasing not just to protect everybody outside of the school environment. And so again, you can look through the nine criteria that we proposed. But there will be additional questions to be asked before mandating COVID-19 vaccine of school children once full FDA approval is obtained. First, there's the question of the ethics of mandating it when the children when the children aren't getting that sick and they're not the super spreaders. We're going to have to ask more or longer safety data before we give these vaccines to children on a mandated purpose. The other question is, can we adequately get herd immunity voluntarily? And does it matter if COVID-19 is going to be a one-time immunization versus an annual immunization in our considerations of whether we're going to mandate it? We also have to ask why we're looking to mandate the COVID-19 vaccine in children. And so we're really doing this for the benefit of others. In fact, younger children less than 10 are again, low likelihood of getting sick and low likelihood of spreading it. So it makes it hard to justify vaccinating these groups to benefit another adult without strong evidence that vaccinating school children is going to be a one-time immunization. And so we're really doing this for the benefit of others. In fact, younger children less than 10 are again, low likelihood of getting sick without strong evidence that vaccinating school children will reduce spread significantly. It also, one could argue that it's hard to justify vaccinating these groups unless the adults whom they're being asked to protect are also willing to get vaccinated. So one question is can we justify vaccinating just the children or if we really do have school policies that are mandated for the children, should we also be mandating it for all the other school personnel? So can we justify mandating school attendance to protect the adults? What will it take though for the parents to feel that there is adequate safety data before they're willing to get their children vaccinated or will they continue to be a strong demand for virtual learning in order to avoid school setting? For those who object to vaccinating children for the benefit of others, does their assessment though take into account that it's not just about protecting the adults from COVID-19, but if the adults don't feel safe and aren't all of the other reasons why we want children in school from food insecurity, from mental health issues, as well as for safety. For those who support vaccinating the children, will universal vaccination of the children make the adults feel safe enough acknowledging that there will be some medical exemptions for some children but is that enough, will that make it so that all the teachers are willing to come back into the classroom? And one question that we also can't answer is there might be unintended effects of mandatory vaccination on different student communities and we need to take that into effect if we make this type of policy at a state, regional or national level. So what are the facts on the ground? It turned out that about according to the New York Times about 80% of K through 12 teachers and staff have already gotten a COVID-19 vaccine dose. In the few weeks that 16 and 17 year olds have become eligible, we've received at least one shot. And compare that to our healthcare employees. We're a poll from the Washington Post and Kaiser Family Foundation found that over four and 10 frontline healthcare workers in the U.S. are not vaccinated even though we were in the sense the first group to be offered the vaccine. And that 18% of American frontline healthcare workers have no plan to get the shot. North Carolina Hospital even more recently showed that those North Carolina hospitals willing to disclose their employee vaccination rates reported between 40 and 75% of hospital staff members have been vaccinated. So in some ways the teachers and the students are doing better than some of our healthcare institutions and we really need to take a deep breath about that as we think about mandatory policies. That's going to mandate in the schools that we're going to mandate in the hospitals as well. So let me end by saying for schools to operate safely to accommodate COVID-19 learning in spring 2021 communities should fully implement and strictly adhere to multiple mitigation strategies especially universal and proper masking to reduce COVID-19 incidents within the community as well as within schools to protect students, teachers and staff members. Realizing that recent data do not support all of the excessive surface cleaning nor the six feet distance between desks. But whether multiple mitigation strategies will depend on vaccine uptake development of new virus strains as well as particular school infrastructures. The TDC is recommending that K to 12 schools be the last settings to close after all other mitigation measures have been employed and the first to reopen and I strongly agree with that statement. And so at least for now given current vaccine uptake and immunity from prior infection vaccine should be voluntary but public health messaging should encourage teachers other school personnel and students especially high school students to get vaccinated. And I would say the same thing for our health care providers and the ancillary staff in our hospitals. So thank you very much and happy to take questions. Great. Thank you very much, Lainey, for that sort of broad overview. We'll jump right into the chat and the Q&A. And so I just want to remind participants who are watching the webinar to submit your questions through the Q&A. And so let's jump to the first one by an anonymous attendee who asks, so was Khan Academy a good replacement for school noting that Kaplan