Influenza Virus Vaccines Commons^™

Efficacy Of Typhoid Conjugate Vaccine In Nepal: Final Results Of A Phase 3, Randomised, Controlled Trial, Mila Shakya, Merryn Voysey, Katherine Theiss-Nyland, Rachel Colin-Jones, Dikshya Pant, Anup Adhikari, Susan Tonks, Yama F Mujadidi, Peter O'Reilly, Olga Mazur, Sarah Kelly, Xinxue Liu, Archana Maharjan, Ashata Dahal, Naheeda Haque, Anisha Pradhan, Suchita Shrestha, Manij Joshi, Nicola Smith, Jennifer Hill, Jenny Clarke, Lisa Stockdale, Elizabeth Jones, Timothy Lubinda, Binod Bajracharya, Sabina Dongol, Abhilasha Karkey, Stephen Baker, Gordan Dougan, Virginia E Pitzer, Kathleen M Neuzil, Shrijana Shrestha, Buddha Basnyat, Andrew J Pollard

Faculty, Staff and Student Publications

BACKGROUND: Typhoid fever is a major public health problem in low-resource settings. Vaccination can help curb the disease and might reduce transmission. We have previously reported an interim analysis of the efficacy of typhoid conjugate vaccine (TCV) in Nepali children. Here we report the final results after 2 years of follow-up.

METHODS: We did a participant-masked and observer-masked individually randomised trial in Lalitpur, Nepal, in which 20 019 children aged 9 months to younger than 16 years were randomly assigned in a 1:1 ratio to receive a single dose of TCV (Typbar TCV, Bharat Biotech International, India) or capsular group …

Covid-19 Bbibp-Corv Vaccine And Transient Heart Block - A Phenomenon By Chance Or A Possible Correlation - A Case Report, Pirbhat Shams, Jamshed Ali, Sheema Saadia, Aamir Hameed Khan, Fateh Ali Tipoo Sultan, Javed Tai

Section of Cardiology

Importance: Bradyarrhythmia during COVID19 illness carries prognostic significance. Electrophysiological side effects of COVID19 vaccine remain largely unknown. It is imperative to report nature of cardiovascular side effects of the vaccine.
Case presentation: An 80 years-old-man presented with complains of dizziness, trepidation and shortness of breath following his first shot of COVID-19 BBIBP-CorV (Sino-pharm). ECG on arrival showed 2:1 atrioventricular block with an underlying old left bundle branch block. The AV block changed into Mobitz type-I over the course of next 2 days and into a sinus 1:1 conduction on fourth day of presentation. However, our patient underwent permanent pacemaker implantation …

Non-Compliance To Social Distancing During Covid-19 Pandemic: A Comparative Cross-Sectional Study Between The Developed And Developing Countries, Faiqa Binte Aamir, Syeda Maria Ahmad Zaidi, Saadia Abbas, Syed Roohan Aamir, Syed Nauman Ahmad Zaidi, Karishma Kanhya Lal, Syeda Sadia Fatima

Medical College Documents

Background: Despite mass vaccination campaigns, the world has seen a steady rise in the number of SARS-CoV-2 cases, with 178,765,626 cases and 3,869,994 COVID-19 related deaths by June 19^th, 2021. Therefore, it is important to enforce social distancing to control its spread. With the variation observed in the severity of the pandemic in different countries, it is also imperative to study the social distancing behaviors amongst the population in developed and developing countries.
Design and Methods: In this cross-sectional study, a total of 384 participants from 14 different countries were surveyed via an online REDCap form.
Results: In …

Covid-19 Vaccination In Sindh Province, Pakistan: A Modelling Study Of Health Impact And Cost-Effectiveness, Carl A B. Pearson, Fiammetta Bozzani, Simon R. Procter, Nicholas G. Davies, Maryam Huda, Henning Tarp Jensen, Marcus Keogh-Brown, Muhammad Khalid, Sedona Sweeney, Sergio Torres-Rueda

Community Health Sciences

Background: Multiple Coronavirus Disease 2019 (COVID-19) vaccines appear to be safe and efficacious, but only high-income countries have the resources to procure sufficient vaccine doses for most of their eligible populations. The World Health Organization has published guidelines for vaccine prioritisation, but most vaccine impact projections have focused on high-income countries, and few incorporate economic considerations. To address this evidence gap, we projected the health and economic impact of different vaccination scenarios in Sindh Province, Pakistan (population: 48 million).
Methods and findings: We fitted a compartmental transmission model to COVID-19 cases and deaths in Sindh from 30 April to 15 …

