Long COVID: Preparing for the Next Major Chronic Illness

00;00;00;03 - 00;00;43;27
Tom Haederle
The government intends to declare the official end of the COVID 19 public health emergency in May, but the pandemic itself appears ready, willing and able to stick around well past that date. Long COVID with symptoms ranging from fatigue to dizziness to shortness of breath and loss of smell, is disabling millions of Americans. And health care leaders across the country are recognizing the need for a coordinated response to stem the impact of what is essentially our newest chronic illness.

00;00;45;26 - 00;01;09;13
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle, with AHA Communications. Long COVID spans a wide range of physical, psychological and cognitive symptoms. What are the best current practices for diagnosing and treating it, and what are the clinical and financial implications for hospitals and health systems that want to tackle this growing area of patient care?

00;01;09;26 - 00;01;30;25
Tom Haederle
Ben Wise, AHA's senior program manager, is joined today to discuss the push for long COVID solutions by Dr. Dwayne Gordon with the AdventHealth Central Florida Division post-COVID Clinic and Dr. Richard Pratley, medical director and senior scientist in Diabetes Research at AdventHealth, Diabetes and Translational Research Institutes.

00;01;31;26 - 00;01;44;14
Benjamin Wise
Dr. Pratley, Dr. Gordon thank you so much for taking the time to to meet and chat with us today. I'm not going to overthink the first question here. What is long COVID and how do we diagnose it? Dr. Gordon, start with you, please.

00;01;44;14 - 00;01;56;05
Dwayne Gordon
Well, that's the million dollar question, Ben. You know, it really is a broad range of symptoms that develop and persist for at least three months following the diagnosis of COVID. To expand on that, 

00;01;56;19 - 00;02;36;15
Dwayne Gordon
these symptoms cannot be explained by an alternative diagnosis, and typically they spend a wide range of physical, psychological and cognitive domains. So specifically, many patients present with fatigue, decreased exercise tolerance, diffuse musculoskeletal pain, maybe a sense of breathlessness or dysregulated breathing. Some of the psychological complaints include severe anxiety, panic attacks, depression and PTSD. Many patients also have insomnia and they'll complain of brain fog, not being able to remember things and impaired ability to focus and concentrate.

00;02;36;20 - 00;02;52;03
Dwayne Gordon
That being said, impairment in these domains have led to significant downstream effects in individuals not being able to complete simple activities of daily living, impairing ability to work and sustain employment and disrupting interpersonal relationships.

00;02;52;17 - 00;03;12;27
Richard Pratley
Dwayne, one of the things that's impressed me is just the diversity of symptoms that are part of long COVID. But it's clear that not everybody has every symptom. And so we really have to have our diagnostic eyes open as we're seeing patients in clinic to see whether or not the things that they're describing could potentially be part of the syndrome.

00;03;13;06 - 00;03;14;10
Dwayne Gordon
Absolutely.

00;03;14;10 - 00;03;19;17
Benjamin Wise
And when did this first come onto your radar, both in the field and in your actual offices?

00;03;19;17 - 00;03;39;25
Dwayne Gordon
So, you know, this came onto our radar, you know, within the last year and and some change perhaps, where we started seeing more patients saying, hey, my symptoms are, you know, prolonged. And our system here started realizing this is becoming more prevalent in our community.

00;03;40;07 - 00;03;43;01
Benjamin Wise
And so discussions began after that.

00;03;43;17 - 00;04;07;03
Richard Pratley
People started describing Long COVID in about the first year of the pandemic. But we knew so little about COVID and we knew so little about the course of things and how this is happening, that it took the medical community a while to get our hands around this, to start collecting the cases and start putting together a description of what Long COVID actually was.

00;04;07;08 - 00;04;25;07
Richard Pratley
And that's where we see some of the heterogeneity. We see different descriptions from different groups, but there are probably 50 or 60 of these case series of Long COVID involving thousands of patients now. And we're starting to get a better picture of what it looks like based upon these studies.

00;04;26;12 - 00;04;38;11
Benjamin Wise
And as the sample size has grown and as this COVID clinic - that we'll talk about in a bit  - has has come into fruition and grown, what kind of data are you seeing on Long COVID? What's the research telling you?

00;04;38;11 - 00;04;44;24
Dwayne Gordon
So you know, there is quite a few different studies out there in terms of long COVID.