is a good replacement for med school? Again, I think what the question is missing is what are all the purposes of school that schools are not just about pedagogy but they're about nutrition, they're about exercise, they're about mental health, they're about safety for the children. So no. Great. The next question then from Martin Shan is about boarding schools. So are boarding schools different from day schools since they can form their own isolation bubble? It's really hard to create an isolation bubble. I mean, many boarding schools, you know, there's still the towns that are next to it and they're the visitors on campus and the students who are looking to enroll the next year. So this idea that any of us really live in a bubble, it's really hard. Number one. Number two, they're private schools, so they have financial reasons to want to reopen, right? Because parents often aren't willing to pay or not interested in paying the high tuition fees if they're not getting the real special one-on-one attention and everything else that comes with in person. But can private schools do things differently? Well, it depends whether it's a school level mandate or a school level mandate. So if it's a school level mandate, both public and private will get COVID vaccines and it's going to apply to both. Great. A bunch of questions. Let me just read through a few to pick a few out. Going into the chat. So do children need to be vaccinated because they might give pregnant mothers or pregnant teachers to be vaccinated? Let's look at the flu, which has been very rarely mandated and the children are more likely to be super spreaders of the flu to their pregnant mothers and their pregnant teachers. And yet we don't mandate the flu vaccine. So it's an interesting should the children be vaccinated? I would start with the pregnant women and the parents should be vaccinated. Again, I think it's a two-way street. It seems unfair from my ethical perspective that we're not going to be able to vaccinate all of the adults by vaccinating the children without mandating them that those same adults get vaccinated as well. And Sif makes a comment that will be interested to hear what you have to say about, but you've probably heard about the schools that are considering or the particular school in Florida that's considering banning vaccinated teachers. So kind of the opposite otherwise they won't be allowed to come back to work. I can imagine your thoughts on that but what are your thoughts on that? I have to confess I didn't hear about this. I'm not sure how they would know whether a teacher got vaccinated. You know, even a teacher got vaccinated they don't have to show their card, right? And I can't imagine the schools are going to be doing antibody testing and it's not clear that even antibody testing is the right way it has to be cellular and we don't even have the proper cellular testing. So I haven't heard of it and I think that's absolutely ludicrous. Yes, I think most of us feel that way as well. So there's another anonymous attendee in the Q&A who asks when school is opened should an employee be allowed to come to work who refuses to get vaccinated? Like can we allow a person with TB or meningitis to come and is there sort of a shared social obligation? Yeah, so this is really interesting but again I just want to replace the word schools and do healthcare systems and it's amazing to me that we don't mandate the COVID vaccine for our employees and in fact while we have a mandate for flu vaccine that we have a lot of individuals who refuse to take the flu vaccine and they come to work every day. So I'm always fascinated why we're picking on the schools and not picking on the hospitals and healthcare systems because we're exposing those who don't get vaccinated are really exposing some of the most sick and most vulnerable individuals our patients. So I just want to start there and many of our patients are elderly and many of our even our healthcare employees are elderly. So it's incredible to me. Again it's the difference if you're not vaccinated versus if you're actively infected, right? So if somebody has active TB of course they're going to be not allowed to come to the school. The problem is that there are a lot of people who get asymptomatic affections from COVID. So they might not even realize that they're spreading the illness which again is an argument for vaccinating the whole country and we've made it access it's open it's free to get the vaccines. Great. Connie Xiaow notes that thanks you for your talk and when considering variants equity etc. what do you think about prioritizing international COVID distributions? Thinking of the disease burden in India infectivity clinical disease rate among our younger population etc. I know there's sort of been issues around sort of vaccine nationalism and this idea that should we be vaccinating populations in the U.S. that are of lower vulnerability when there are still populations sort of internationally of much higher vulnerability. How should we globally think about resource allocation in the context of vaccinating children? I hate the idea that it's an either or. I think the answer is why not be doing both. You know there have been questions I don't think it was last week but a couple of weeks ago one of the speakers was talking about the issue of whether we should be allowing other countries to be able to make these vaccines and things of that sort and just to increase but we're really producing these vaccines at a really rapid rate that we should be able to start being able to supply it around the country around the globe. So the question of whether to vaccinate those who are at lower risk really comes down to the question of are they at low enough risk