Dr. Catherine Brissette: Thank you for joining us for this Expert Panel Discussion, sponsored by Pfizer, to discuss the human health disease burden of Lyme borreliosis (LB) in Europe. This is a follow-up conversation in relation to a special issue of the journal, Vector-Borne and Zoonotic Diseases (VBZD) published in April, 2023 (volume 23, number 4) entitled, “Lyme Disease in Europe.” The topic is critically important because new research shows that the disease burden in Europe is larger than is currently appreciated. We hope today to discuss particularly what the potential steps there may be to mitigate the disease burden.
With us for this discussion are Dr. Moniuszko-Malinowska from the Department of Infectious Diseases and Neuroinfection Faculty of Medicine at the Medical University of Bialystok; Dr. Charles Nuttens, Medical Manager of Medical and Scientific Affairs Vaccines, from Pfizer France; Dr. Per-Eric Lindgren from the Department of Biochemical and Clinical Sciences, Division of Inflammation and Infection of Linköping University in Sweden, and Dr. Frederick J. Angulo, DVM PhD, Lead, Scientific Affairs, Tick-borne and Enteric Diseases Franchise Vaccines, Antivirals, and Evidence Generation from Pfizer, Inc.
To begin, I find it very striking that when studying Lyme disease and Lyme borreliosis, it is challenging to find information on statistics in Europe. There are several different governments and agencies, and there are many differences in reporting. Considering these challenges, I invite the panel to open this discussion about their opinions about whether the burden of Lyme disease is underestimated in Europe? And if so, why?
Dr. Charles Nuttens: When you read the article on the surveillance systems across Europe in the special issue (Nagarajan, et al, 2023) you can easily understand that surveillance systems vary significantly from one country to another. This leads to a high variability in incidence estimates between countries because the systems do not capture Lyme disease cases in the same way. For example, some countries have only passive surveillance. I believe most countries, if not all, lack optimal surveillance systems, which probably leads to an incorrect incidence – at least in primary care.
The problem may be different in the hospital setting. A disseminated form of the disease will often require hospitalization, but the question is how the hospitalization is coded in the hospital discharge database. Is it well-coded? Is it recognized as Lyme borreliosis? If the patient is not coded with a Lyme-specific ICD-10 code, it will lead to an underestimation of the number of cases. Thus, leading to possible underestimation in a hospital setting.
Dr. Brisssette: Excellent points. Dr. Lindgren, would you like to comment on this?
Dr. Per-Eric Lindgren: Thank you, Dr. Brissette. I am from Scandinavia. In Sweden, Lyme borreliosis is not yet a notifiable infection. There has been plenty of discussion as to whether or not it should be transformed into a notifiable disease. In general, the density of ticks has increased a great deal during recent decades, not only in Sweden but in the whole northwest of Europe.
We have some data on seroprevalence from different tick-borne pathogens, and very clearly, the prevalence is increasing not only for borreliosis but also for other tickborne pathogens. This means that people were likely to have been bitten by ticks and contracted a disease, but frequently do not seek medical care. This is something we need to be aware of and try to increase our awareness of ticks and different tick-borne pathogens.
I would also like to mention that I am a project leader of EU Interreg Project NorthTick, where we are collaborating between the seven different countries in the North Sea region. We can clearly see that the situation is similar in most countries in northwest Europe, like Denmark, Norway, northwest Germany, and the Netherlands, as it is in Sweden, while it is a little bit different in the UK and Belgium.
Dr. Brissette: We have two problems; one problem of Lyme borreliosis being underestimated, and another is that we also have this problem of overdiagnosis. What do you think the best surveillance system would be that would truly capture the correct burden of Lyme borreliosis?
Dr. Frederick J. Angulo: I believe the important idea is to emphasize the purpose of Public Health surveillance is to take public health action. You would not want to burden clinicians or laboratories with establishing a surveillance system that is not linked to any action. So, with Lyme disease, when you discuss what would be the appropriate surveillance program for Lyme disease, you must consider what would be the action that will result from such a surveillance system.
The classic purpose of public health surveillance systems is to detect outbreaks and to respond which, – hopefully – will mitigate outbreaks, but that's not the case with Lyme disease since Lyme disease does not occur as outbreaks. But another important purpose of a public health surveillance system is to identify areas of high risk. And that is an appropriate purpose of public health surveillance for Lyme disease because it is a disease of different geographic areas and where the infected ticks are found.