00;04;45;05 - 00;05;07;02
Dwayne Gordon
And you know what? What we're seeing is that, again, there is that heterogeneity with the description of long COVID. However, there are some common themes that many of the studies are showing. And again, they do span those domains we were talking about.

00;05;07;22 - 00;05;37;03
Richard Pratley
I want to point out that Dwayne hit on earlier is the impact in patients lives is difficult to carry on their activities of daily living. It's difficult to be successful and functional in their job, and relationships can suffer as well because of the the impact that this has on the way people feel, on their mood. And so I think we're still just scratching the surface on the impact of Long COVID.

00;05;37;03 - 00;06;02;28
Dwayne Gordon
And I may add one more thing. You know, there was a recent meta analysis of about 54 studies, and it suggests that just about 6.2% of individuals diagnosed with acute COVID infection symptomatic will go on to indeed have Long COVID. So that's something that we have to think about in terms of the burden of care on the health care system.

00;06;03;15 - 00;06;22;23
Richard Pratley
This doesn't sound like a high percentage, but when you consider the millions of people that have been infected by COVID, we're really talking about millions of people entering into the health care system with what essentially is a chronic disease for which we don't have obvious cures. So this is going to put a strain on the health care system, in my estimation.

00;06;23;10 - 00;06;28;11
Benjamin Wise
What are patients reactions to receiving a Long COVID diagnosis?

00;06;28;11 - 00;06;55;17
Dwayne Gordon
You know, it's interesting because many people who come to our clinic come with the idea to perhaps that they do have Long COVID. And so therefore, it's not typically a major surprise. Many times, it's a are you validating that I do have Long COVID? And is this real? Because I've been told, for instance, that it's not real, though I have all these symptoms.

00;06;55;17 - 00;07;12;27
Dwayne Gordon
Sometimes they are told by maybe another clinician that, hey, the Long COVID does not exist, and, you know, they're having very real symptoms. So many times as we're doing our evaluation, we're having that type of discussion to discuss do your symptoms really fall into a long COVID diagnosis?

00;07;13;10 - 00;07;33;11
Richard Pratley
And people are grateful to hear that it's not all in their head. I think they hear that from other people and it really makes them doubt themselves. But understanding that, yes, what their experiencing is part of long COVID and they need criteria I think is a valuable, perhaps it's the first step to healing for many people.

00;07;34;09 - 00;07;47;06
Benjamin Wise
As you started to observe these conditions. Can you tell me about what AdventHealth did and what your departments did to begin prioritizing long COVID and and how you came to develop your post-COVID clinic?

00;07;47;06 - 00;07;58;04
Dwayne Gordon
Absolutely. A lot of the leadership here at AdventHealth has gotten together, had discussions around, hey, what is going on in our community and where is the need next?

00;07;58;04 - 00;08;26;08
Dwayne Gordon
Yes, we've taken care of the acute COVID cases. We've dealt with the sickest patients in the ICU, but now we have this chronic condition, as Dr. Pratley rightly put put out there. It's a chronic condition. And so we have developed a clinic that has a multidisciplinary team that works together in this same brick and mortars clinic. And essentially, we come together and we work to create a cohesive plan for these patients.

00;08;26;08 - 00;08;56;08
Dwayne Gordon
So we'll do a comprehensive evaluation. And our multidisciplinary team includes a primary care physician, which is myself, a neuro physical therapist and a behavioral health specialist. We also, of course, have our supportive staff and we work closely with our administrative leaders and research team. You know, just really to ensure our strategic vision includes all of the important elements that we want to accomplish for each of our patients.

00;08;56;21 - 00;09;27;00
Dwayne Gordon
Maybe I'll spend a little bit more on what that looks like. So when our patients come in, for instance, they will have typically on day zero. So when they come to our clinic for the first time, what we do is we do a comprehensive evaluation. We will start with a 60 to 90 minute visit, and it's usually a detailed timeline of the patient's initial symptoms, including whether or not they were hospitalized.

00;09;27;00 - 00;09;55;20
Dwayne Gordon
Did they require oxygen? Did they get subsequent rehabilitation? What was their vaccination status, you know, and so on. And then, of course, we go through their past medical history, co-morbidities, and then we delve deeply into what are their current symptoms. What prior workups have they had and perhaps what treatments have they sought or received at outside facilities And then from there, this is very important.