that all of the teachers, the hospital personnel that everybody else in society are going to say that's fine we can reopen even without vaccinating the younger children and I still see a lot of hesitancy we read about in the newspapers all the time about teachers being hesitant about coming back to work, about store employees hesitant to come back to work. In some ways we're not going to achieve full effectiveness of the vaccines until it really gets the whole population vaccinated but I don't want to think of this as an either or. I think this should be an and. We should be distributing our vaccines and really helping out the rest of the world. It's interesting that some of the rest of the world is also making their own vaccines and so I think it's also a global responsibility to help countries like India which are really suffering right now. Right. Some schools had sessions for lunch and Internet access so I think kind of addressing some of the equity issues and some of these other other issues around the importance of schools but the question is why did they not have sessions for like Jim music art with safe distancing so so do you have a sense of why schools may have chosen to have some things in person but other others remotely and how they chose activities over others. Also music is really hard even singing you're going to have a greater spread of any viruses that you have and all of many of the instruments you're blowing out you know air across the room so I could see why it was really hard to have a lot of music in person the and again for phys ed a lot of activities require groups to congregate and not to keep six feet apart so I think there are a lot of reasons like that I mean tennis is a lot safer than for example you know soccer where people are coming in although soccer played outdoors is also quite safe because we're coming to realize but so I agree with the person who's asking that again that schools serve a lot more than just academic pedagogy that you know all of these other activities are really very important. So in that in that same vein um I don't know if there's been discussion about sort of vaccine passports sort of within school systems that may you will allow you to take to participate in activities where there would potentially be a higher risk of transmission like you said like like contact sports or something like like music what what is are there policies or discussions about vaccine passports in school and what what would be your concerns about so remember right now everything's under an EUA and right now we only have an EUA for children over 16 the studies in the younger children are going to take a little bit longer because they're also thinking about different dosings so um so by September of 2021 when the next year starts at fast we'll have our high schools immunized this won't really be applying to the younger kids so I just want to put you know this whole notion of passports you know there are reasons that some children can't get vaccinated for medical reasons and there are some children who are going to be vaccinated and for medical reasons may not mount a good response so this notion that even if you have a passport that we therefore know who's at risk and who isn't isn't fully accurate and and I do want to again the importance of the equity issues that I don't want to be excluding children who have illnesses that make it impossible for them to get vaccinated or that the vaccines might not be effective so so given all of that I'm not sure how useful those vaccine passports are going to be I mean this as you pointed out is a solidarity this is a community response we all need to be getting vaccinated in order to protect ourselves and each other Eric while asked could one other reason for children to be vaccinated also be to decrease the chance for the virus to replicate whereby decrease its chance to generate more variance right well that's the real reason to go global as well right and to go global really quickly probably more likely in a place with everybody unimmunized and a country like the US where we do have so many of us already being vaccinated so it's a really important issue to vaccinate everybody Julie Campbell asked should students who opt in person who opts sort of in person learning be mandated to submit to weekly COVID testing so I think this sort of speaks to some of those mitigation efforts how much of that should be mandatory yeah so part of that is also going to depend on what the level of of SARS-CoV-2 is in the community right if we have a high level that might be necessary because many of many of the children the vast majority of the children are going to be asymptomatic so without testing we're going to have people spreading it without realizing it so I do think as I said I do think that we're going to have to impose mitigation strategies and I think I'm more comfortable with imposing mitigation strategies even than the vaccine at this time getting a saliva spit test is 100% safe spit into a tube it's nobody even touching you so that there can't be concerns of safety and this way we can really try to make it so that the schools are as safe as possible certainly we have a question from an anonymous attendee when do you sort of anticipate or when do we anticipate young children will have an approved vaccine available yeah I'm rooting for end of the year 2022 and again remember we still have to get the BLA for adults now that should be coming next month or in June right so each of these are just a step-wide process so the adolescent you're going to need six months of data in order to be able to do the BLA for the adolescents so studies started in February and March so those aren't going to be coming in until August or