An appropriate surveillance system would be one that could distinguish what areas in a country are at higher risk than other areas in a country. Potentially, if the surveillance system is sensitive enough, it could identify then, in those areas, where there is a risk of Lyme disease and where there would be appropriate interventions to be undertaken. This is particularly interesting to us because we have a candidate for Lyme disease vaccine. If the vaccine should be shown to be safe and efficacious in the clinical trial, then identifying areas that are at the highest risk of Lyme disease would be the appropriate areas to emphasize where vaccines could be used. The key question is then, what would be the appropriate type of surveillance system? I think you want a surveillance system that is sensitive enough to understand where the areas of risk are. That surveillance system could be focused on different types of presentations of Lyme disease – the surveillance system could focus solely on neurological Lyme disease, neuroborreliosis.
Equally, you could have a surveillance system that is focused only on all disseminated cases, or you could have a surveillance system that's focused only on laboratory-confirmed cases. But in all those instances, you need to understand how much medically attended Lyme disease is occurring for each of those cases that are captured in surveillance. So, I do not believe that there is one answer on what the appropriate surveillance system should be. What is important is to understand the extent of underascertainment of your surveillance system.
Dr. Brissette: Dr. Lindgren?
Dr. Lindgren: Regarding the identification of risk areas, for example in Sweden, we have a quite homogeneous prevalence of the Borrelia sensu lato in most of Sweden, besides the northern parts, where we have a lower prevalence and lower density of ticks. But in most parts of Sweden, there is a high density of ticks and a high level of Borrelia prevalence 25% to 30% in ticks.
The risk of contracting the disease is also highly linked to human behavior and awareness of ticks. If you are outdoors doing recreational activities and you are aware of the danger of ticks, then you should know to screen yourself and/or family members daily and to safely remove any ticks that you may find which can significantly lower the risk of contracting Borrelia infection. For certain high-risk groups – people like forest workers, hunters, and so on – there would certainly be a need for vaccination.
Dr. Brissette: Absolutely. Microenvironments are also very important. We have areas in countries where the risk is pretty homogeneous but others where it is segregated, so getting that granular view of the landscape. Dr. Nuttens?
Dr. Nuttens: It is difficult to have an ideal surveillance system for various reasons – political, financial, and limited time for doctors to report cases. I think we currently have decent surveillance systems in some countries already. One of the roles of the surveillance system is to determine which populations are at high risk of Lyme disease.
When I looked at the different articles published in the special issue of VBZD, I noticed that not only the regions with the highest incidence rates but also the age groups at higher risk – older adults and children– were well characterized. With the current surveillance systems – even if they are not perfect due to their inability to capture the true incidence rate – we can detect these populations at higher risk.
Based on that we can develop public health interventions such as targeted communication. In the future, it would be great to improve, step by step, the surveillance system to capture the full burden of Lyme disease.
Also, there is a need to have a surveillance system consistent over time to analyze the evolution of Lyme borreliosis. What is important is not only the incidence rate today, but what will be the incidence rate in five or ten years?
Dr. Brissette: Yes, absolutely. That's a great point, especially with climate change and the expansion of many of the tick vectors in various parts of the world. Dr. Lindgren?
Dr. Lindgren: An aspect regarding risk groups are all people who are, in some way, immunocompromised. For example, someone who had received an organ transplant or getting cancer treatment. These groups are getting larger and larger, and even tick-borne pathogens like anaplasma, Rickettsia, and Babesia could cause severe infections in these people. They are still quite rare, but they are increasing in frequency.
Dr. Brissette: Thank you, all, for your responses. I would now like to pivot a bit and talk about some of these public health interventions. Let us assume we have identified some high-risk groups. What are your insights about whether this vaccine – which looks very promising right now – is safe and efficacious and is out on the market? What is the strategy? Is this going to be marketed to high-risk individuals? How does this get rolled out to be the most beneficial for most people?
Dr. Angulo: Before we talk about vaccines, I would like to mention the disappointment that exists in terms of trying to mitigate or prevent Lyme disease through other actions. For example, in the United States, there are many efforts in high-risk Lyme disease areas to try to educate the general public about steps that can be undertaken to prevent Lyme disease. Not just education, but also issue warnings to the public, that if they do get bitten by a tick, the tick needs to be promptly removed because it does take some time for the transmission of the organism from the infected tick to enter the human. If the tick is removed carefully and rapidly, the risk of infection is reduced. These efforts have rarely been successful in preventing Lyme disease. There is frustration, if you will, in the high endemic or in the endemic areas of Lyme disease on how to mitigate the disease. Insecticides do not work. Interventions in the geographic area do not work. Personal protection measures do not seem to help. So what else could be done?