00;09;56;00 - 00;10;25;11
Dwayne Gordon
We actually take a moment to pay special attention to what are their current social history and stressors, because many times there can be some confounding factors. And so it's actually incredibly important because many people have outside stressors that might be influencing some of what they're experiencing. Not necessarily all, but we want to put a big picture together. Each of our patients then have a EGAD 79 in a lump score.

00;10;25;11 - 00;10;42;11
Dwayne Gordon
It does help with anxiety, depression and what is their mentation like? We also do a comprehensive physical therapy assessment and then a behavioral health assessment to complete that picture. That's initial assessment.

00;10;42;11 - 00;10;50;04
Benjamin Wise
You know, what a what a full approach. You know, it strikes me in reading about post-COVID clinic that not only are you doing this great, if not inspiring work in this new and growing area, but it's also just a really good example of kind of cross-sector teamwork and that you're pulling in lots of people from different disciplines. How did those initial conversations happen? How did that plan to maybe like helps larger strategic plan? And organizationally speaking?

00;11;08;22 - 00;11;29;04
Dwayne Gordon
You know, Ben, honestly, this is one of the best things that's come from this clinic is this multidisciplinary approach to patient care. Because I will tell you, it benefits the patients immensely. And to answer your question, you know, from the very beginning we discussed: what is the best model to approach these complex patients?

00;11;29;14 - 00;12;10;20
Dwayne Gordon
And it was not just a physician or just a physical therapist or just a behavioral health specialist. We realized these people are coming with a multi-organ, multi-issue type of condition and it spans so many different areas. And I failed to mention that we do have a case manager who helps with some of the social aspects. But you know, I will tell you this, it's been a blessing and probably one of the best ways to practice medicine, in general, with this multidisciplinary team because we do get to emphasize all of these important aspects in these patients lives and the areas that have been impacted greatly.

00;12;10;20 - 00;12;15;22
Dwayne Gordon
So I think much of the success of this clinic has been attributed to that.  

00;12;15;22 - 00;12;21;28
Benjamin Wise
And what might a typical day look like at the post COVID clinic if there is such a thing?

00;12;21;28 - 00;12;34;28
Dwayne Gordon
Yes, yes, there is such a thing as a day, but a typical day, you know, I'll say then for sure it's unique each time because each of our patients come with unique presentations.

00;12;34;28 - 00;13;10;03
Dwayne Gordon
But typically what we'll do is we do have these are much longer appointments, as I was mentioning earlier, and we do start with that comprehensive evaluation that I described for each of our patients. We use our hallways for our physical therapy assessments. You know, the whole space is being used to its max potential. And what we are doing then after we do that initial assessment, just to kind of fill out what that day looks like, we then meet together, we discuss the patient's case and we tease out what are the main things that are going to benefit them.

00;13;10;06 - 00;13;33;01
Dwayne Gordon
For instance, are they going to need a graduated exercise program with physical therapy or occupational therapy? Are they going to need to work with a speech therapist on not just speech related issues, but also cognitive exercises, which many people don't even realize that speech does those things. And so they work in concert. We work together to put that plan in place.

00;13;33;01 - 00;13;56;14
Dwayne Gordon
Then we look at what medications they may need. We also look at what is their social situation. Do they meet criteria for the grant that we have for providing them some extra support there? And then we also look at, you know, do they need a sleep study to diagnose sleep apnea, which impacts these patients because they have a lot of insomnia and different things?

00;13;56;22 - 00;14;23;15
Dwayne Gordon
What other studies do we need? Chest x ray, CTS, echos or pulmonary function studies? So we do that comprehensive evaluation. One thing I would point out just briefly is, we tell our patients from the get go, we are an ability clinic, not a disability clinic. And so it's actually incredibly important to specify that because we tell our patients we are not filling out disability, we are trying to make sure that you get the best ability and you can get back to work, get back to being functional.

00;14;23;21 - 00;14;41;10
Dwayne Gordon
So that's kind of the big structure of what we share with our patients. 

Benjamin Wise
But with such a wide range of symptoms in a wide range of patients that you see, is it safe to assume that treatment plan to also vary a lot? And what might some of those look like? 

Dwayne Gordon
Right. It does vary a bit, but I would say there's a common thread.