Impact Of The Covid-19 Pandemic On Loneliness And Social Isolation: A Multi-Country Study, Roger O’Sullivan, Annette Burns, Gerard Leavey, Iracema Leroi, Vanessa Burholt, James Lubben, Julianne Holt-Lunstad, Christina Victor, Brian Lawlor, Mireya Vilar-Compte, Carla M. Perissinotto, Mark A. Tully, Mary Pat Sullivan, Michael Rosato, Joanna Mchugh Power, Elisa Tiilikainen, Thomas R. Prohaska

Department of Public Health Scholarship and Creative Works

The COVID-19 global pandemic and subsequent public health social measures have challenged our social and economic life, with increasing concerns around potentially rising levels of social isolation and loneliness. This paper is based on cross-sectional online survey data (available in 10 languages, from 2 June to 16 November 2020) with 20,398 respondents from 101 different countries. It aims to help increase our understanding of the global risk factors that are associated with social isolation and loneliness, irrespective of culture or country, to support evidence-based policy, services and public health interventions. We found the prevalence of severe loneliness was 21% during …

Simulating Influenza Epidemics With Waning Vaccine Immunity, Chun-Miin Chen, Alia C. Stanciu

Faculty Journal Articles

In this study, we simulate an influenza epidemic that considers the effects of waning immunity by fitting epidemiological models to CDC secondary historical data aggregated on a weekly basis, and derive the transmission rates at which susceptible individuals become infected over the course of the influenza season. Using a system of differential equations, we define four groups of individuals in a population: susceptible, vaccinated, infected, and recovered. We show that a larger number of initially infected individuals might not only bring the influenza season to an end sooner but also reduce the epidemic size. Moreover, any influenza virus that entails …

Usability And Acceptability Of A Mobile App For Behavior Change And To Improve Immunization Coverage Among Children In Pakistan: A Mixed-Methods Study, Abdul Momin Kazi, Nazia Ahsan, Waliyah Mughis, Saima Jamal, Raheel Allana, Mehreen Raza, Sahrish Muneer, Muhammad Ayub Khan Mughal, Hussain Kalimuddin, Fareeha Sameen

Department of Paediatrics and Child Health

Background: Pakistan's immunization uptake rates are still significantly lower than anticipated despite several initiatives. Lack of awareness, forgetting about vaccination schedule, and vaccine misconception/misinformation are a few of the major drivers that mitigate the rates of immunization. The current COVID-19 pandemic emphasizes the importance of immunization. The significant reductions in regular childhood vaccination during pandemic have increased the risk of outbreaks of vaccine-preventable diseases. Concerns among parents over possibly exposing their children to COVID-19 during child visits may have contributed to the reported declines. Innovative and cost-effective mHealth interventions must be implemented in order to address the problem of inadequate …

Acceptance Rates And Beliefs Toward Covid-19 Vaccination Among The General Population Of Pakistan: A Cross-Sectional Survey, Farah Yasmin, Waleed Asghar, Maryam Salma Babar, Hiba Khan, Shoaib Ahmad, Zaid Hameed, Muhammad Sohaib Asghar, Hamza Nauman, Abdullah Khan Khattak

Medical College Documents

Developing countries like Pakistan have previously suffered from barriers to acceptance of vaccination by the public because of financial and belief barriers. This study aims to explore these beliefs and highlight concerns regarding vaccine hesitancy in the general population of Pakistan since they are a hindrance to an effective coronavirus disease-19 (COVID-19) immunization in the country. A cross-sectional study was performed involving 1,778 participants from all four provinces of Pakistan. Results from the study showed more than half of the participants to be unsure of the safety (50%) and efficacy (51%) of the vaccine, whereas 42% were concerned about the …

Respiratory Syncytial Virus-Associated Mortality Among Young Infants In Karachi, Pakistan: A Prospective Postmortem Surveillance Study, Abdul Momin Kazi, Obianuju G. Aguolu, Waliyah Mughis, Nazia Ahsan, Saima Jamal, Ayub Khan, Hanya M. Qureshi, Inci Yildirim, Fauzia A. Malik, Saad B. Omer