This brings us to the excitement about a safe and efficacious vaccine. Demonstrating that there is a safe and efficacious vaccine is a major hurdle. It takes lots of time and effort. There are candidate vaccines that are being explored. Should we be fortunate enough to have a safe and efficacious vaccine, then how best to provide that vaccine, and to whom we should provide that vaccine, will be a very fruitful public health discussion. Certainly, it would be of most benefit in the areas where the risks are the greatest, and certainly, the vaccine would be most valuable amongst the people who have the greatest exposure to ticks.
Dr. Brissette: Any other thoughts, Dr. Nuttens?
Dr. Nuttens: I agree with Dr. Angulo. I also think we need to differentiate the population risk, and the individual risk. For example, a person can be in an age group for which we observed a limited incidence rate, but this person could spend a lot of time in nature. He will then be at higher risk compared to others of the same age. I think everyone should consider and evaluate their activities and their own individual risks.
Discussions with health authorities are needed to determine the optimal vaccine recommendation. Ideally, the vaccine should be accessible to anyone who wishes to receive the vaccine, according to their own risk of being bitten by a tick and their overall risk.
Dr. Brissette: Dr. Moniuszko-Malinowska?
Dr. Moniuszko-Malinowska: Firstly, my experience from the study on Lyme vaccines shows that the uptake by individuals should not be a big issue. I was surprised some participants in clinical studies were not vaccinated against tickborne encephalitis but they were very keen on taking part in the Lyme vaccine program. It shows that the fear of Lyme is even bigger than that of tick-borne encephalitis.
Secondly, Pfizer is very well established in Poland and the first target group for a Lyme vaccine would be the same group that we are currently using the TBE vaccine for. So, forestry workers, military personnel and older people, who sepnd a lot of time outdoors. It is also important to emphasize travel medicine, cause many people travel to areas of high risk for Lyme Borreliosis and it is a big concern. I think there are many possibilities for a Lyme vaccine and uptake should not be a big problem.
Dr. Brissette: Excellent. Dr. Lindgren?
Dr. Lindgren:
Regarding identifying risk areas, I have the feeling that it is very, very, very difficult to identify specific risk areas and to take different preventive measures other than vaccination. I think that the Swedish population would truly appreciate an effective Lyme borreliosis vaccine. We get a higher and higher coverage of TBE vaccination in Sweden every year. If it is, in some way possible to combine these two vaccines in the future, it will facilitate vaccine uptake even more, as people will feel they are more protected against tick-borne diseases. Unfortunately, two separate vaccines against TBE and Lyme Borreliosis might confuse some people.
Dr. Moniuszko-Malinowska: I wanted to mention that, as Dr. Lindgren said, we were also thinking about the potential combination of the TBE vaccine and Lyme vaccine. If possible, it would be a great solution for Poland to vaccinate everyone, especially since the modern vaccine world is also trying to combine vaccines for other diseases. It would be very beneficial in this case.
Dr. Brissette: How we can identify risk areas using surveillance and/or incidence data where intervention could be recommended? For instance, the United States identifies a risk area as 10 out of 100,000. What are the panel's thoughts on applying this threshold in Europe?
Dr. Angulo: I think for potential future interventions including vaccine use we need to know geographically where the greatest risks are. We know from studies that have been conducted that many people who are at risk of developing Lyme disease do not recognize that they're at risk.
Many people bitten by ticks do not recall having been bitten by ticks, and with some areas in Europe where the risk of Lyme disease is so high that it is prudent to provide the vaccine to everybody – if it is safe and efficacious – to that population because the risk is so high. In other areas, the risk may be lower, but some people within those lower-risk areas will be at particularly high risk because of their activities.
To support all these discussions about how a vaccine should be used, we need to understand where the areas of risk are, and that brings us back to the need for enhanced surveillance. so that we can have science-based discussions about which areas are at risk –and specifically who is at risk in those areas. It also should be considered if a certain area has such a high risk for the entire population within that area above a certain threshold that it would be prudent from a public health perspective to offer a Lyme vaccine to everybody in that area?
