Educational Webinar: The Value of Rapid Antigen Testing

Good afternoon. Thank you for joining us today. My name is Brandon Martin here at mckesson Medical Surgical and with thanks to our friends at BD. I am excited to welcome you to today's presentation, The value of rapid antigen testing presented by Doctor Ames Adalja. Before we get started, I'd like to direct your attention to our disclaimer while you are reviewing that information. I will remind you that today's presentation is being recorded and within a day or two, you can expect to receive a link to download a copy of the presentation. You can also download the slides by following the link under presentation materials to the left of your screen. If you have a question, feel free to enter it into the Q and A panel at the bottom left corner of your webinar window at any time and we will do our best to answer at the end of the presentation. We are excited to welcome today's presenter, Doctor Ames Adalja Dr Adalja is a senior scholar at the Johns Hopkins Center for Health Security. His work focuses on emerging infectious disease pandemic preparedness and biosecurity. He was also an adjunct assistant professor at Carnegie Mellon University and University of Pittsburgh, as well as a physician at University of Pittsburgh Medical Center, butler Health System, and Va Pittsburgh Health System. Dr Adalia has served on us government panels to develop guidelines for infectious disease emergencies and a National Academy steering committee for Diagnostic Excellence. He is board certified in infectious disease, critical care medicine, emergency medicine and internal medicine and actively practices in the Pittsburgh area. Doctor Adalia. Thank you so much for being here today. Without any further ado the floor is yours. Hi, thank you for that introduction and thank you for uh signing up to listen to me talk um as you heard, um my name is Amish Adalja. I'm a senior scholar at the Johns Hopkins Center for Health Security. And I do a lot of work on pandemic preparedness on the future of infectious disease, the intersection of infectious disease and national security. Um and, and really uh making the, the, the human species more resilient to infectious diseases. And one of the things that does that is, is being able to know what people are sick with and that's how this kind of ties into today's talk. Um I've been a major advocate of rapid diagnostic testing uh to know what people are sick with and, and that's kind of what I'm gonna guide you through uh in the next uh 30 or 40 minutes. And I'm happy to take questions at the end um regarding this topic because it is a broad topic. So just moving through the slides, um obviously, um there's a disclosure here. I mean, I am being paid by Beckton Dickinson for this presentation. So I think that this first slide is an important one and many of you probably have went through some of this with, with COVID-19 trying to understand what the right test modality might be. So, what I would do first is to ask you to step back and ask a question. What question am I asking the test to answer for me? Am I trying to figure out what my patient is sick with what I am sick with or am I trying to figure out, am I contagious? And I think that this is, this helps you figure this all out. So, antigen tests are very rapid and very quick and we have home tests now for, for COVID home tests for influenza and lots of primary care offices and er s and urgent care use antigen test. And the thing is when you use an antigen test, it gives you a quick answer. And if the test is positive that this person has X virus or has RSV or flu or COVID or, or, or group a strep, you've got your answer and you can stop, you know what this person is sick with and you can put them on a treatment modality that fits that, that, that clinical condition. If they're negative, you have to take a step back and say, and they're sick, they've got symptoms in front of you. You still haven't answered the question. What is my patient sick with? So you may need to do a molecular test and that might mean doing a molecular test for the same thing you tested for in an antigen or it could be doing a molecular test for something completely different. Um So, so that, that's just the important point to know is what, what are you doing here? And the molecular test is gonna be more sensitive. But if the antigen test is positive, there's no real reason to go do a to a molecular test. Now, if the question you're asking is not, was my patient sick with but am I contagious and using the COVID paradigm for this there a molecular test isn't really gonna help you because the molecular test is gonna be positive if there's any viral genetic material available. And it's not necessarily going to say this person is actually shedding viable virus. And in that situation, an antigen test, if it's negative tells you you're not contagious uh for COVID. So that's two ways to use these tests. And I think it comes back to just taking the full context into account and understanding what question you're asking the test to answer for you. And, and that's something that was a lot, a lot of confusion during the COVID pandemic. And hopefully people understand that uh that that distinction right now. And this slide really goes into more detail about this pro this uh this issue. So I'm gonna kind of walk through this to explain the differences between molecular tests and antigen test. So it says, um you know, starting from the top molecular says laboratory in