Immunology of Long COVID with Professor Akiko Iwasaki

February 27, 2024

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Dr. Akiko Iwasaki presents her research on long COVID for those interested in a more scientific session than the LISTEN Town Halls. She’ll discuss the latest results from long COVID immune phenotyping analyses and present hypotheses around the disease pathogenesis of post-vaccine syndrome (PVS).

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00:00Welcome everyone.
00:01We're pleased and honored to be hosting Dr.
00:05Kiki Owasaki this evening and to
00:07have so many people in attendance.
00:09I'm Leslie Krumholz.
00:10I'm the Co founder of Hugo Health, Kindred.
00:12And for those of you that
00:14don't know really quickly,
00:16Kindred's building a network of what
00:18we call data enabled people who've
00:20been impacted by COVID and who
00:21want to contribute to research in
00:23partnership with leading scientists.
00:25I I strongly encourage anyone
00:27who is not a member of Kindred
00:30to check us out.
00:31I have put our a link to the website as
00:34well as information about the Listen Study.
00:36If you're interested in joining Listen,
00:37you need to actually join Kindred first.
00:40The Listen Study is being led
00:41by Doctor Akiko Iwasaki and Dr.
00:43Harlan Krumholz.
00:44So I'm not going to take up
00:45another second of your time.
00:47I'm going to pass this right
00:49over to Akiko for introductions,
00:50kick off this very important
00:52presentation and once again,
00:53just to say thank you so much for
00:55spending an hour of your evening with us.
00:58So, Akiko,
01:00thank you so much. Leslie.
01:01I'm delighted to be back on the town hall
01:04again with the Kindred, Hugo Health.
01:06And I'm also delighted to be sharing
01:09the stage with my colleagues,
01:12Ornali, Cesar Arlen,
01:13So very happy to be here. All right.
01:18So I'm going to jump in to my talk.
01:21Let's see. OK.
01:25Hope you can see this.
01:28OK, So what I wanted to do today
01:31was to give you an overview of our
01:34current understanding of long COVID,
01:36particularly immune responses in long COVID.
01:39And also I'll spend some time at the
01:44end speculating on how vaccine related
01:47long haul could occur based on some
01:50of the data that the Yale Listen
01:53study has already collected from
01:55many of you participating tonight.
02:00So before I go in to discuss long COVID,
02:02I just want to emphasize that
02:04COVID is not the only infection
02:06that results in post infection,
02:08post acute infection syndromes.
02:10And I was fortunate enough to
02:13co-author a review with Yon,
02:15Choko and others on this topic.
02:18Which is really important to keep
02:20in mind because it means that many
02:23other viral and non viral infections
02:25can lead to prolonged symptoms,
02:27some of them leading for decades of
02:31disease and others kind of having
02:34an offset that is much later than
02:37what we're seeing with long COVID,
02:40something that happens decades
02:42after the infection.
02:43So there is a lot of complexity into
02:45these post acute infection syndromes.
02:48They haven't been really well studied
02:50and that's something that we're going
02:52to change by studying these diseases at
02:54the molecular and immunological level
02:57to understand what might be going on.
03:01So the long COVID pathogenesis,
03:03there are multiple hypothesis
03:05that have been raised.
03:07I just want to go over
03:08the four major ones there.
03:10There are many others
03:11that have been proposed.
03:13The first hypothesis is the viral
03:16reservoir or viral pathogen associated
03:19molecular patterns and this is you
03:22know hypothesis that says that
03:24they're even though the viruses
03:26are considered acute infection,
03:28it could.
03:29It's possible that these viruses may
03:32remain in some form of replication capacity,
03:36may not be infectious particles
03:38but they are remnants or they are
03:41parts of the virus that resist being
03:43removed and that could be persisting
03:47in a person and and that could lead
03:51to recognition of these pathogen
03:54associated molecular patterns like
03:56RNA structures or it could also lead
04:00to the expression and persistence
04:02of viral antigens that lead to
04:05chronic stimulation of lymphocytes.
04:07So that's one hypothesis.
04:09Another one is autoimmunity.
04:11Many infections are are precede the onset
04:15of multiple types of autoimmune diseases,
04:18multiple sclerosis and lupus and many others.
04:21So it's possible that the COVID
04:24infection can be leading to stimulation
04:27of bystander or molecular mimicry
04:30autoimmune responses and that could be
04:34prolonged and having leading to symptoms.
04:38The other possibility is dysbiosis of gut
04:43microbiome or reactivation of latent viruses.
04:47So all of us,
04:49many of us,
04:50most of us carry multiple different
04:52viruses and many of these viruses
04:55don't cause any diseases,
04:57but they are remain in the host
05:00as a latent form.
05:02And these types of viruses can
05:05become reactivated upon immunological
05:07stimulation or immune suppression
05:09that may be caused by COVID and that
05:14reactivation itself could trigger
05:16this virus to become activated,
05:19replicate and then cause disease.
05:22The final possibility is tissue
05:25damage and this is you know virus
05:28infection and or immune responses
05:31that are in induced by the infection
05:34that can be triggering tissue damage
05:37that is hard to repair like fibrosis
05:40and that could be lingering or very
05:43difficult to restore in a long term
05:46and could be leading to disease.
05:48And I'll give you examples of
05:51each these of these hypothesis.
05:53So there are over 100 papers now
05:56demonstrating some form of viral
05:58antigen or RNA that's present in people
06:03with COVID months after the infection.
06:06And many of these virus antigens
06:08and RNA has been located in
06:11the gastrointestinal tract.
06:13So this may be a a,
06:14a place of reservoir or at least
06:18some antigen being remnant there.
06:20There was a very nice study by Jim
06:23Heath's group that demonstrated that
06:26Ebb Epstein Barr virus viremia at
06:29the time of COVID diagnosis is one
06:32of the four predictive factors for
06:34developing long COVID over the three
06:36months period that they were studying.
06:39So it's been reported in other studies
06:42also that EBV can reactivate and and
06:46seems to be happening preferentially
06:48in people who develop long COVID.
06:52The other finding from the same
06:55paper demonstrated that Lupus related
06:57auto antibodies are elevated at the
07:00subclinical level in patients at
07:03the COVID acute face who then go on
07:06to develop long COVID,
07:08the second second of the four predictive
07:12factors for developing long COVID
07:15and then there is this tissue damage.
07:18So we with with Professor Michelle Monje's
07:21group at Stanford demonstrated that
07:24even a mild respiratory only infection
07:27with SARS COVID 2 in the mouse model,
07:30it can lead to significant damage in
07:33the brain for extended time period
07:36for over six weeks post infection.