September and we're really not very far along in the studies on younger children so it's going to be probably as I said the end of the year early 2022 and to sort of follow up a little on this is is there data that asks parents the likelihood that they are to vaccinate their children I think the data that you showed was for sort of adults deciding on vaccination but is there data that asks parents the likelihood that they're going to vaccinate their children and if so what does that data show well hopefully the data shows that if a parent is going to vaccinate themselves are going to be willing to vaccinate their children I can't imagine a parent refusing for themselves going to want to vaccinate their children so no I don't know of any specific polls of that sort but I think it's going to be really important that again I really want to start let's get the adults vaccinated we are the super spreaders and we are the ones more at risk Micah asks if you could comment on the disconnect between policies schools implemented and pediatricians recommendations and the data to sort of support those recommendations how can we fill this gap that's a great point Micah but I would say that the data we're changing on a weekly basis right when I first they shut down the outpatient clinic for about a week and then we came back and we were cleaning everything like crazy in between every single patient our keyboards I mean it was this whole production and then we came to realize that COVID really isn't spread from fomites and on surfaces and yet it took a long while to get rid of that and I think part of it was just the evolving nature of our understanding of this illness I'm not surprised that in some places policies are slow to take up the science and sometimes you got conflicting science right just because the first study says that fomites aren't a problem doesn't mean that the second third and fourth won't and so it was really hard to make good policy decisions but now we have a lot of data what's been incredible about this pandemic is how much data we have and so we do know what we have to do to mitigate the risks and we should be implementing it in all the different ways and so mass vaccines indoors until all of us are vaccinated makes total sense but outdoors if you're vaccinated your risks are really low schools tend to particularly schools in cities tend to be very heavily congregated they're too small for the purposes of what they're doing in a good day let alone in a pandemic and so that raises big issues for us on how to make it safe so part of what's going to make it safe is going to be doing frequent testing a follow-up question is that there is important data on racial and poverty disparities that missing in-person school for 10 or more school days per year substantially impacts sort of mental health and educational achievement would there not be mandatory summer schools to catch up it's a great question the question the fact is though that missing 10 days actually has impacted everyone and again the gap widens so I understand that but the question is why wouldn't we have access to summer school virtually everyone the question though asked mandatory and that raises other issues again of what you're going to get into issues of what families other plans are and things of that sort so it's going to be a hard one of course we could ask the question why do we have a nine month school year that there's always the summer slide we're no longer an agricultural society where we need our children to be held in the farms in the early you know late summer early fall so in some ways you could argue that we'd all be better off because all children slide during the summer obviously though as Mike pointed out it's worse for children who live in poverty I totally agree I would hope that at least we make it voluntary and that we have the resources and that hopefully in tonight's talk we're going to hear about not just the resources for the three and four year olds for preschool but also for summer school for all of our children particularly our children who are and who live in title one communities yes a follow-up question I had along a similar vein is you know what efforts are being done to sort of recapture those students that who have sort of been lost in the process are there policies in place what are the recommendations that are happening that try to recapture these students particularly those from vulnerable populations what is being done to sort of recapture them so here my knowledge is purely anecdotal since my daughter is a second grade teacher in a title one school they have been doing a lot of outreach and going around to community centers and places where people are and trying to locate children who miss kindergarten for example just parents who never sign their kids up it's hard it's really hard to find children whose parents have in a sense opted out and so again to Mike Missall's point the title one schools are the ones who are struggling the most and the other ones who are trying to do the outreach but they need the resources and so we really need to give the resources to locate these kids to get them into some degree of supplemental school summer school would be great even some after school programs in order to get them to be able to catch up from the missing year and a half that they've missed to date I could almost imagine sort of the future sociologic and anthropologic books that are going to talk about this lost generation it's going to be a sad one again and exacerbated the disparities Michael also asked should teachers have the right to a paycheck if they do not do sort of in-person classroom teaching or I guess we could sort of ask the question a little bit more broadly should we