parentheses, we do have a couple uh molecular tests that are available for at home use. But in general, this is a more sophisticated test um that often goes by the name of PC R or, or NAT, which stands for nucleic acid amplification test. And it's often gonna be something where you have to um need lab personnel to perform testing. There is simplification occurring but it's not as simple as an antigen test, which for example, can be done by a health care provider with minimal training or as we all have done during COVID-19 at home, um with very, very uh sparse types of training in general antigen tests are faster. And one of the important distinctions and this goes to what you're actually looking for is the antigen test is looking for a specific protein of the virus. Whereas as I mentioned earlier, the molecular tests are looking for viral genetic material. And this, this kinda helps understand why Amazon tests can be used as contagiousness tests. Because if a virus is making a protein that means it's replicating, that means it's valuable, whereas genetic material could end up being viral debris. So the fact that the antigen test is looking for protein tells you it's kind of looking downstream. So, yes, it might not be able to, to be a sensitive as a molecular test to pick up genetic material. But what it's actually finding is viable protein or viable virus because it's actually getting to that step where it's synthesizing protein. And that's why antigen test can be used as contagiousness test. Whereas molecular test can't be, the sample types are usually the same from nose or throat. Um As we talked about that, um that the samples can be samples can be collected by myself or by provider. Obviously, laboratory personnel often require for molecular test. The processing time is often longer for molecular test, 2 to 3 hours at some places, you can get it down to maybe 45 minutes to an hour, but it tends to be much longer than antigen testing in general. And uh because of that, the the communication time could be longer. And we know in the bad days of COVID that sometimes it took uh up to a week to get an answer back because of the way testing was doing was being done. It's obviously not that bad anymore, but sometimes uh it can take time compared to an test where you can just look down and have the answer. As I said before, molecular tests are highly sensitive, they're considered the gold standard. But what they're testing for is biogenetic material, whereas antigen tests are less sensitive, um especially in those without symptoms. But if it's positive, you have your answer. And if it's negative, you know that that person is not likely shedding viable uh virus and is not contagious. Uh windows of detection are going to be much longer based on that same phenomenon that a molecular test is very sensible. If so up to 90 days post symptom onset, someone can be positive. And if you're anybody that works in a hospital setting, we sometimes run into this problem where someone's COVID PC R test is still positive and we don't know if it's a new infection or if it's prior and sometimes the antigen test can be used to adjudicate that to see if someone is contagious because the antigen test is only gonna be positive 5 to 7 days. Usually when most infectious, which again goes back to the fact that antigen tests are also contagious this test and you don't need to do a confirmatory test um with the molecular test because it is the gold standard, the, the antigen test. Um You could do serial testing. But so sometimes if you're wondering if this person was exposed, um are they going to contract COVID? For example, you might test them every 48 hours or you could do a follow up PC R testing, which again goes back to what I mentioned earlier. What questions are you asking the test to answer? Um Are they contagious or what are they sick with? And again, if someone is sick and your, your first antigen test is negative, you still have uh work to do to try and figure out what's making people sick. But I think in general, you know, although this is, you know, saying molecular versus antigen testing, I don't think of them as antagonistic. I think of them as complementary and they both have different roles and different usages. And I'm glad we have both. And in the early days of COVID, we were wanted anything uh to test people within the fact that we've really seen flourishing of both types of tests is is really good and simplification of both types of tests and standardization of both types of tests is really, really um a major, a major advance. Now, this slide kind of goes over some of what I've alluded to in a little bit more detail. And as I said earlier, different tests are appropriate at different times and for different objective. And I, I often use the colloquial term is, you know, what am I asking the test? Um And that's that first check mark. What's the testing objective? What are you trying to figure out? What, what information are you trying to glean from the test? And then you wanna know what's the patient's condition? Are they symptomatic? Are they not symptomatic? Were they exposed? Are they not exposed? Um Can the patient, what's the patient's access to to the patient care and lab. Is it easy for them to do something at home or is this something where, where they're at, at a hospital? And you can do you have more tests at your fingertips there and how quickly do you need to know the answer? All of those are going to be really important. Now, just going back to the graph