07:39Whereas similar types of prolonged damage
07:42was not seen with mild influenza infection.
07:46So there's something about SARS COV
07:49two that may trigger this long term
07:52tissue damage even if the infection
07:55itself is completely resolved.
07:57So we suspect that long COVID is a
08:01multiple diseases under one umbrella
08:03and that there are multiple endotypes
08:06of diseases with different drivers,
08:09molecular drivers.
08:09And if we can identify,
08:11if we can subset long COVID into the
08:15right types of disease drivers and
08:17target the root cause of disease,
08:21that would be the best way to
08:23go forward with therapeutics.
08:27There's also the interesting paper where
08:31they train dogs to detect inactivated
08:35source COVID to infected supernatant.
08:38And these dogs were able to identify
08:41in a blinded manner 51% of the long
08:45COVID patients their their clothes,
08:48whereas 0% of the controls
08:50were identified by these dogs.
08:52This to me indicates that there there
08:55are volatile organic compounds released
08:57by the people with long COVID and
09:00likely having to do with the virus
09:03infection itself and that's why I put
09:06that in the viral reservoir category.
09:09And there's also papers from David Waltz
09:12group that demonstrated circulating
09:14spike protein in people with long COVID.
09:17So so this sort of reservoir antigen RNA,
09:20there's a lot of accumulating evidence
09:23for it but that that may not be the
09:27only root cause for long COVID.
09:29So today I want to discuss our latest
09:32work on collaboration research that we
09:35we've done with Mount Sinai Group led
09:39by Doctor David Petrino who is just an
09:42amazing human being and a great leader
09:45who is treating people with long COVID.
09:48Thousands of people with long COVID from
09:51the very beginning of the pandemic and he,
09:54his team listed here.
09:56Jamie Wood,
09:57Laura Tabakov,
09:58Dana McCarthy and our team at Yale
10:03have collaborated to dissect the
10:06immunological phenotypes of people
10:09with long COVID and these are the
10:13Co first authors of the paper.
10:16John Klein who led the study and and
10:20currently working on the revision of
10:22this paper along with Jill Jaycox who
10:25is a MDPHD student in arm ring slab
10:28who is using this rapid extrasolar
10:31antigen profiling to look for
10:34antibodies against our own antigens,
10:37auto antigens as well as viral antigens.
10:40Rahul is a brilliant student in David
10:44van Dyke's slab who does machine
10:47learning on all the parameters that
10:49we've measured to try to predict which
10:52factors are most contributing to long COVID.
10:55Paywin Liu tirelessly looks at everyone's
10:58peripheral blood mononuclear cells
11:01using real time flow cytometry to look
11:04at the cell types in in the blood.
11:07Jeff and Sasha have been working very
11:10closely together to look at the patient
11:12data as well as antibody reactivity
11:14to extra extra SARS COV 2 antigens.
11:20So this Mount Sinai Yale long COVID
11:24study is currently in Med archive.
11:27Anyone interested can read this about
11:30Just to briefly go over what we've
11:33done was to recruit participants
11:35from the Mount Sinai long COVID
11:38Clinic and to study a variety
11:42of electronic medical records,
11:44symptoms survey flow cytometry,
11:46to look at cells that are in the blood.
11:50Human exoproadium.
11:51This is the reef technology developed by
11:54Doctor Rensolm to look at auto antibodies.
11:58We we did start scopy 2 antibody
12:01profiling peptide display library
12:02to look at linear epitope mapping
12:06of antibodies from these patients
12:08and used plasma proteomics to look
12:12at plasma factors that are distinct
12:15in long COVID patients.
12:19First, just briefly about the demographic
12:22nature of these participants.
12:24The long COVID patients listed and
12:28always in purple have most of them
12:31are between 30 to 60 years of age.
12:34There were some younger and some older,
12:36and similarly the convalescent control.
12:39These convalescent control groups were
12:41people who were infected around the same
12:44time as those people with long COVID,
12:46but have recovered from COVID
12:49and their age group was similarly
12:52enriched in 30 to 60 years of age
12:55and some younger and some older.
12:57There is no significant difference in the
13:00age and the sex is a female dominant.
13:03This is seen over and over in
13:05in every study on long COVID.
13:08There's definitely sex bias for female.
13:12Also we focused on people who did
13:16not who were not hospitalized.
13:19We wanted to focus on so-called mild
13:22COVID that then turn into long COVID
13:26because this is we believe is a distinct
13:29disease from those people who were in
13:31the ICU and who were receiving drastic
13:34medical treatment versus people who
13:36were staying at home and you know,
13:40fighting the virus infection.
13:41But then develop long COVID.
13:44So days from acute COVID in the
13:47convalescent control and the long COVID
13:49or again not significantly different,
13:51they were overall 400 days out
13:54from the original infection.
13:56So these are the first wave of
13:59COVID that hit New York City.
14:02And so we're looking at a much
14:04later time point than most studies
14:06that have been reported.
14:08First looking at the immune cells
14:10that are in the peripheral blood and
14:14looking at various different cell types.
14:17What we noticed was that there is
14:20increase in non conventional monocytes.
14:23These monocytes are known to patrol
14:25the body for viral infections
14:27and other infections.
14:29So that's elevated in long COVID,
14:32there's a reduction in dendrite
14:34cell subset known as CDC ones
14:37and these cells are critical in
14:40priming cytotoxic T cells and type
14:421 TH one cells which are important
14:45to fighting the virus infection.
14:47We also see elevated activation
14:49of activated B cells as well
14:52as double negative B cells.
14:54So these are the features that
14:56are were elevated in long COVID.
14:58So it it again suggests that the B
15:01cells are being stimulated by something,
15:03whether it's SARS,
15:04COVID 2 or some other antigens,
15:06we don't know
15:09in terms of the T cell subset.
15:11So here we're listing the CD 4T cells
15:15on the top and CD8T cells on the bottom.
15:18There's really no need to go into
15:20the detail of these markers,
15:22but suffice to say that the
15:24CD 4T cell and CD8T cells,
15:26there is a significant increase
15:28in the exhausted T cells.
15:31And so these exhausted T cells
15:33have been seen in chronic viral
15:36infections and cancer.
15:37When the T cells are stimulated over
15:40and over seeing the same antigen
15:42and they basically go into this
15:45state of exhaustion where they are
15:47not no longer very functional.
15:49And so that is elevated
15:51in the long COVID patients
15:55and interestingly when pay when
15:58looked at the ability of these
16:01T cells to secrete cytokines.