I look forward to those discussions with competent authorities in Europe, but I think this emphasizes the need for surveillance and understanding the strengths and limitations. In other words, the under-ascertainment of surveillance, so that you can have science-based discussions about what that threshold would be.
I do not know exactly what the threshold should be, but it certainly would make sense to define a threshold for areas in Europe where the risk is so high that everyone in that population should be recommended the use of a vaccine, while other areas in Europe where the incidence is not so high, and then it would be appropriate to consider the vaccine only for the people who are at the highest risk in those areas. I think if we set a threshold of 10 per 100,000, you could then conduct a cost-effectiveness model and demonstrate the benefit of providing the vaccine and protecting from those infections that you anticipate with the incidence of illness and show that it is cost-effective.
Dr. Brissette: Dr. Lindgren?
Dr. Lindgren: I have not heard about any discussions about thresholds in Scandinavia. I think it is rather difficult to define a certain risk area. It also has more to do with the number of people out in the environment - in recreational areas, heavily populated areas, and popular natural reserve areas. We must also consider that even if the prevalence of Borrelia bacteria and ticks is approximately the same throughout Sweden the proportion of the different genospecies varies by area. Therefore areas with a higher prevalence of Borrelia garinii or Borrelia bavariensis, which are more related to Lyme Neuroborreliosis would be of greater concern also for vaccination.
Dr. Moniuszko-Malinowska: I just quickly had a look at the data from Poland. If we consider an incidence threshold of 10 cases per 100,000, then entire Poland would be called a high incidence area as the lowest regional incidence is 26 cases per 100,000. So, this might be a good threshold, but I think it should be decided by each country separately, because the situation in each country in Europe is different.
Dr. Angulo: It might be useful to point out that in Europe, there is a threshold approach for the use of a tickborne encephalitis vaccine, as recommended by the World Health Organization, for areas where the incidence of tickborne encephalitis is at least 5 or more cases per 100,000.
As this threshold approach is used for another vaccine-preventable tickborne disease it may be an appropriate tool for Lyme disease, but I think a critical part of that is the need to understand what the true burden is within the country and then make science-based decisions about who the vaccine should be made available to.
Dr. Brissette: I am wondering about the United States and in Canada, in which we have emerging areas of Lyme disease where we had not seen it before. We have the expansion of the tick vector. Are there particular areas in Europe where you are seeing that same sort of trend where you had never seen this before in a particular part of your country, but now you are beginning to see more ticks are turning up positive? Are there more human cases? Dr. Moniuszko-Malinowska?
Dr. Moniuszko-Malinowska: About 10 years ago, we had only two endemic areas for Lyme disease in the northeastern part of Poland, which is called the Green Lungs of Poland because we have many forests there. Only forest animals live in that area and there is a very low density of people but when the awareness of Lyme was increasing from year to year, and the doctors from the whole of Poland started to use diagnostic tools, it was discovered that Lyme disease was also prevalent in other parts of Poland beside the Northeast.
It is a very complex situation because, firstly, we have to consider climate change, which has caused the spread of infected ticks, then secondly, the doctors' awareness, and lastly, diagnostic tools. This is a complex explanation of the situation.
Dr. Brissette: Dr. Lindgren?
Dr. Lindgren: In Scandinavia, we have big areas of ticks expansion. This area has a very low human population. It is in the mountains in the northwest part of Sweden towards the border of Norway. We are not concerned so much about the tick expansion into these kinds of areas. However, the most highly populated areas in Sweden are also highly endemic to ticks and tickborne pathogens.
Dr. Angulo: It is difficult to interpret the trends in Europe of Lyme disease because surveillance is not as longstanding. But there is clear evidence of finding ticks, infected ticks, in a broader geographic area and at higher elevations than before.
In countries that have the longest-standing surveillance, the trends appear to be increasing. This is not surprising because, as with other tickborne diseases – and most remarkably – tick-borne encephalitis, we see an increasing incidence of tickborne encephalitis in Europe in a broader geographic scope – perhaps due to climate change – so that is expected.
Dr. Brissette: Dr. Nuttens?
Dr. Nuttens: I was at the NorthTick Conference in May of this year with Dr. Lindgren. A geographer from Belgium did a brilliant presentation on a model trying to predict the geographical expansion of the tick-living area. It was demonstrated that the ticks would go North and live in higher altitudes due to climate change.