when you look at the, this graph and on the bottom, it's, it's this is both for flu and for SARS COVID two, what you can see here is that when a person does not have symptoms, detection is going to be unlikely. And why is that? Because viral loads are low as well as the V replication being lower. Although the PC R may pick up some of those individuals there in that lower at a lower threshold. Because again, it's looking for viral genetic material which precedes protein synthesis. But once you start to get a higher viral load, once you start to have symptoms, you will likely have both positive PC R and the antigen. And then the normal course of illness is the viral load falls. And at that point, it will fall below antigen detection sensitivity, which also is heralded by um loss of contagiousness. But the PC R may still be positive for some time and then eventually the PC R will become negative. So that's the time course of understanding when each of these tests would be positive and I think you can see that they both have a role. Um And often times when somebody is symptomatic both will be positive. So that's the idea that that you can, if you have an antigen test positive on somebody with symptoms, your answer is there, you don't have to move forward. And again, this was something, there was lots of misinterpretation of what this all meant. I do a lot of media and was talking to the, the press a lot about what test to use when and was this really a false negative or, or was this a false, a false negative with the antigen test? And someone that's asymptomatic? And the answer is often no, the answer is like they're not using the tests appropriately and this took some time for education. And I think now the, the general public and certainly health care providers are, are pretty well attuned to when you use each of these tests and what information they give you. So Anderson testing, it says, you know, build for the demands of today. People want to know what they're sick with. I think that's one of the long tails of the COVID pandemic because people don't, aren't satisfied with just knowing they've got some virus. Um They wanna know what virus it is, they want to actually know. And I think that there's a great uh potential for rapid energy testing to expand beyond what we're doing now with COVID and flu and a few other things um to everything. I, I mean, ideally I have this vision of the future where people have a device in their kitchen or in their bathroom where they can just swab their nose and know exactly what they're sick with. Um That's really what I've been advocating for for some time and written papers about that. So I'm excited about um this uh uh this whole um process. That's that, that we're kind of ushering in uh with the COVID-19 pandemic because people were trying to move this stuff forward before COVID-19. And now there's a lot more momentum now because people saw how well an energy testing could be done by, by um lesser trained individuals, including people at home. And that's really led to a renaissance in, in trying to kind of democratically distribute testing outside of hospitals uh and health care facilities to, to homes. So what, what makes an antigen test useful? As I said, very short turnaround time, it accurately detects uh infection, it's very easy to use and you get the results at point of care. Um So that really makes it very suitable when, when you can um develop a target that, that people are interested in and not uh knowing um no prescriptions are required as we get some more at home management tests just to talk about at home testing for a second before COVID-19. The only at home diagnostic test that we had was HIV and that was an antibody test and it took about 10 years for the company to get it through because there was such resistance to allowing people to test themselves at home. Um, and now we've got COVID tests and we've got influenza test and we're going to probably get more and more, uh, R probably RC, probably group a strep, probably sexually transmitted infections, probably hepatitis C. So there really is a renaissance going on and I think it's gonna be really good when it comes to understanding the burden of illness, of these infections and connecting people to, to treatment. Obviously, no medical professional is required when you're using a home test. And these are all been clinically valid and trusted. And it took some time to actually convince regulators that this would actually work. And I think people really understand that um they're cost effective and most importantly, it expands access to testing more and more people will figure out what they have. And that gives us information what of what people are sick with. I mean, I think eventually people will, will be voluntary reporting and there'll be ways to understand this of, of what's going on and what's circulating in the community. I also have the same idea of having that box in everybody's house and then they're kind of some of the people are network. So, you know, people are testing themselves for something. So that tells you there's something going around in that community. And if they're all testing negative, then it might tell you there's something new in that community. So I think there's a lot of value not just in clinical care, but in epidemiological surveillance and health security and preparing for future uh epidemic and pandemic threats uh with, with home testing. So I really think this is a major, this should be a major, major priority uh not just