00;14;41;24 - 00;15;06;06
Dwayne Gordon
The common thread is the majority of our patients do indeed require therapy sessions, both mental behavioral health, but as well as physical. As I was mentioning, speech therapy. That is literally the common thread that many of our patients require. And we are working with another team on a breathing trial where we help patients kind of reset their breathing pattern.

00;15;06;07 - 00;15;31;13
Dwayne Gordon
Many of our patients come in feeling breathless or have dystonic exertion where they're getting short of breath frequently or they have dysregulated breathing, where they're taking shallow breaths. We're actually working on a protocol to implement that, so that helps them relax and be mindful of their breathing. So these are some of the common threads. And then yes, we have certain little areas that we do help them individually with other components that are unique to them.

00;15;32;03 - 00;15;45;10
Benjamin Wise
Talking about anything related to this, it's hard not to think about the role that misinformation plays both in the medical and larger societal function. In what ways has misinformation affected your work or the work of the clinic?

00;15;45;10 - 00;15;55;17
Dwayne Gordon
So I will tell you, at times it's been a significant challenge. You know, there are many patients who have been told that if they only take this concoction of medications, they will feel better.

00;15;55;26 - 00;16;18;16
Dwayne Gordon
And some of these medications have been proven in trials to do much for these patients. And then also, you know, sometimes people are just told, like we mentioned earlier, hey, Long-covid doesn't even exist. And so what we're doing is when we talk with our patients, we tell them, hey, we validate what you're experiencing. Some of it is intangible and we can't put a finger on everything tangibly.

00;16;18;17 - 00;16;40;24
Dwayne Gordon
However, we we want to encourage you that we are seeing progress in what we're doing for our patients. And you know, though we don't have all the answers and we realize that, we share that upfront. We don't have all the answers. But I will tell you that we do see success with a multidisciplinary approach and we're here to support you and get you functional.

00;16;41;10 - 00;17;08;23
Richard Pratley
And I think one of the issues that's not just in Long-covid, but in general, that we've had to deal with this misinformation and we can just explain, you know, the the best that we can do what the evidence is that we understand as practicing physicians and people who stay up with the literature. There is, as Duane mentioned, so much stuff that's out there on the Internet and misinformation.

00;17;09;02 - 00;17;26;06
Richard Pratley
All we can do is present the best evidence that we can in a logical fashion and not emotional fashion. And we have to let people make their own decisions. But generally, I think the people that seek out care are people who understand and believe in this pathway.

00;17;26;17 - 00;17;46;21
Benjamin Wise
And I'm guessing that because of the nature of of of your day-to-day work and also because of the research that you're doing that maybe you're in touch with other peer or colleagues that are looking at post-COVID issues or Long COVID. And just kind of wondering, do you share information with other Long COVID clinics and what's that website community like?

00;17;47;17 - 00;18;15;25
Richard Pratley
Well, from the research side, there's actually a very large NIH study on called the Recovery Study, and they're recruiting literally thousands of patients across multiple centers, doing in-depth evaluations across these multiple domains that Duane mentioned. And in addition, collecting bio specimens and doing things like imaging to really understand the pathogenesis of Long COVID. I think we're at a point where we know what it is.

00;18;16;04 - 00;18;35;07
Richard Pratley
We know how it affects people. We're starting to understand things that might help people with Long COVID who really don't understand specifically why this is happening, and that "why" is how we would get to better treatments for Long COVID. So this is still a very important area of research.

00;18;35;20 - 00;18;44;28
Benjamin Wise
And Dr. Pratley, specifically with AdventHealth Translational Research Institute. What what kind of data and research are you currently looking at and exploring?

00;18;45;11 - 00;19;21;23
Richard Pratley
One of the things I'm really proud about with AdventHealth is our response to COVID. Shortly after the pandemic became a serious issue, leadership rolled out an organized initiative that included infrastructure, clinical care, nursing everything. And included in that was a science response to COVID. So we rolled up a scientific review committee that reviewed all of the literature and forgot how many papers we looked for and made recommendations to the hospital system based upon our best understanding of the literature.

00;19;22;01 - 00;19;57;00
Richard Pratley
We also had a committee to review and vet clinical trials. We were doing a lot of research before COVID and all of that essentially had to shut down with the exception of some very critical trials. And so we had staff that was adept at research, it's expert in research, and we pivoted to doing research around COVID. All of these people went on and did COVID research in our acute care, and our intensivists probably ran over a dozen studies of immunomodulatory therapies. Separately, we ran studies of diagnostics, point of care diagnostics for COVID.