16:03So cytokines are important factors that
16:05are released by T cells to communicate
16:08with other cell types throughout the body.
16:11What we saw was an elevated cytokine
16:15secretion or production from CD4T cells
16:17from long COVID patients for Illinois 2,
16:20Illinois 4, Illinois 6,
16:22these are cytokines.
16:23Illinois 4 in particular are
16:25known as TH2 cytokines.
16:27And these cytokines are very
16:30important for fighting Hellman's
16:33infection like these worm infections,
16:36but are not very effective in
16:39fighting virus infections.
16:41And we're seeing elevated levels
16:42of all these cytokines,
16:43in particular the Illinois 4,
16:45Illinois 6 double positive T cells,
16:48T cells that secrete both of these
16:50cytokines were pretty much only uniquely
16:52found in the long COVID patients.
16:54So this is interesting because the
16:56the kind of T cell you want to
16:59fight a virus infection is known
17:01as type 1 or TH1 immunity.
17:03And we're not seeing that.
17:04We're seeing something that's
17:06diverting from that protective
17:08immune response against viruses.
17:12We then looked at antibody responses to SARS,
17:16COV 2 antigens. So what we noticed was
17:21that antibody against the spike protein
17:24or the S1 region of the spike protein
17:27or the receptor binding domain that
17:30actually binds to the target cells,
17:34they were elevated in the long COVID patients
17:38over healthy controls or combosion controls.
17:41So the healthy controls I forgot to mention
17:44are people who've never been infected
17:46with COVID but live in the same area.
17:49And all of these people have
17:51gotten 2 doses of MRA vaccines,
17:54so they should have equal levels of antibody.
17:56And yet what we're seeing is an
17:59elevated levels of anti spike
18:01antibody from lung haulers.
18:03And I'll come back to the functionality
18:06of these antibodies later.
18:11We next looked at what are the most
18:15distinct factors that are found in
18:17long COVID patients compared to long
18:20long COVID patients or controls.
18:22And what we found was that the number one,
18:25the most significantly different
18:27factor we found in the plasma of long
18:30COVID patients for the cortisol level.
18:33So cortisol is a very important hormone,
18:36it's known as stress hormone,
18:38but that is a bit of a misnomer because
18:42it's needed for everyday physiological
18:45function like how we the nutrient handling,
18:50glucose utilization, wakefulness.
18:54You know many different aspects of
18:57Physiology is controlled by cortisol.
18:59And if you look at this panel here
19:01on the bottom, the long COVID,
19:03the COVID patients in purple,
19:05they had about half the level of
19:07cortisol compared to the healthy control.
19:11And this is the most significant
19:14because they were uniformly lower
19:16than the control groups.
19:17Whereas other factors there is
19:19a huge variation.
19:21Some people have very high
19:22levels and low levels,
19:23but the cortisol level was
19:25the most tightly different,
19:27distinct between these groups.
19:30So cortisol is secreted by the adrenal glands
19:34and it performs very important function.
19:36It's a diurnal hormone,
19:38which means it it is the highest
19:41level right around the time you wake
19:44up and then it level levels down
19:46during the during the day and the
19:49wakefulness is controlled by cortisol.
19:51If you have very low cortisol,
19:52it's very difficult to wake up and
19:55be motivated to start your day and
19:59it's tightly regulated through this
20:02hypothalamic pituitary adrenal axis,
20:05the HPA axis.
20:07And so we wondered,
20:09this low cortisol whether it's.
20:12Driving higher levels of this other hormones
20:16for them from the pituitary called ACTH.
20:20Usually when you have lower
20:21than normal level of cortisol,
20:23ACTH goes up in order to
20:26compensate for that low level.
20:28So you make more and more cortisol.
20:30That is not what's happening
20:32with long COVID patients,
20:34meaning that something
20:35upstream about adrenal gland,
20:37potentially the pituitary
20:39glands or the hypothalamus,
20:41there may be dysfunction up in the
20:44CNS region and that's leading to
20:47this low lower levels of cortisol.
20:49And it's important to note that the
20:52collection of the the plasma of the
20:54blood was around the same time in
20:56the all the three different groups,
20:58meaning that the changes in the
21:01cortisol level has nothing to do with
21:04the diurnal nature or when we pick
21:07these blood samples from these patients.
21:11So and then cortisol is #1 but there
21:14are other inflammatory factors such as
21:17interleuking 8 Iol 8 is a very well
21:21known chemokine that attracts neutrophils.
21:24These are highly inflammatory cells.
21:27We also have many different chemokines.
21:29Again,
21:30chemokines are these factors that
21:33recruit white blood cells to
21:35many different tissues as well
21:37as some some complement factors.
21:39So there was definitely
21:41something inflammatory going on.
21:43What's driving this and why the cortisol
21:46level is lower is currently unknown.
21:48We suspected something to do
21:51with the HPA access deficiency.
21:56OK, So what about these other hypothesis,
21:59We didn't look at dysbiosis in this study.
22:02We probably should do this in the future,
22:05but we did look at reactivation of
22:09latent viruses and we did this in three
22:12different ways and found the same answer.
22:14So one way in which we did this
22:17was to look at the REAP score.
22:19This is the rapid extrasolar antigen
22:21profiling which enables us to look
22:24at an antibody reactivity to like
22:26thousands of different antigens,
22:28some of which were viral antigens.
22:31And as I mentioned just a few slides ago,
22:34the antibody level against the
22:37spike receptor binding domain,
22:39it was elevated for long COVID patients.
22:43However, what was striking is that we
22:47also saw elevated antibody levels against
22:51these latent viruses that normally we
22:53wouldn't have these antibodies against.
22:55So it's seen by virus their
22:58steroid zoster virus.
23:00These are sort of mononucleosis and
23:03chickenpox viruses that most of us
23:07before the vaccination for chickenpox.
23:09Most of us carry these viruses
23:11inside of us without any symptom.
23:13But under certain stress,
23:15such as a COVID infection.
23:18Some people are elevating this level
23:21of reactivation of these viruses.
23:23And what's intriguing is that
23:25this is highly elevated in long
23:27COVID compared to the convalescent
23:30control or the healthy control.
23:32And what's also important to note is that
23:35the serum prevalence meaning that people,
23:37how many people have latent viruses,
23:40there was no difference in these groups.
23:42So it's only the reactive,
23:44so reactivation dependent antibodies
23:46that are elevated and there were
23:49some other differences like herpes
23:51simplex virus specific antibody was
23:54slightly lower than the controls.
23:58So I told you we did this
24:00three different ways.