in the, in the clinical realm but everywhere. So let's let's look at uh some of the the targets here. Um So COVID-19, we still don't understand seasonality. The other four co common Coronaviruses have really stark seasonality. It's taking COVID-19 some time to get to that point. I think eventually it will, we do know we see acceleration when it gets colder, but we also see acceleration when it gets really hot like right now when there's an uptick uh because that drives people indoors perhaps and um coupled with waning immunity, it leads to cases increasing. So I think eventually we will get more seasonality with COVID-19. It's just taking some time. Um And it is expected to, as I said, become seasonal. We've got uh a whole host of tools, more tools for COVID-19 than for any other respiratory virus. We've got anti virals or Devere plod mal, the purr, we've got immune modulators, take care of the sickest of the sick patients. And we know that this is the result of COVID-19 having a tremendous disease. Burden with over 1.1 million uh deaths and really hospitals in crisis uh during the early days of this pandemic. Thankfully, now, even with this uptick, we've seen this decoupling decoupling of cases from hospitalization. So cases are up all over the United States. Hospitalizations are up a little bit but nowhere near what was happening. Probably about 1% of patients in the hospital right now are COVID um when uh I was working in the IC US and in the hospital in um in the Pittsburgh area back in uh January of, of uh 20 21/75 percent of the patients in the hospital that I was working in were COVID patients that's very, very different influenza A and B. Uh We're just starting the, the flu season. Um It's gonna be starting soon. It usually traditionally peaks around February. Um but it can be off season and remember that COVID-19 scrambled all of these other respiratory viruses um which we'll talk about in a second with RSV. So the season now isn't quite back to what it used to be. Um And remember that there are two halves to the globe. There is a northern hemisphere in the southern hemisphere. I know I'm probably speaking to everybody in the northern hemisphere today, but there is a place called Australia and New Zealand and they're in the middle of winter right now at the end, coming towards the end of their winter into spring. So you can have a typical flu transmission. So somebody was off the plane from Australia and they have flu like symptoms that could be flu. Uh So just remember there is another hemisphere to the, to the world we have uh uh a host of anti virals uh that are available for influenza. You could see them listed there. Tamiflu Relenza, which is the inhaled version, which doesn't really get much use per which is the only intravenous formulation of flu anti viral. And biloxi and flu has a tremendous disease burden in the United States. You know, we we see tens of millions of cases per year, hundreds of thousands of hospitalizations and tens of thousands of deaths per year. So getting better at flu and that means diagnosing flu because if you diagnose flu, then you can actually put them on anti virals and you can prevent hospitalizations, you can prevent death. So th this is uh the anti virals can't work alone. Um They need to be coupled or, or linked or companion. Uh They, they, they're kind of compa with a companion diagnostic because if people know that this person has influenza A, they won't give them an inappropriate antibiotic, they may link them to Tamiflu which will lead to better outcomes. So knowing what people are sick with is not just an academic exercise that actually needs to changes in treatment. So RSV um which has now become everybody's favorite virus because we've seen uh a real revolution with, with vaccines, approved for adults, vaccines, approved for pregnant women just yesterday. Uh a new monoclonal antibody. So this is a major um advance in RSV after decades and decades of nothing. Um RSV usually peaks in late December to mid February. This is where you see major scrambling of that virus because of COVID-19. Uh last year we had off season RSV because too many young Children didn't get infected with RSV. And then all of a sudden got it at once. Uh They had a very, we had a very big increase in the pool of susceptible that led to major RSV surges that put stress on pediatric hospitals. I remember the leading cause of infant hospitalization is RSV and pediatric hospitals have very little capacity compared to adult hospitals. There is no treatment. We do use RIBO VR and immuno compromised individuals. It is typically self limiting. However, if you look at um the burden, it's actually comparable to influenza. A 2.1 million outpatient visits, 235,000 hospitalizations per year, 6 to 10 1000 deaths in adults. Um So that's considerable that that reaches almost influenza levels when you think about high risk individuals with COPD, for example, and how many of them get hospitalized often it's RSD behind it. So this has a major burden of, of disease. And although we don't have anti virals, I think it's important to diagnose people with RSP because then you can refrain from giving an inappropriate antibiotics that they get hospitalized. They need to be an infection, they need to be a droplet precautions. So RSV testing is important in adults and I think um it's gonna become even more important as we get more serious about tackling RSV um and understanding its true burden of illness. So this is uh something that's important to, to