00;19;57;11 - 00;20;28;08
Richard Pratley
We did studies with convalescent plasma, and then later on, as things developed, we engaged in a vaccine trial. We rolled out three clinics with temporary buildings at our different campuses, hired staff, and screened over 500 people and enrolled 400 people in a vaccine trial. So this is a very integrated response. That was supported by the science that we do at Adventhealth to try to make a difference in COVID itself.

00;20;28;20 - 00;20;52;03
Richard Pratley
Now that we're entering sort of a new phase, some of the acute research is not so intense anymore. And the vaccine trials that we're doing have come to an end. But what we're now focusing on is this problem of Long COVID understanding that better. So one of the studies that we're currently doing is a study where we're doing imaging in people who are suffering from long COVID.

00;20;52;11 - 00;21;21;04
Richard Pratley
So we'll put them in our research MRI and we're imaging the heart, liver, kidneys, pancreas, spleen, looking for evidence of inflammation, fibrosis and other abnormalities that might explain some of the consequences of Long COVID that we see. I just saw a patient in our research clinic who'd come from Duane's clinic, so we worked very closely together just to recruit patients for the research study.

00;21;21;04 - 00;22;05;28
Richard Pratley
She'd been in the ICU for six months, now walking and talking, and grateful to be able to participate in research in order to find the cure and to find out more about the consequences of COVID. That's one of the gratifying things about research, is you get to hear their stories, which are in many cases really amazing. Had another patients who had severe heart failure and had a heart transplant. Developed COVID, was in the ICU, survived COVID, and then came to our unit to get imaged because he was so grateful that the intensivists were able to bring him through this acute episode.

00;22;06;08 - 00;22;17;11
Richard Pratley
So really working with the research patients is through the lights. We feel like we're making a difference that hopefully will help people not just at AdventHealth but around the world.

00;22;18;01 - 00;22;27;02
Benjamin Wise
That's very impressive and sounds like some excellent work being done. What would are plans for this research either to grow within that Adventhealth or to share with the larger community?

00;22;27;17 - 00;22;57;22
Richard Pratley
Thing that we're doing with research that was really stimulated by COVID now is teen science. So the group that the NIH that's running this large consortium is made up of dozens of investigators. And what we're learning is that when we collaborate with other teams that are doing similar things, we have more power to analyze questions. We get more insights from the data, and we can create more knowledge out of our small, separate studies.

00;22;57;27 - 00;23;04;10
Richard Pratley
So that's the next step is to kind of expand that activities, working with people around the world.

00;23;04;28 - 00;23;25;27
Dwayne Gordon
Absolutely. And I'll throw one thing on there. We also are gathering, of course, all the data from our patients in our clinic that's ongoing, and we are going to continue to analyze that to see their outcomes with the direct treatments that we're implementing. And thus far, I will tell you it is very promising. 

00;23;25;27 - 00;23;34;25
Benjamin Wise
Just like you asked me: Would you have any advice for a hospital or health system that's thinking about starting their own Long COVID research or a type of post-COVID Clinic?

00;23;34;25 - 00;23;45;28
Dwayne Gordon
Absolutely. I would put it this way. We know Long COVID is here to stay. It's called Long COVID for a reason, But I think we would like to shorten it, stay in our communities.

00;23;46;03 - 00;24;14;23
Dwayne Gordon
And I think the best way to do that is to really make strategic decisions, to implement, you know, dedicated multidisciplinary clinics as well as robust research for Long COVID patients. You know, if we invest upfront in these clinics, I really do believe we will pay dividends down the line in decreasing unnecessary doctor visits, decreasing days lost from work, and ultimately increasing the health of our communities at large.

00;24;15;01 - 00;24;50;05
Dwayne Gordon
You know, I encourage really everyone to be thinking about this, because I will tell you a quick 15-second anecdote. You know, yesterday we had our first patient actually graduate from our program. She graduated because she's completed her four visits with us over a six month period where she got all these treatments, all of these therapies. And she came in to to our clinic with oxygen and having difficulty walking even 5 to 10 feet.