24:01Another way we measured ABV reactive
24:05antibody is through ceremune
24:07which is a linear epitope mapping
24:10strategy very different from REAP,
24:12but we found the same answer.
24:14So this is the REAP data for the
24:17GP 42 which is a glycoprotein
24:19on the surface of the EBB.
24:22The IgG against this is elevated
24:25in long COVID and also this middle
24:29panel is from the Ceremune analysis.
24:32We found that only GP 42
24:34reactive antibody elevated,
24:36but we can pinpoint the specific amino
24:39acid sequences within the GP 42 that
24:42the patients are reacting to and we
24:44mapped that right here in this pink.
24:46So this particular set of amino acid is
24:50being recognized much higher in long
24:52COVID patients compared to controls.
24:54And GP 42 is a very important
24:58viral antigen that is required
25:00for entry into B cells,
25:03so activated B cells,
25:05GP 42 reactive antibodies.
25:08Type 2 is like Illinois 4L6
25:10secreting CD4T cells.
25:12They're coming together to tell us something.
25:16And indeed when we look at the
25:19correlation between GP23 or 42
25:23specific antibody in aisle 4,
25:25aisle 6,
25:25double positive CD4T cell frequency,
25:28we see there is a linear correlation
25:31in in long COVID patients,
25:33meaning that these things
25:35may be linked to each other.
25:38And it's well known that EBV because
25:41they express this GP 42 blocks the
25:45T cell activation through blocking
25:47of MHC Class 2 and they kind of
25:50divert these T cells into a TH2 bio 4
25:54secreting cell type compared to TH one.
25:58So in our heads we're kind of making some
26:00links in between these observations.
26:05What about autoimmunity?
26:06Well, we found a lot of functional auto
26:10antibodies during severe acute COVID.
26:13When we look during the early phase of
26:16the pandemic hospitalized patients and
26:18ICU patients had a lot of these auto
26:21antibodies that blocked the immune
26:23system itself like type 1 interference
26:26specific antibodies for example.
26:28So we were expecting to see a lot
26:30of auto antibodies, but we didn't,
26:33we did not see auto antibodies
26:36significantly different in long
26:39COVID patients compared to controls.
26:41We did this in many different ways.
26:44This is the Jill Jacobs work with
26:47Aaron Ring and this is basically
26:50looking at different patients on
26:52the different columns and different
26:53rows to indicate auto antibody
26:55presence against different antigens.
26:57There really isn't a universal pattern
27:00or anything enriched that we can see
27:03in the long COVID patients compared to
27:06the controls and antibody reactivity
27:08per patient was not different.
27:11There was no difference in antibody
27:13reactivity number to long COVID
27:16propensity score.
27:17This is sort of the severity score
27:19that we calculated.
27:20So All in all,
27:22we don't see a signature for auto
27:25antibodies against extracellular antigens.
27:28It's possible though that there
27:30are intracellular antigens that are
27:32being targeted by auto antibodies,
27:34and that's something that we need
27:36to separately examine.
27:40Using the machine learning
27:42algorithms that have been conducted
27:44by Rahul in David van Dyke's lab,
27:48we were able to separate long
27:50COVID versus non long long COVID
27:53participants just based on immunological
27:55phenotyping alone with a 96% accuracy.
27:58And when when they asked what are
28:01the factors contributing to this
28:03distinction of long COVID patients,
28:06they saw that autoantibody had
28:08very little predictive ability,
28:10whereas antibody against the spike of
28:14source COVID 2 had some predictive ability.
28:18But it was really the cytokines for
28:21cytometry and antibody against our
28:23EBV and things like that that were
28:26able to distinguish people with
28:28long COVID versus those without.
28:33And when they looked at all the
28:35different parameters that we've
28:37included in the analysis and asked
28:39what are the most significant and
28:41most differential factors that we
28:43see that are either lower in long
28:46COVID or higher in long COVID.
28:48We found that cortisol came out as
28:51the number one factor as a lowest
28:54factor in long COVID patients with
28:57the highest degree of specificity.
29:01But there were other things like the TCM,
29:04these are the central memory CD4T
29:07cells that were also lower and
29:10then CD8T cells for example were
29:13also lower but not as significant.
29:16What's higher in long COVID patients
29:18are these activated B cells,
29:21EBV reactive antibodies,
29:23and exhausted T cells.
29:25So this is starting to paint a
29:28picture of dysfunctional immune
29:31responses and reactivation of
29:34endogenous viruses that may be
29:36sort of distinguishing at least the
29:39biological factor for long COVID.
29:44So these are the keys
29:47findings from this study.
29:49I didn't have even time to talk
29:50about patient reported outcomes,
29:52but they alone were able to predict or
29:56identify COVID patients with 94% accuracy.
29:59So ask the patients in order to
30:03diagnose Second immuno phenotyping
30:05reveal these distinct increases and
30:07decreases in different cell types.
30:10I guess notably the exhausted T
30:13cells being elevated pteroscopy
30:152 specific antibody response,
30:16particularly spike specific
30:19ones were elevated evidence
30:21of herpes virus reactivation.
30:23EBB and VCB were detected
30:26in a subset of patients.
30:29We did not see any significant
30:32increases in auto antibody to
30:34extracellular antivisions and long
30:37COVID alone using machine learning
30:40can efficiently predict sorry.
30:42Immunological data alone can predict long
30:46COVID patients with very high accuracy,
30:49and the low cortisol level was the
30:51strongest predictor for long COVID.
30:55So I'm going to show you a couple of slides
30:59looking at sex differences in long COVID.
31:01This is not even on Medarchive yet.
31:03It's fresh off the press or whatever lab.
31:06And this is analysis that are done by
31:11Julio Silva and Takahiro Takahashi.
31:13They took the same set of my long COVID data
31:17and started to look at sex differences.
31:20And what's striking about this analysis
31:24is that female and male patients
31:27suffer from distinct symptoms.
31:29There are some that are overlapping
31:31but some that are very distinct.
31:33So females are indicated in
31:36blue and males are in pink.
31:38So please forget your stereotype.
31:41Basically over here on the top with the
31:44curves are overlapping with each other.
31:46There are some of the common symptoms
31:49that is you know for example,
31:51sleep disorientation,
31:52urinary issues, ingestion,
31:54reflux.
31:55These are similarly reported for
31:58male and female patients,
32:00whereas there are some symptoms that
32:04are slightly higher in female over male
32:06but they're not that that separated.
32:09Whereas there are these sets of symptoms,
32:11at least in our in the Mylan COVID,
32:13participants were quite different.