incentivize students or not just teachers in some way to do in-person and I want to point out that the data are that school staff and teachers are doing better than many of our hospital systems so are we going to not give paychecks to all of our hospital personnel who don't want to come in and are refusing the vaccine so we have the same issues everywhere is my point at some point it's going to be an interesting question whether some schools are going to retain an option of school being virtual for the near future or even forever possibly I would just argue that since the data show that children learn much better in person remember it's not just learning academics it's also learning socializing how to interact with people how to negotiate when you have a fight and things of that sort that you're really going to miss that virtually and so I do think that even the best virtual learning for our young learners is not the best system and that's what we want them in person so part of it depends on whether the schools are private or public whether they're unionized whether they're state policies and things of that sort so I really can't answer the question specifically I do hope that all of these individuals who are sort of fighting returning to the way things were are getting vaccinated and making it so that they're less likely every year we have schools open and we have flu and flu kills a lot more young people than COVID does and so it's fascinating it's important that we're discussing this but we also just need to think about it in the big picture very few places mandate flu vaccines even in K through 12 let alone any adult population do you think that what we're going through now especially seeing that the market decrease in sort of respiratory virus illness that maybe there will be more mandates in the future I don't know having not gotten a cold in 14 months despite being a general pediatrician I asked myself will I continue to wear a mask in the clinic it's been nice not getting infected I do have to say though that the kids cry a lot more because they can't see that I'm smiling behind my mask I haven't learned to smile with my eyes I guess and whenever I take the kids' masks off to to examine their throat and their nose I always ask them to smile first because it's so rare you get to see kids smiling because they're all behind these masks so I think that there's going to be a lot of voluntary use of masks but I do think that we are prone as a country to forget the lessons we've learned and I would bet that within 5 to 10 years you're going to see nobody in the medical centers wearing masks Catherine De Palma asks I'd love to hear your take some more on the ethics or the politics of patients asking their physicians to write accommodations of not returning to work and the variability in the basis for requests what are our thoughts for how physicians might be basing their decisions we should have some really strict guidelines so this is an interesting thing let's talk about vaccine mandates and vaccine exemptions so different states have different willingness to have exemptions all have a medical exemption obviously if you're at risk from getting the vaccine you shouldn't be getting the vaccine and many states have religious exemptions and fewer states have philosophical exemptions when California just to give an idea when California decided after the outbreak of measles in Disneyland in California they decided to get rid of many of their non-medical exemptions because they realized that one of the problems was that they were pockets of populations that were unvaccinated and what they found was the number of medical exemptions went up like five-fold and they actually prosecuted at least one doctor for falsifying this they should have prosecuted a lot more because you don't get up to 5% without a lot of people just lying so I think they really should this gets back to doctors and self-policing we call ourselves a profession we're supposed to police ourselves and each other and we do a really poor job of it so the question is should we have some very specific criteria on what are the reasons why somebody has to be working from home and my answer would be yes and they should be and that if anybody is writing excuses that don't meet those that we should question and revoke their licenses this is more of a doctor problem than it is of the patients I was surprised that in our clinic that how quickly parents started asking for if a child has mild asthma can I have a mask exemption I imagine in certain sort of closer communities or close-knit communities where everyone knows everybody even like sort of Hyde Park that denying some of those requests may be challenging but not denying those requests is also going to be challenging because you can have the whole community looking for the exemption sort of a medical practice issue that should be dealt with at a professional level but Maria Donahue asks Lainey as a pediatrician what recommendations do you have for the Academy of Pediatrics to close the mental, social and educational gaps post-COVID so how do you see the schools doing testing to see if children can progress to the next grade how will this impact the variety and emotional distress I haven't heard about a lot of testing if anything we got rid of SATs we got rid of a lot of end-of-school testing in many schools across the country in 2020 not exactly sure how much is going to be done in 2021 and how you're going to accommodate all of that and some children have real stresses from taking these exams or being held back I think again we just need to be offering a lot of services this summer to help these kids really get back to grade level and then having discussions with families if