know. Um and especially because COVID flu and RSB are clinically indistinguishable. And you hear that term triple demic, which I don't like because there's actually about a dozen different respiratory viruses that circulate but distinguishing them is impossible clinically. So being able to use tests to be able to say this person has COVID. This one is RSP, this one is influenza and put them on the right treatment pathway is gonna be really, really critical. The last one on this side is group A strep which we all know is a major C is, is the, is, you know, known as strep throat and cases occur year round, but it's usually a winter and spring disease. And you know, strep group, a strep is an important infection. Um It not only does it cause strep throat causes things like fever, it causes things like rheumatic fever and it can cause invasive disease. And it's really important to diagnose people because you can prevent some of the complications if you link them to treatment. And first line antibiotics include penicillin and amoxicillin and, and we have other second line uh drugs as well and it is a considerable burden of illness. 5.2 million outpatient visits uh and greater than 2.8 million antibiotic treatment. So you wanna be able to diagnose people with group A strep and be able to uh put them on treatment. And it's increasingly important because other diseases like COVID-19, like influenza, like ad no virus, for example, all overlap with group A strep and you need to be able to understand how to distinguish these because they all have different treatment modalities. So it it is something that the, the more you test the, the better. I think it is when it comes to distinguishing these infections and putting people on the right treatment paradigm. And I, you know, I wish we had like the tricorder in Star Wars that, that bones used to use where he would just use that wand and sweep people and know exactly what it is. But we're sort of getting there with, with the amount of infectious disease testing. Um And I think it's only going to get better and I think it really, the, the emphasis here is really understanding that there's different treatments and we do poorly when we don't know what people have. Our, our prescriptions for Tamiflu are very, very low. It's under utilized, our prescriptions for Pax Lod and COVID-19 under utilized uh and the amount of inappropriate antibiotics because people don't actually test for group A strep and they say, oh, you probably have strep throat, the inappropriate antibiotics. 80% of them are four infections like that upper respiratory infection. So we can get a lot better at clinical care and be more resilient to these threats if we use tools that science and medicine have given us. So why test again? This is just emphasizing what I said that you cannot tell the difference between any of these infectious diseases and even sometimes even allergic rhinitis uh clinically because they all have overlapping symptoms and it can be very nebulous, especially as more and more people have immunity from vaccination and prior infections to COVID, they don't necessarily all present the same. Um So for example, with COVID, um we used to talk about loss of taste or smell that's basically gone from Omicron. Um most, most people don't have loss of taste or smell. So it's not the clue and they, they have all these other symptoms like shortness of breath and muscle aches and pains, which all of them have. So there's no way to tell these apart. No, not even Hippocrates could tell these uh these things apart. Um When it comes to strep, we have scoring systems like the centaur criteria, but it's really hard to uh distinguish them all because again, any of any person can have kind of atypical presentations of COVID or influenza that look like strep throat, for example, um the scarlets uniform rash is highlighted there that causes scarlet fever. And we have seen increases in scarlet fever uh in, for example, in England, uh with a after COVID that there were more strains of, of strep that were circulating that had the scarlet scarlatina toxin, uh had scarlatina toxin production. And um that's one thing you can look for it just to, to refresh people's memory. It's not just something that happened on Little House on the Prairie, it happens. Uh Even today, uh it's a sandpaper rash, they also get a strawberry tongue. Um and it is something that, that is uh uh a more serious consequence of streptococcal Hargis, allergic rhinitis and allergies. A lot of people are going to get allergies and probably get inappropriate antibiotics because people can't distinguish it between allergic rhinitis and COVID or flu or whatever it may be. So that's just important to keep in mind that even non infectious diseases are kind of grouped in there. Usually the itchy and watery eyes gives it away, but not everybody will have that. And then the common cold, all of those respiratory viruses can cause common cold like symptoms because remember, you know, coronaviruses are common cold viruses. RSV is a common cold virus and so is influenza in the sense if you have a very mild symptoms. So it's not, these condition specific symptoms aren't something that you can really hang your hat on anymore. Um Or ever probably could things aren't exactly like they are in textbooks. Um So that's why diagnostic testing as a major role, even with things that people think they, they may know really well because there's a lot of atypical aspects to it. So this is that triple gimmick that I mentioned