32:16There were female dominant
32:20symptoms that included numbness,
32:24dizziness, and many other
32:26features that are listed here.
32:29And there was the only one that
32:31was significantly male dominant,
32:33which is sexual dysfunction and hair loss,
32:36is the most significantly
32:39different reported symptoms
32:40that were predominantly female.
32:43And if you look at the symptom burden,
32:45there is overall higher symptom
32:48burden in the female and then
32:51organ system involvement was also
32:53higher in the female participants.
32:59And what was another striking thing
33:01that we found was that in long haulers,
33:05especially in females,
33:07I already told you that long haulers have
33:10higher levels of anti spike antibodies.
33:12But when you ask the question of
33:15are these antibodies functional
33:17in neutralizing the antibody,
33:19the answer is no.
33:21That these people with long COVID,
33:23even though they have elevated
33:25levels of anti spike antibody,
33:27their functionality is quite low.
33:30So female and male.
33:31If you look at the long
33:33COVID compared to control,
33:35the steepness of the curve indicates
33:38how potent the antibody is against
33:41neutralizing the virus and you
33:43see that there is a lot lower.
33:45So slope for the female and
33:48male participants and when you
33:51calculate the relative potency,
33:53the female long COVID patients
33:55have the lowest level of potency
33:58with respect to neutralizing
34:00antibodies compared to male patients.
34:03So even though the elevating
34:06levels of antibodies suggest
34:07that there is persistent antigen,
34:10we are seeing that these
34:12antibodies are not very functional.
34:14So it would be consistent with
34:16presence of virus or antigen
34:19remaining in these people.
34:21But these are pure speculation at this time
34:25and people with high disease
34:29burden tended to have lower levels
34:32of antibody potency compared to
34:34those with moderate levels or or
34:37the organ system involvement.
34:38Again, it's consistent with the
34:41notion that if you have very
34:44high potency antibodies,
34:46you're slightly better off
34:47with the symptom burden.
34:52So based on these hypothesis data,
34:55we hypothesize that the original
34:59four different pathways to long
35:02COVID it's unlikely or at least
35:05for the extracellular antibodies.
35:07We don't see much correlation of
35:10auto antibodies for long COVID.
35:14And we also think that with the increased
35:18levels of antibody with decreased
35:21level of potency in long COVID,
35:24it's possible that it supports
35:27this viral reservoir hypothesis.
35:29And we also found EBV and VCB
35:32reactivation that is much more
35:35prevalent in long COVID patients.
35:38So and then tissue damage we did not look at,
35:41we just looked at the blood
35:43from participants.
35:43So we don't know the tissue
35:45level analysis yet.
35:48So this is sort of like
35:50what we're seeing overall.
35:51It's still a very,
35:52very early phase.
35:53This is a sort of hypothesis
35:57generating research.
35:57We don't we we need to do a lot
36:00more work to understand this better.
36:02But at least we're seeing some
36:04hypothesis that's more likely or less likely.
36:07And what I wanted to do for the
36:10remaining hopefully 5 minutes or so,
36:13I don't know if I can do it so quickly.
36:14But I I wanted to share with you a again
36:17unpublished data on post vaccine long haul.
36:22So this is all based on Yale
36:24Listen study that many of you are
36:29participating and this it was done by
36:31Bornelli who is on the panel tonight.
36:35So any specific question you
36:36can address to her.
36:38But she asked the question how do
36:40symptoms and demographics compare between
36:43long COVID and post vaccine long haul?
36:46And because the Yale Listen study
36:49already has many participants who
36:51have either long COVID or Long,
36:54the purple is the pasque control not
36:58control pasque participants and green
37:00bars indicate vaccine adverse events.
37:04The Grays are people with both
37:06who have both long COVID and
37:09vaccine post vaccine long haul.
37:11And here's the demographics.
37:13There seems to be again
37:16dominant female over male.
37:19The numbers of participants reporting
37:22these symptoms in our study and then
37:26total number of participants in these
37:29three groups is 200-6135 and one O 8.
37:32We would love to increase these numbers
37:35by recruiting more people into the study.
37:37This is already revealing
37:38something very important.
37:39So I encourage for those of you
37:41who are not on the listen yet,
37:43please get on to this study.
37:45It's you basically join through Kindred
37:49online and Leslie can help you if
37:52you have any problems getting on.
37:54And the mean age again is very
37:57similar much younger than what
37:59you would see for severe COVID
38:01but typical of long COVID.
38:05So Bernali wanted to compare the
38:08health status of people with ask
38:12versus vaccine adverse event versus
38:14both and these are your data people
38:18who reporting poor health fair good,
38:21very good, excellent,
38:23do not know the percentages are very
38:26similar overall in the three groups
38:29and also another survey with EQ VAS,
38:32again very similar pattern we're seeing.
38:35There's nothing significantly
38:36different in the three groups.
38:41This is based on a questionnaire
38:43that we have on, you know, listen,
38:46it asks you, have you ever been
38:50told by a doctor before COVID,
38:52so before January 2020,
38:53that you have any of the following diseases?
38:57And there are two questions here.
39:01But essentially, if you look at the bars,
39:04there are strikingly similar percentages of
39:08people reporting allergies or arthritis,
39:12asthma, whatever,
39:13whatever diseases you look at,
39:15they're very, very similar there.
39:18There may be some differences and
39:21some of these psychiatric diseases,
39:23but these numbers are just very low.
39:25We can't really make any
39:27conclusions from this.
39:28We need more people to participate
39:30so we can understand the differences.
39:32If there is any
39:35another questionnaire currently,
39:36have you ever been told by a doctor
39:39that you have any of the following?
39:42Again there are two sets of questions and
39:45and of course the the the most different
39:49answers turned out to be Pask itself.
39:52So people with Pask or people who have both,
39:54obviously they have the highest
39:57level of unanswered yes compared to
40:00vaccine advanced event adverse events,
40:02whereas reverse is true people who have
40:06vaccine adverse events or reporting.
40:08Obviously these two last groups,
40:11but the PASK people, there's nothing.
40:14So this is sort of an internal control.
40:16The, the survey is working very well,
40:19but if you look across the other things,
40:21they were just very little difference.
40:23The only significance that we saw is
40:27migraines and neurological conditions that
40:29are slightly different between these groups.
40:32But again we need a lot more people
40:35to participate so we can really
40:37understand you know how significant
40:39these differences if any are.
40:41But overall again incredibly similar,
40:43right.