they haven't about what's better to stay on grade level and just really struggle the following year and at what point are you going to sort of acknowledge that this child needs additional help so I think we need to have a lot of resources and I'm really hoping we can hear about that tonight into our schools so that we can try to help with these educational gaps that have been created and disproportionately created I do want to emphasize that I do acknowledge that it's a disproportional harm that's happened during this pandemic and that we really need to be providing these resources into our inner cities but how am I going to convince the parents that they want to do it is another issue knowing that you're sort of not speaking to sort of what's going on in colleges and universities but Robert has sort of I think a more general question about what makes sort of colleges and universities different than K through 12 do you want to tackle that question? Not really they're all adults and I'm a pediatrician I'm going to stick to the pediatric questions. Great and so you recognize that we're close to time one of the questions that sort of I had initially when you sort of showed that slide about all the things that we didn't have in place in terms of why not I mean it's sort of been touted how from sort of a pandemic readiness standpoint the United States was best ready to handle this a major pandemic and we sort of failed miserably do you know if that sort of pandemic preparedness included policies around schooling and if not was our sort of slow pivot just a real failure of imagination in sort of what might happen during a pandemic particularly to a whole segment of our population that had particular needs like very important needs of education and all the sort of secondary benefits that come along with it. Yeah so there are two issues here I think so the first is back in the H1N1 around 2007-2008 there was a whole slew of thought and very good thought and lots of National Academy of Medicine ILM reports all about you know prices and pandemic management and things of that sort and again when we were talking about how long does our memory hold the answer is not a decade because we you know after a few years people I mean what have we done in the past 10 years we destroyed our public health public health departments we defunded so much of it we defunded the CDC all the organization we defunded our international presence with CDC so the people who might have been there in China and could have you know warned us what was happening we destroyed that whole system and hopefully that this pandemic teaches us not only to reinvigorate it but not to ever let it fail again in some ways we could argue you know over 100 years ago was when we really started to see the split between medical centers and public health centers and maybe this pandemic should teach us that we really have to rejoin those that we can't think that they're separate silos public health and medical care and you know medical care is the patient in the room and public health is all the patients outside of the room I get it but somehow we need to be thinking about this as a much more joint system than we have so that's the first issue is that a real failure to remember what we thought we were worried about in 2008 the deep funding of all of the public health programs did not help us in one bit the second half of that question was I forgot the sort of main questions yeah like what you know was this a failure yeah and then but I want to point out I don't think we were wrong to close the schools in March of 2020 we didn't know it was so much unknown that the smartest thing was just to go into lockdown but they started coming out and by you know by April and May there were many schools that were saying no the kids aren't the super spreaders we're reopening and internationally they looked at it but all again imposing strong mitigation strategies and having some really good success so I think part of our problem was we weren't following the science enough it was a very politicized issue whether it even existed and so we weren't following the science and weren't therefore able to make good you know timely weekly changing decisions that needed to be made and recognizing that we're pretty much at time what might be one or two things that you are particularly hopeful that we will have learned from this pandemic what will we have learned again I think that the importance of public health would be one of the most important lessons and that we really need to reintegrate that into medical schools and medical services and the second thing I hope we've come to realize is that it's not like we love to say we're all in this together but some of us are being disproportionately harmed and we need to acknowledge that at all times during this pandemic and future pandemics wonderful thank you very much Laney Mark I'll turn it over to you to say your final any final remarks I just want to thank you very much Brian and Laney spectacular talk and lovely question and answer period I had one question about why the University's lab school has been so slow and opening but I guess Brian didn't want to read that one I volunteered to be on the committee but I wasn't chosen sorry to hear that and the fellows will be joining you in about 10 minutes right if Yolanda could send me the link again so I will join on to that correct link I will join on at 30 oh good Yolanda said she'll do that thanks so much I just wanted to announce to the group that the last two weeks of the lecture series will be the next two weeks Will Parker will speak next week and Brian Callender will speak on the 27th lecture as the concluding lecture thanks Laney so much thank you very much bye bye