00;24;50;13 - 00;25;10;18
Dwayne Gordon
And now she's off of oxygen, She's back at work and is functioning optimally. And we are thrilled to see what she's doing. And we're not taking all the credit for that by any means. But I would say that some of the interventions and the team members who have been around her and working with her, she was incredibly grateful and we were just happy to be part of that journey.

00;25;10;18 - 00;25;16;08
Dwayne Gordon
And I think we need to invest in that so we can move the needle for our patients and for our community.

00;25;16;08 - 00;25;40;13
Richard Pratley
I think the advantage of having a team like this in a clinic like this is that you learn from every patient and eventually will get to the point where we have more standardized approaches and treatments to patients with Long COVID. We only get there by showing sharing our collective experience. And that experience is our learnings from every patient as they come through.

00;25;40;16 - 00;25;52;14
Richard Pratley
Because, as Dwayne pointed out, every patient is unique. They all have unique needs and we need to address them in a personalized way. In some ways, it's sort of the ultimate in personalized medicine, if you will.

00;25;52;27 - 00;26;13;10
Benjamin Wise
Well, I have a couple more questions, but I know your time is valuable and I'm so appreciative of it. But before I get to my last questions, I was wondering, is there anything that I haven't asked or that that we, the community should be asking and aren't asking more regularly? I just wanted to make some space for for anything that was on your mind about this topic that maybe doesn't normally get asked or covered.

00;26;13;27 - 00;26;36;24
Dwayne Gordon
You know, I think you've covered quite a bit, Ben, but I would I would just throw it out there briefly. I think this is a conversation that we should have openly in many forums. This is going to be a large potential economical burden and also impact people on many different levels. And we need to be ahead of this and hopefully not behind the eight ball.

00;26;37;01 - 00;26;42;13
Dwayne Gordon
And so I think we should definitely have transparency and openness around this topic.

00;26;42;29 - 00;27;11;13
Richard Pratley
I think there are a lot of opportunities to leverage telehealth, remote patient monitoring and interventions in the home, perhaps with home visiting nurses or therapists as a way to augment sort of the more intensive clinics that Duane is doing. And I don't think we've gotten to that stage yet, but I think there's still opportunities to improve care and explore new treatment options.

00;27;11;13 - 00;27;36;21
Richard Pratley
So, you know, if I had advice for health care systems, I would say keep an open mind. Use your networks to raise awareness about Long-covid. As Duane said, commit resources to caring for these people because we believe it will pay off in the long run and explore and research treatment options because that's how we're going to get to the best care for these individuals.

00;27;37;09 - 00;27;52;04
Benjamin Wise
Thank you. And all of that makes so much sense and I so appreciate those perspectives. And so I guess, in closing, are there other top lessons learned regarding long COVID that you'd like to share with your peers or the community? Any final thoughts?

00;27;52;04 - 00;27;59;00
Dwayne Gordon
I would recap that we need to invest upfront. We need to work together as multidisciplinary teams.

00;27;59;07 - 00;28;25;28
Dwayne Gordon
We need to make sure we invest in the research infrastructure at different institutions. And frankly, we need to be patient with this patient population. They do require a lot of resources and a lot of dedicated care to getting them back to functionality. But I will tell you, based on what we're seeing, it's worth it. And we should put the work in upfront because we will benefit our communities.

00;28;26;15 - 00;28;46;28
Richard Pratley
Well, I agree with Duane, and I want to just emphasize that this is not something that health care systems should put their head in the sand about. As Duane said, this problem is not going away. And even if the current COVID activity is in a little bit of a lull, it's going to come, it's going to go and we're going to keep seeing patients with Long COVID.

00;28;46;28 - 00;28;59;19
Richard Pratley
So the sooner we get better at managing it and have systems in place to diagnose and care for these individuals, the better off our patients will be and better off our communities will be. 

00;28;59;21 - 00;29;06;00
Benjamin Wise
Dr. Pratley, Dr. Gordon, thank you so much for your time today, as well as all that you're doing for your community and your patients. Really appreciate it. Thank you.

00;29;06;16 - 00;29;07;29
Richard Pratley
A pleasure. Thank you for having us.

00;29;08;07 - 00;29;10;02
Dwayne Gordon
We really appreciate it. Ben, Thank you.

00;29;10;19 - 00;29;35;26
Tom Haederle
The views and opinions expressed here do not necessarily reflect the official policy or position of the CDC. The involvement of the CDC should not be viewed as an endorsement of any entity or individual involved.