40:47This is a question about select all that
40:50you believe you have had as a result
40:53of past or vaccine adverse events and
40:56this is a patient's own assessment of
40:59what symptoms may be attributable to
41:03long COVID or post vaccine long haul.
41:06And again they're very, very similar.
41:08There are some things that are slightly
41:10different and brain fog, memory issues,
41:12difficulty speaking and so on,
41:15but overall very similar.
41:20Now I mentioned over and over we need
41:23more people so that we can really
41:25look at this in a larger population.
41:27But so far these surveys are showing
41:31us that these these three groups
41:34are very strikingly similar.
41:36So currently there's this remarkable
41:39overlap in symptoms and sex ratio
41:41for long COVID and age group.
41:44So based on this,
41:47what we hypothesize is that there
41:50must be a significant overlap in
41:52the drivers of these diseases.
41:54For instance,
41:55it's possible that the vaccine
41:58stimulation of innate immune responses
42:01could be similar between the acute
42:04COVID infection and vaccine and
42:07what's trigger downstream is similar.
42:09And we know for both of these that
42:12there is inflamosome activation
42:14on RNA sensor stimulation.
42:16These are two key innate recognition
42:19pathways that are triggered
42:21by vaccine and virus.
42:23So that could be the commonality
42:26and this should result in acute you
42:29know within within hours or days
42:32symptoms whereas vaccine stimulation
42:34of adaptive immune response.
42:36There's also one thing that
42:39overlaps between COVID infection
42:41and vaccination which is the spike.
42:44So it's possible that anti
42:48spike antibodies that form,
42:50you know,
42:52it's causing immune complexes that
42:54may be leading to vascular activation,
42:57microblogs or other issues.
42:59Now whatever hypothesis here
43:01is absolutely speculative.
43:02There's no evidence for this.
43:04So please take this with a huge
43:06grain of salt.
43:07But based on the symptom data
43:09and demographic data,
43:11these are the kinds of things that
43:12we're starting to think about.
43:13Because of the similarity,
43:15there is also anti spike antibodies
43:19or T cells that could attack
43:21spike expressing host cells.
43:23It could be endothelium,
43:25it could be epithelium.
43:26Epithelium is definitely a
43:28target of virus infection.
43:30The the vaccine can be taken
43:32up by different cell types and
43:33expressed the spike protein.
43:35So again there may be some overlapping
43:38on the vulnerable cell types.
43:40There may also be antibodies that
43:42target auto antigen that is similarly
43:45induced by spike in the virus.
43:48Similarly for T cells and vaccine induces
43:52potentially reactivation of latent viruses,
43:55in which case we're kind of
43:57triggering the same pathway as
43:59what we see with long COVID.
44:01So Oh yeah,
44:03I don't know if I have time for this,
44:04but just very briefly,
44:06I know some people are very
44:07interested in the peripheral pain
44:09and small fiber neuropathy and I've
44:12been thinking a lot about this.
44:13There may be a way of connecting
44:16the low cortisol level that we see
44:19in the long haulers to release of
44:22immune suppression in the local
44:25tissue that enables sort of chronic
44:30pain trigger by damaging the
44:33endothelial cells within the skin
44:35as well as the neurons themselves.
44:37And there are lots of regulatory and
44:40stimulatory lymphocytes that are controlled
44:42by cortisol that could be released as
44:45a result of this low level cortisol.
44:47There is also local factors that immune
44:50cells can secrete that can increase
44:53pain sensitivity or increase the the
44:57the pain inducing factors themselves.
44:59So there's a lot to think about,
45:01but I'm trying to kind of put a lot of
45:04the findings that we've already have into
45:07trying to explain what may be going on.
45:10These are all just hypothesis generating
45:13things and so we haven't tested these.
45:17OK, I'm going to end here because
45:18I really want to take questions,
45:20but I can't end without thanking
45:22everyone who's like really dedicated
45:25to try to understand long COVID
45:27and post vaccine long haul.
45:29And that includes not only
45:31members of my own laboratory,
45:34but the Yale lesson and Yale
45:37recover study participants.
45:39And particularly when I highlight
45:41Harlan without whom none of these
45:44Yale lesson study could be done.
45:47And also David Petrino just an amazing
45:50partner that enabled this first study
45:53on Mylan COVID to be happening and
45:55all the amazing people who do this
45:58immune profiling data analysis day in,
46:01day out without whom none of these
46:03insights could have been developed.
46:06We're also expanding this to MECFS
46:08cohort with the help of Amy and Michael
46:12and the Polybio team and and also
46:15the CNS information collaborators
46:17that I didn't really even have
46:18a chance to talk about today.
46:20But we are enabling these studies with
46:22a huge team of people who are dedicated
46:26to understanding these diseases.
46:28So thank you for your attention.
46:33I'm happy to take questions
46:36and I will start with the
46:39first question that's there.
46:40A young man told me that he had long
46:43COVID that caused cardiac symptoms.
46:45He said that he was sure it wasn't
46:47a vaccine reaction because his
46:49doctor told him he had long COVID.
46:51How would his doctor disaggregate
46:53COVID from vaccine reaction?
46:57Yeah, that's very difficult to disaggregate
47:01because it's it's known that COVID can
47:05cause a significant heart problems.
47:07I mean Harlan is the expert
47:10cardiologist on this panel,
47:11but COVID itself can have a significant,
47:15you know, cardiovascular problem and
47:18so does mRNA vaccine in a in a subset
47:22of people younger, younger male,
47:26adolescent males in a very small subset.
47:29So if he had COVID and have been vaccinated,
47:34it's it's a little difficult
47:36to tell what caused what.
47:37But if you look at the post
47:41vaccine myocarditis studies,
47:43they often tend to occur a few
47:46days after the second dose.
47:48So you might be able to kind of
47:50look at the timing of the cardiac,
47:53cardiac issues that this person had to
47:56try to link what what may have led to this.
48:00Again,
48:00it's very hard to parse these apart.
48:05The next question is,
48:07I would like to know if there
48:09is a study forthcoming in
48:10children living with long COVID.
48:13There are doctors at Yale Pediatrics who
48:15have been working on long COVID kids.
48:17I'm hoping that your team is
48:19working with Pediatrics to start
48:21some longitudinal studies.
48:24Absolutely. Great question.
48:25So we're very fortunate to have one
48:28of the clinical fellows from Yale
48:30Pediatrics working with us on long COVID.
48:33So she and her colleagues are starting
48:37to collect by specimen to be able
48:40to do similar kinds of studies.
48:43You know that that study is just beginning,
48:47you know, so it's it's it's not we
48:49don't have any data or anything yet,
48:50but we would like to extend the
48:52study of course to children.