earlier and you can see that line, that spike. What, as I said, what happened was everybody got RSV, everybody gets RSB before the two years of old age. But what happened with COVID-19 because of the social distancing because of the mask because of schools being closed and probably because of some viral interference between SARS CO V two and RSV. There were not that many RSB cases and then when people started to get back to the day to day life, there was a huge pool of susceptible Children that hadn't gotten their RSV yet and they were due, they, they, they still owed RSV something. Um They all, they all owe a debt to RSV and they all got it at once. And that's what really drove the that triple demic was RSV coupled with flu. And there was um some uh stress, especially on pediatric hospitals, which I said don't really have much capacity. And almost everybody knew someone that got one of those three viruses and, and I think hopefully this is gonna go back down to normal. People. Predict the RSB season will be more normal this year. But we'll have to see um and you can actually get infected with more than one of these viruses at once. The co infections are possible and they likely cause more severe infection. Uh One of the points of this is that we need to be serious about respiratory illness is not even though they cause lots of common colds. There are serious complications that occur from them and they exact a tremendous burden on the health care system. Every here, even when there's not a pandemic, uh respiratory viruses play a major role in emergency department visits, urgent care visits, hospitalization, COPD exacerbation, chf exacerbations, they drive inappropriate antibiotic use. They cause a lot of absenteeism in schools and at workplaces. So this is something that we wanna get serious about. And part of that is using tools like diagnostic tests. So people know what they're sick with, they know what they need to take this. They need know what they need to take to get to get better, they know to stay home because they might be contagious. And it also gives us more epidemiology which then maybe prompts pharmaceutical companies to want to invest and make new anti virals or new vaccines um for some of these other respiratory viruses. So I think it's really important to, to uh take respiratory viruses seriously because they are the major threat that we face as a, as a, as a species in terms of where pandemic threats emanate from. They go, they're going to emanate from respiratory viral families. And the better we are dealing with the ordinary respiratory viruses that plague us day in and day out, the better we're gonna be uh with any kind of emerging respiratory virus that that that appears. So the fact that everything overlaps it's really important to, to kind of take advantage of multi analy management testing, meaning you can use one sample, do one test on it and get results from multiple different pathogens. So you could say this person is positive for flu negative for RSV, negative for COVID. And this is becoming um standard of care. Really. It's it's becoming something that people do routinely because you can't tell these things apart and you don't wanna be jamming a thing up a person's nose, especially a child. Multiple times, people get annoyed, adults get annoyed and I tend to be aggressive with diagnostic testing. So I always order more things to jam up people's noses and often get complaints from the nurses that the patient refuses, uh refuses it. And remember this helps you get to treatment faster. So instead of doing them sequentially, let's test this guy for COVID. It's negative. Now let's test them for flu. It's negative. Now let's test them for RSP, it's positive. So that, that takes a lot longer. Um And you can imagine that if you were giving them Tamiflu or you're giving them pack of it the quicker you, those have windows Tamiflu 48 hours, ideally, you, you give it, you have a longer window if you're talking about someone hospitalized with severe uh risk for severe disease, but packs will be five days. So the quicker you get people to treatment, the better their outcome is going to be. So having that answer faster because you're testing for multiple analysts at once makes it not only uh more comfortable for the patient and easier work flow, but you actually get to the answer faster. Um And you can detect co infections and, and I think it really is um important, especially, you know, people don't think about the, the con the last conservation of health care resources and supplies. During COVID, we didn't have enough um swabs. There was issues about having uh the swabs and they can't be cotton, they're not really cotton swabs. They, they're because cotton will make a false positive on a PC R test. But, but um the, the materials for those were in shortage and people were trying to 3D print them. So that's also an important aspect of, of multi ana antigen testing is that it conserves the, the samples that could come into shortage again if we run into a problem or um during uh a pretty brisk respiratory virus season. So one of the tools that you can use um is the BD vitor system for rapid detection of COVID flu A and B. Um This is something that's clear away. Obviously, I'm just to remind you BD is sponsoring this and I'm being paid by BD just to um so this is um a device that they have that can do multi analyst testing for two of the most important respiratory viruses, two respiratory viruses that have overlapping symptoms and different