Dr. Brissette: Of course, each country is different. We have discussed how approaches are going to need to be different, but it would be great to get sort of a continent-wide view. Our first question is to the whole panel: Does the panel think there is any way European countries could agree on some sort of common approach? Dr. Angulo, would you like to answer?
Dr. Angulo: I do not think it is necessary to have the same surveillance system in all countries, but I do think it is very helpful to at least have common-case definitions if different surveillance systems are in use. If there is a surveillance system that is focused on reporting all clinically diagnosed Lyme disease cases to have a standard case definition of what would meet a case in that scenario, or if there is a surveillance system that is only laboratory-confirmed cases, then what would constitute a laboratory-confirmed case?
I don't think we need a standard surveillance system, however, case definitions would be very helpful and to understand the extent of under ascertainment of your surveillance system from each country so that you can actually compare the burden of disease between countries.
The basis for all of this is a surveillance system to have at least some sort of data on the burden of illness in their countries. Therefore, I hope that countries will continue that surveillance, and continue to adopt and follow standard case definitions.
Dr. Nuttens: I would like to echo what Dr. Angulo said regarding the difficulties of changing the surveillance systems. In France, we have one main surveillance system monitoring Lyme disease in primary care, a national sentinel network composed of general practitioners. This surveillance system does not only monitor Lyme disease; it also reports other diseases. It may be complex to change the surveillance system or to optimize for Lyme disease detection. However, the case definition is specific to Lyme disease and can be adapted or standardized with other countries. For standardization, a European consortium could bring different countries together. Dr. Lindgren is leading the NorthThick initiative (https://northsearegion.eu/northtick/) that includes the North Sea countries. This initiative could be extended to all European countries to work together on applying a standardized case definition. I strongly think a European initiative is needed on Lyme disease. It exists in other diseases, such as RSV for example. We should try to initiate something similar for Lyme disease.
Dr. Brissette: That is a fantastic idea. Dr. Lindgren.
Dr. Lindgren: Thank you. I am glad you brought this up, Dr. Nuttens, because in Northtick, one of our main goals has been to harmonize our view on both laboratory diagnostics and managements of tick-borne infections generally, but we've concentrated on Lyme borreliosis more specifically.
Within NorthTick, several of the national health authorities have been involved in the work from Scotland, Netherlands, Denmark, and Sweden, so we have had quite different views in many aspects, but we have started to talk and discuss with each other.
We are now on the way to applying for a new EU-Interreg project with countries around the North Sea region, excluding the United Kingdom this time, but including France. What you're mentioning, Dr. Nuttens, would be excellent if it could be in some way expanded if we could do something together in the whole EU. So that sounds very, very attractive. Let's try!
Dr. Brissette: Dr. Moniuszko-Malinowska? Your thoughts?
Dr. Moniuszko-Malinowska: I would like to say that, in 2011, there was a case definition in Europe created by Professor Stanek and others, which I know you are all familiar with. Perhaps the time is now to update all the definitions as it was stated. I also found, that we have a monitoring system on the European Centre for Disease Prevention and Control (ECDC) website (https://www.ecdc.europa.eu/en). The only question is whether we can rely on this data because it shows that, for example, in 2021, there were only 978 cases in Europe of Lyme neuroborreliosis. I think that this data is limited but at least we already have some data.
Dr. Nuttens: I compared the French data from my epidemiology analysis to the data provided in the ECDC Atlas of Infectious Disease (ECDC 2023). It seems that only primary care cases from the Sentinel network are reported by the ECDC Atlas. The hospitalized cases extracted from the hospital discharged database are not reported, probably because it is not a surveillance system. Also, the more severe Lyme cases are missing on the Atlas, unfortunately.
Dr. Moniuszko-Malinowska: Perhaps we should also think about how to improve this tool to be more reliable.
Dr. Nuttens: It would be great to have all European countries reporting their Lyme related data on a unique repository. It could be different types of data, such as epidemiologic, clinical, or sociologic data.
Dr. Brissette: The important question would be – who would spearhead that?
Dr. Angulo: The appropriate person would be at the ECDC. This would be a very important first step in having surveillance for neuroborreliosis. The limitation of that system is, of course, the case definition of a neuroborreliosis case is very strict. It must have laboratory confirmation and the extent to which laboratory testing is done and specimens collected, and specimen testing is limited in some regions and countries.