48:54Yeah. Thank
48:56you. OK, cool. The next question is,
48:59so somebody says kudos to you,
49:02but however elegant this study academic
49:05recognition of the pathogenicity of SARS
49:08Co V2 S protein via vaccine is impaired.
49:12All five of my physicians and myself
49:14who is also a physician were not aware
49:17of the clinical relevance of S protein
49:20vaccine in my significant CNS autonomic,
49:23retinal and cardiac events.
49:26There are publications for long COVID
49:28yet which are silent about vaccine
49:31impacts and this person is also talking
49:34about multiple recent articles impacting
49:36spike in blood pressure dysregulation.
49:39Could you please comment on this?
49:42Yeah, I mean we need to change that.
49:45That's why we're doing this.
49:47Yeah, listen study is we are going
49:51to approach vaccine related long
49:53haul with the same scientific
49:56rigor as we do for long COVID.
49:59And so hopefully this question
50:02can be no longer relevant.
50:04You know in a in in once we do these
50:07studies and hopefully others are
50:09also engaging in similar studies,
50:12the vaccine related adverse
50:14events are a very tricky issue
50:17that many people shy away from.
50:20Of course all of us here
50:22are pro vaccine people.
50:24I mean I developed my own vaccines
50:26in the lab using a nasal spray.
50:29So we know the importance and the
50:32clinical benefit of vaccination.
50:33But we also have to acknowledge that
50:36there are small subset of people we
50:39don't know how small but a subset of
50:41people who are suffering extreme you
50:44know health issues after vaccination
50:46and it's it's not healthy to ignore
50:50or dismiss the potential link between
50:53the timing of the vaccination and
50:56the onset of these diseases and if
50:59we don't look we won't find it.
51:01So I agree with this person's
51:04comment that we we have very little
51:07evidence for vaccine induced
51:10impact on the health but we that's
51:12because we haven't looked.
51:14I think we really need to start
51:16looking at this and that that's
51:18the whole point of this comparison
51:20in Yale lesson study.
51:22So
51:22the next question is talking about
51:24if we have looked at reactivation of
51:27bacteria like Borrelia or Bartonella.
51:30Yeah. So the great thing about using
51:33this stereo immune technology is that
51:36they have many tick borne diseases and
51:40vector borne diseases in their panel
51:43that's BeenVerified using distinct
51:45cohorts that are prior to COVID.
51:48And so we are very fortunate to
51:50be working with their development
51:52team to be looking at antibodies
51:54against other pathogens that are not
51:57necessarily just viral in order to
52:00be able to detect anti bacterial,
52:03anti parasitic antifungal antibodies
52:06that may be also elevated in post
52:10vaccine or post COVID diseases.
52:13So we are absolutely going to
52:15be looking at all of those.
52:17Thank you, Akiko.
52:18The next question is most general
52:21physicians have no information or
52:23ability on testing cytokine profiles.
52:26Are there any specific resources available
52:28to individuals for cytokine testing?
52:32Yeah, I don't I there is a
52:35clinical test that looks at
52:38different inflammatory cytokines,
52:40but the types of cytokines and
52:43chemokines that we're detecting goes
52:45much wider than the clinical panel
52:47that the physicians normally use.
52:50And if you use those panels,
52:52you may not pick up the differences.
52:54So unfortunately I don't know of any
52:58commercially available sites that would
53:02do a cytokine profiling for patients,
53:05but we are doing it.
53:08So if you are enrolling in our study,
53:11we will be looking at those and we will be
53:13sharing some data back with the patients,
53:16not everything because some of
53:17them are very complicated in
53:19terms of interpreting the data.
53:21But for some standard things we can
53:23certainly give back to the patients and that
53:26that's the whole point of this you know,
53:28collaboration with the patients.
53:30So, yeah,
53:31if you're interested again doing
53:33the study and we can work together.
53:36So the next question is,
53:38was the reactivated virus like what
53:40the antibodies IG GS or IG Ms.
53:43was any live reactivation studied or seen?
53:47Yeah, so we focus on IgG for now.
53:50We are doing some IG M and other isotypes
53:55just to be thorough in our analysis.
53:59We also did EBV virenia analysis,
54:03which is detecting the DNA from ABV in
54:07the circulation and we don't see that.
54:10So it suggests that the reactivation
54:13must have occurred recently,
54:15but it's not an active Vibrania
54:18that's going on and that's been
54:20seen by other groups as well.
54:21So it's the acute phase of the COVID
54:24that you're likely reactivating.
54:26But after that, the virus itself,
54:28the genome is gone,
54:30but you're still have this antibody
54:32signature in these people. So
54:36the next question is talking about cortisol.
54:38Do the lower levels of cortisol
54:40fall outside normal lab values
54:42for the time of day that they are
54:44being drawn in long COVID patients?
54:47Yeah. So I should emphasize that all of
54:51our studies are done in the research labs.
54:55These are not the clinical cortisol
54:57measurements that the doctors order.
54:59So and we are actually trying to do a more
55:03thorough study on cortisol by collecting
55:07saliva from participants over 2 days,
55:10so many many time sampling so that we can
55:13look at the diurnal pattern of cortisol
55:16level in long COVID participants compared to
55:19convalescent control and healthy control.
55:21So that study is ongoing and once we have
55:24data from that that that's what the My
55:27long COVID study once we have the data,
55:29we should be able to tell much better
55:31what is the pattern during the day,
55:33throughout the day of the cortisol
55:35in the long COVID participants.
55:39So here's a question which was sent by
55:42mail by one of the participants.
55:44I believe I suffer from
55:47vaccine related adverse events.
55:49Is there any test that can ascertain
55:52if any and how many spike proteins
55:54are in your system and if so is there
55:57an any approach to remove them?
56:00Right. So I did mention David Walt's
56:03paper that looks at circulating
56:07spike and nucleocapsid using a very
56:10sensitive assay called Simoa assay.
56:13And in their hands they did see
56:16spike that's being elevated,
56:18especially the full length spike,
56:20not so much the S1 region of the spike,
56:23but they were able to detect the
56:25full length spike as well as some
56:28nucleic caps but not too much.
56:30So it's really the full length spike
56:33that's being detected more from
56:35the long COVID participants in in
56:37that study we have done some Eliza
56:40which is another way of looking
56:43at proteins in the blood and have
56:46seen some spike circulating in
56:48a subset of long COVID patients.
56:51There isn't again there is no clinical
56:54test that doctors can order yet
56:56to look at the circulating spike.