treatment pathos. So what they look at is um the SARS CO V two nuclear caption antigen or influenza A or B nuclear protein antigen. They're looking for all three of these, you take an anti or nasal swab, it takes about a minute to, to get the sample and then 15 minutes for the test development once you add it to the cartridge. And I said, I said this is simple, minimal operator training. That's how it got a clear, a clear waiver and, and the results are very easy to see there. There's nothing, it's not like those, you know, the sitcoms or whatever when someone has a pregnancy test, I'm trying to see if it's positive or negative. It's pretty clear and you can look at the, the clinical prediction, the positive predictive value, the negative predictive value. I draw your attention to the negative predictive. Um the, the I'm sorry, the um the positive predictive, the PP A, you know, if this is positive, it, it's something that really can stop your diagnostic work up that you don't necessarily have to do anything afterwards once you know that something is, is positive. And I think that this is, this is how you want it to be that you, you get your answer as quickly as possible and, and you link that person to treatment as quickly as possible. But the the clinical performance is, is um is very good and is clinically useful um uh when, when they're deployed. So a couple um summary, summary um points here and then we can move to some questions in a, in a couple more slides but um increased diagnostic confidence, giving significant symptom overlap. I think I've harped on that but you cannot tell these apart. Um and being able to test multiple analysts at once can really allow you to have a lot of confidence that you know what your, what your patient is sick with and then link them to specific treatment. That means it decrease, not only does it, it not only does it link you to appropriate treatments but it decreases the risk of unnecessary or inappropriate prescribing. Remember we're in a situation when it comes to antibiotics that we're uh we have bad bugs and no drug and it's becoming harder and harder to find treatments for certain people would have that have certain types of infection and what's driving that is inappropriate antibiotic prescribing. It said that 80% of antibiotics are inappropriately prescribed a lot of them for upper respiratory tract infections, just like what we're talking about today. And if we don't get a handle on that, if we don't empower providers to have the confidence to, to tell their patient you don't gonna benefit from an antibiotic. Um That, that's gonna be a, that, that's gonna be a problem. And I think that there's still work to be done there um because there's so much patient demand for antibiotics that even if they're inappropriate and there's some kind of defense is also defensive medicine. But I think when you put tools like this in a provider's hand, they are much better. Even if the studies uh kinda have mixed results, they are much more likely to not that I think have the confidence to do it whether or not they do it. Um It sort of depends because they still get scored on patient patient satisfaction. But having these types of tools and making them the norm really helps, especially because patients then they, they like to know what they have. So if you could tell that patient, you've got RSV, they can put that on Facebook and they, they have a disease, not, they can't just put, I've got some viral infection. Nobody really sympathizes with it. But if they can tell them I've got RSV or got influenza. Um and I can tell you a funny story about that. Um If you ask me a question about people putting stuff on online, but that, that actually helps people when they know what they have. Um It, it makes them more likely to accept whatever treatment you're giving them rather than saying you've got some virus, uh increased patient convenience. This can be done rapidly. You get everything on the same day and get linked to treatment. That was part of the advantage of the test to treat program with Palova that you could test people in a, in a pharmacy and then link them to Palo it very rapidly. Um That's, that's kind of the paradigm is if you wanna do it that way, that's, that's, that's practice people when they know they have something, especially specifically that they have RSP or flu or COVID. It mitigates community transmission because they change their behavior. They may cancel the um the happy hour they're going to go to or they don't go to their house or whatever it may be when people know that they're sick and know that they're contagious, they change their behavior. That was one of the problems with in the early days of COVID-19 that we were blind. People didn't know if they were sick. People didn't know if they just had some mild cold or if they were um or, or if they have something more serious. But knowing what you have changes behavior again, I've, I've hopped on this point multiple times. It can promote faster initiation of anti viral therapy. Remember there is a window for both Tamiflu and Pax Ovid. The quicker people are diagnosed, the quicker they can be put on anti viral therapy. The better the outcome can be Tamiflu ideally 48 hours, Palo its five days. Um And I think that's, that's key is being able to get people linked faster if we want to actually decrease the morbidity and mortality of these diseases. And again, since these are clear ways they have very, they're very easy to use low training requirements. This is