Of course, too, neuroborreliosis cases are only a fraction of all Lyme disease cases. We can expect these numbers to provide useful information on Lyme disease burden, but they are only the tip of the proverbial iceberg. I believe it is important to build upon it. But even if those other surveillance systems are not implemented, understanding the extent of under-ascertainment of the Lyme borreliosis cases in each country is critical so that you can compare the numbers that are being reported to ECDC each year between countries.
Dr. Brissette: Dr. Angulo, I have a question for you. Do you think that the under-ascertainment multipliers based on seroprevalence should be utilized more?
Dr. Angulo: Yes. It is not necessary to do annual estimations of the under- ascertainment. The intention of the under-ascertainment multipliers is to have an understanding that as you continue to do ongoing surveillance, you know the extent to which the surveillance system underascertains medically attended Lyme disease cases in the country.
Maybe a snapshot will be needed every 5 years or so to understand the extent of under-ascertainment.
I think it is essential that such estimates be derived, yet they do not need to be derived annually. They just need to be derived so you can understand your surveillance system.
Dr. Brissette: I am wondering about whether the panel believes there are any roles for citizen science in gathering data. What are your thoughts on tapping into that? Do you think there is any role for that, Dr. Nuttens?
Dr. Nuttens: There are citizen projects ongoing in France. One is called “Citique” and is similar to other projects in other countries. Citique provides an app on which participants can self-report tick bites. Participants can also send ticks to the laboratory for identification and pathogen detection. The investigator generates a map indicating the location of where the person was when they were bitten, which identifies the risk areas. This project inevitably has some limitations, such as the unbalanced usage among geographic areas, which could bias the identification of risk areas, but at least it is a good start. Additionally, the application provides information that is not monitored by the surveillance system so it is useful to the researchers as well as to the participant that received information about Lyme disease and risk areas from the app. This project is well appreciated in France and has already generated useful information. I think it is just the beginning. In the future, it is going to be a fantastic tool.
Dr. Brissette: Great! Dr. Lindgren, would you like to comment?
Dr. Lindgren: In some of the North Sea region countries, there have been very good and successful citizen science projects occurring. Both in the Netherlands and in Belgium, they have worked with apps and people reporting tick bites. But also, in both of those countries, labs have received ticks from people that have collected the ticks from their gardens and from urban areas where they were bitten.
We have a similar approach in northern parts of Sweden to get some kind of overall surveillance of the type of tick species we have there and about the different pathogens we have because we also have emerging ticks with pathogens coming from the east and northeast – from Finland and Russia.
Dr. Brissette: Yes. Dr. Angulo, your comments?
Dr. Angulo: I believe that such efforts, citizen science efforts, for example, are a useful additional piece of information. However, the reality remains that Lyme disease is largely a disease that is seen by clinicians. Surveillance is inherently a governmental function and needs to be sponsored by the government. That's been demonstrated consistently across all infectious diseases. Citizen science projects are just a proxy for what you really would wish to have, which is a government-supported public health surveillance system that focuses on the most sensitive case definition, which would be clinician-based reporting systems.
Dr. Nuttens:
What Dr. Angulo said is very important. Citizen science projects will never replace surveillance systems. They are initiatives that should exist in addition to a robust surveillance system.
Dr. Angulo: I think they are excellent educational tools, so therefore, I do not want to discourage their use because anything we can do to educate the public about tickborne diseases, including Lyme disease, is valuable.
Dr. Brissette: Right. Dr. Moniuszko-Malinowska, your thoughts?
Dr. Moniuszko-Malinowska: In Poland, we have a social initiative where, on an interactive map, people can report ticks that they have removed, either from themselves or from animals. This is already used throughout the whole country. I think that people are becoming more and more aware. Though it is not direct proof of Lyme – or any other – disease, it also shows you the risk of getting tick-borne pathogens. This is somehow also a useful tool just to see which regions the ticks are more often noticed.
Dr. Brissette: This has been a great conversation. Any last thoughts from the panel?
Dr. Angulo: Was a pleasure to discuss with expert minds.
Dr. Nuttens: Yes; I agree! Thank you.
Dr. Moniuszko-Malinowska: Thank you.
Dr. Brissette: So many great ideas were shared here today.
Thank you, everyone, so much – for your time and your valuable participation in this great discussion.