56:58There should be that somebody
57:00should be developing these things,
57:02but we don't have it yet and we're trying
57:05to develop our own way of analyzing,
57:08but it's not widely available yet.
57:12And OK, so the spike, is it the spike,
57:15the the, the entire problem.
57:17If we get rid of spike, do we cure people?
57:21We don't know.
57:22There are things that we could do to
57:25look at these issues in a clinical trial,
57:28but no one has done those studies yet.
57:31So for instance,
57:33we could imagine monoclonal antibody
57:36therapy to remove spike from the patient
57:40if it if it works well in various tissues.
57:45There are some areas of the body
57:47that's not accessible by antibodies.
57:49So we may need to design A much
57:51smaller molecule to get rid of spike.
57:53But again this we don't know whether
57:55spike itself is causing the disease or
57:58it's something that was triggered by the
58:00spike that continues to to cause problems.
58:06So the next question is from
58:08a participant who is in
58:09another part of the world,
58:11so is unable to join us.
58:13But the question is regarding
58:14the two hypothesis after the
58:16four that you've discussed.
58:17So, so she is saying that in
58:21the previous meeting you had
58:23mentioned like in today's meeting
58:24you had mentioned that Aisle 2,
58:26Aisle 4, Aisle 6 cytokines are
58:28higher in long COVID participants,
58:30which means that a strategy
58:32could be to take ibuprofen,
58:33but if there is a new presence
58:36of residual virus that would
58:38not be a good thing to do.
58:40So she would like to hear your
58:41comment. Yeah, that's the thing.
58:44We can't just, you know jump
58:46to a conclusion that these
58:49cytokines are just generally bad.
58:51So for instance,
58:53cytokines suppressing therapies may
58:55make things worse if these cytokines
58:57are actually keeping the virus at Bay.
59:00And and so yeah, it's really difficult
59:04to recommend a particular therapy at this
59:06point because we just don't know enough.
59:09One thing that could be done is to
59:12treat the reservoir virus if there
59:15is with something like Paxilavit
59:18and that will tell us like how many,
59:21how many, what's the subset of people
59:24who benefit from antivirals like this
59:26and what are their sort of biomarkers.
59:29So we can target the right people
59:31for the right therapy.
59:33But right now I I don't think we
59:35have enough insights to say OK,
59:37you need to shut down this virus
59:39or you need to shut down this
59:41cytokine for treatment.
59:44So
59:44here is a question.
59:46Can you explain the elevated antibodies,
59:48are they less potent or effective
59:50because of the chronic activation
59:52or were they less potent and
59:54effective to begin with?
59:56Excellent question.
59:57I wish I had a time machine to go back and
01:00:01collect the samples from people before,
01:00:04I mean during the acute phase.
01:00:06There are other studies though,
01:00:08that have looked at the disease course of.
01:00:11People who've gotten COVID
01:00:13during the acute phase,
01:00:14they measure the antibody levels and they've
01:00:18they've seen a a positive correlation
01:00:20with having elevated anti nuclear
01:00:23antibody to a shorter disease course.
01:00:26So this makes immunological sense
01:00:28because if you can mount a rapid robust
01:00:32neutralizing or blocking antibody early
01:00:34during the phase of the infection,
01:00:36then you should be able to
01:00:38recover from the infection.
01:00:39Whereas if you started off
01:00:40with a poor level of antibody,
01:00:42poor level of T cells,
01:00:44you could have these lingering
01:00:46levels of virus and that could
01:00:48lead to these chronic syndromes.
01:00:50So I believe even though I have
01:00:52very little data to support it,
01:00:54that the failure to mount a robust immune
01:00:58response earlier in the phase of the
01:01:01infection may have led to long COVID.
01:01:04Yeah.
01:01:05So there are about 50 more questions.
01:01:07I know time wise we are running
01:01:09short for getting overtime. Yeah.
01:01:13So do we respond to them later
01:01:16or could a few questions be,
01:01:19there's a couple of options.
01:01:20I think you know there's
01:01:21that's a lot of questions.
01:01:22So I think it'll take a little while
01:01:24for you to kind of go through them.
01:01:25There probably some duplicates
01:01:27which might be helpful.
01:01:28What I would suggest is we go through
01:01:30them and then this will be recorded so we
01:01:33can add some slides to the end and put
01:01:35some answers to some of those questions.
01:01:38I can also say that you know November
01:01:4130th is the next town hall for Listen.
01:01:44So that's another opportunity
01:01:45for the Listen members.
01:01:47So if you aren't in Listen yet,
01:01:49you can do that.
01:01:50And then that we,
01:01:51they have Akiko and Harlan do a
01:01:55monthly town hall meeting for
01:01:56members of the LISTEN study to
01:01:57get questions and answers and talk
01:01:59more specifically about the study,
01:02:01but also to do this type of dialogue.
01:02:03So that's happening on November 30th.
01:02:05So there'll be another opportunity to
01:02:07answer more questions and you know Akiko,
01:02:11thank you.
01:02:11This has been an incredible,
01:02:13incredible opportunity for people
01:02:15to get answers to their questions
01:02:18and to hear the amazing research
01:02:19that you're all doing.
01:02:21I loved personally seeing those
01:02:24the the responses to our Listen
01:02:27to our Kindred surveys and to
01:02:29see what is coming from that,
01:02:31the information that's coming from that.
01:02:32So I encourage people that are on Kindred
01:02:35but haven't answered the surveys yet,
01:02:37to answer those surveys and get
01:02:38them over to the listen team.
01:02:40As you can see,
01:02:41that data is incredibly important.
01:02:43And so,
01:02:44so thank you to everyone
01:02:46who's participated so far.
01:02:48And I just want to call out Talia
01:02:50who you see on the screen as well.
01:02:51She's our community manager
01:02:53on Kindred and you'll,
01:02:55if you know,
01:02:55if you get emails from her and
01:02:57she's our content person,
01:02:59it's doing an incredible job on that end
01:03:01keeping everybody up to date and informed.
01:03:03So thank you to everybody here.
01:03:07Just saying thank you.
01:03:11Yeah, Thank you, everyone.
01:03:12Really appreciate your questions.
01:03:14Yeah. Thank you very much.
01:03:16And we'll we'll hear from you
01:03:17love all the hearts and claps
01:03:19and everything like that.
01:03:20Thank you screenshot that it's amazing.
01:03:25Oh, thank you.
01:03:29Thank you. See you in the next month.
01:03:34Wow.
01:03:37Thank you. Thank you all.
01:03:40Bye, bye. Bye.