something um that is not hard for anybody to um to do. So I'm happy to take um questions, just a couple pictures. There's a little bit there, I just wanna see here. Um, yeah, there's a, there's a picture of, of the, the DD device there. Um, for those of you who have not seen it yet, that's what it looks like. And it's kind of cool with all those little cartridges. Reminds me of a Nintendo or a game console, a game boy or something like that, which I think gets us towards that tricorder concept from Star Trek. So I'm happy to take questions in the, in the remainder. I don't, um, I see one question there but I don't know if the moderators need to come back on or what's going on at this point, but thank you for listening and hopefully that was interesting to you, Doctor Azalia. Thank you so much. I, I really appreciate that. Um, we will give, uh, just a couple minutes here in case anybody has a question. Um, I can answer. Um, let me, you want, there's a, I think there's something there in the Q and A I don't, you want me to take that one? I'm not sure. I just, I'm deferring to you guys. Um No, I just said, I think that's OK. 10. Ok. Yeah, I'll, I'll answer that. I, I kind of alluded to this. Somebody's asking me there's a question about the Q health system. Um So the Q health system is, is a molecular test that you can use at home. And I talked about that earlier. Um that molecular testing is becoming simpler and there are some molecular tests that are available at home. Um They're not as common, they're a little bit more expensive and yes, they do have a role. And I think that it was great that they came um that, that, that, that technology is simplifying to the point where it can be used in them. I personally have not used the QL system, I've seen it used. I know some of my colleagues that, that have used it. Um And I think again, all of these have roles. Um Remember the key, the Q is a, is a nucleic acid test. So it's not gonna be a contagiousness test, but it can be a test that you would use um to figure out what someone is sick with. Um So yes, I think what we're finding is there, as I said earlier is a major renaissance in diagnostic testing. And I'm in, I'm of the view that, you know, let all that flowers bloom here because it's gonna make us, uh, much more resilient with all of these things. Um, all of these things kind of come ha have their day in the sun because we just get better and better at dealing with, with respiratory viruses. And that makes us much, much more resilient as a species aga against these threats that, uh, continuously plague us. And as, uh, uh, viruses continue to evolve too, I imagine. Right. We're, we're not, it's not going to just, and you know, viruses are not static, there's going to be new viruses that, that infect us, there's going to be uh changes that, that, that occur that we, you want to stay ahead of. And the way to stay ahead of that is by diagnosing things you don't wanna be blind. Um That's, that's the point is we have tools that illuminate all of this biological dark matter that's out there. All those viruses that make us sick and within those families, there are going to be important viruses that never get diagnosed. But if it becomes a paradigm that we test people that we understand what they're sick with, it's much less likely that we run into a situation where we're, we're, we're surprised think back to the 2009 H one N one pandemic. Those first two cases back in April of 2009 were in two little kids. And what happened was they happened to go to clinics in California that were part of a research group that was actually typing flu viruses. So it's a regular urgent care clinic. They went to, they both were mild cases, but because their flu viruses looked a little weird on the testing, it got sent off. And then we actually realized we were at the beginning of a new flu pandemic. And imagine if they didn't do that. Imagine if someone, they went to some PC P and said you got, you guys, you guys have your kids have some virus, find it gonna be better. The lag time before people knew would have been much longer that we were dealing with a novel flu virus. And although a lot of people might think of 2009 H one N one as not a bad pandemic in many ways, it wasn't. But you know what the average age of death was 37. So think about the millions of life year loss even though 15,000 or so people died, which isn't very much compared to seasonal flu. The average age of death was 37. So you multiply how many life years they had left times 15,000 and it doesn't look as rosy as it once did. Ok. Well, as we near the end of the hour, I definitely wanna thank everyone for their time today. And uh Doctor Adalia, thank you so much for joining us this um this afternoon. Uh with a fascinating topic. We appreciate your uh sharing your expertise with us today. I do wanna let everyone know that you can find a full list of our uh upcoming events at uh M MS dot McKesson dot com slash educational dash webinars. You'll be able to register for future webinars, share with your colleagues or sign up to receive regular updates on our webinar schedule. I'm gonna leave us here on our product information, disclaimer and go ahead and take the opportunity to once again. Thank you, uh Doctor Amish Adalja. Thank you so much for joining us today. Uh Definitely appreciate your time. Um And uh for anyone else just be on the lookout for uh a recording of today's presentation along with a copy of the slides. Um And again, thank you all for your time today.