Department of Paediatrics and Child Health

Background: Respiratory syncytial virus (RSV) is an important cause of infant morbidity and mortality and a potential target for maternal immunization strategies. However, data on the role of RSV in young infant deaths in developing countries are limited.
Methods: We conducted a community-based mortality surveillance from August 2018-March 2020 for infants ≤6 months in Karachi, Pakistan. We tested (reverse transcription-polymerase chain reaction) nasopharyngeal swabs from deceased infants for presence of RSV. We performed verbal autopsies and calculated odds of RSV-associated mortality with 95% CIs and used multivariable logistic regression to evaluate associations.
Results: We collected 490 nasopharyngeal specimens from 1280 …

Effectiveness Of Typhoid Conjugate Vaccine Against Culture-Confirmed Salmonella Enterica Serotype Typhi In An Extensively Drug-Resistant Outbreak Setting Of Hyderabad, Pakistan: A Cohort Study, Mohammad Tahir Yousafzai, Sultan Karim, Sonia Qureshi, Abdul Momin Kazi, Hina Memon, Amber Junejo, Zohra Khawaja, Najeeb Ur Rehman, Muhammad Sajid Ansari, Rafey Ali, Heera Mani Lohana, Farah Naz Qamar

Department of Paediatrics and Child Health

Background: Salmonella enterica serotype Typhi (S Typhi) is a major public health problem in low-income and middle-income countries. We aimed to investigate the effectiveness and impact of the typhoid conjugate vaccine Typbar-TCV against S Typhi among children in an outbreak setting of extensively drug-resistant (XDR) S Typhi in Pakistan.
Methods: This cohort study was done from Feb 21, 2018, to Dec 31, 2019. A census survey of all households located in the Qasimabad and Latifabad subdistricts of Hyderabad, Pakistan, was done at baseline, and 174 005 households were registered in the census. The Typbar-TCV immunisation campaign was initiated at temporary …

Determinants Of Vaccine Hesitancy In Indonesia: A Scoping Review, Nuril Hanifah, Ike Herdiana, Rahkman Ardi

Makara Human Behavior Studies in Asia

Complete children immunization coverage in Indonesia declined from 59.2% in 2013 to 57.9% in 2016. Therefore, a study on understanding the vaccination barrier is necessary to improve future coverage. This scoping review aims to identify the determinants of vaccine hesitancy using the model of the World Health Organization-Strategic Advisory Group of Expert (WHO-SAGE) working group and to map them on the basis of region, target population, and vaccine. This research used publications from seven databases (Science Direct, Wiley, Scopus, SAGE, PubMed, Springer, and Taylor & Francis) from 2015 to 2020. A total of 10,212 publications were identified and filtered by …

Impact Of Coronavirus Disease 2019 On Prevention And Elimination Strategies For Hepatitis B And Hepatitis C, Syed Tabish Rehman, Hareem Rehman, Shahab Abid

Section of Pulmonary & Critical Care

The coronavirus disease 2019 (COVID-19) pandemic has resulted in significant morbidity and mortality since its first case was discovered in December 2019. Since then, multiple countries have witnessed a healthcare system collapse due to the overwhelming demand for COVID-19 care. Drastic measures have been taken globally in order to curb the spread of the virus. However, those measures have led to the disruption of other aspects of healthcare, increasing the burden due to other medical conditions. We have also stepped back in achieving the ambitious goal set in place by World Health Organization to eliminate viral hepatitis as a public …

Acceptance Of Covid-19 Vaccine In Pakistan: A Nationwide Cross-Sectional Study, Mohammad Aadil Qamar, Omar Irfan, Rubaid A. Dhillon, Areesh Bhatti, Mir Ibrahim Sajid, Safia Awan, Wajiha Rizwan, Ali Bin Sarwar Zubairi, Zouina Sarfraz, Javaid Ahmed Khan

Department of Paediatrics and Child Health

Introduction: The coronavirus disease 2019 (COVID-19) vaccine is available across various countries worldwide, with public-private partnerships ensuring all individuals are vaccinated through a phased approach. Irrespective of the geographical spread, several myths pertaining to the COVID-19 vaccine have stemmed, ultimately limiting the national administration of vaccines and rollouts. This study assessed the acceptance of the COVID-19 vaccine among the general public in Pakistan.
Methods: A pre-validated questionnaire was administered from January 2021 to February 2021 to assess the public attitude and acceptance of the COVID-19 vaccine. Logistic regression analyses were run to identify factors associated with the acceptance among the …

A Systematic Review Of The Rationale For Vaccine Hesitancy Among American Parents, Jordan Luttrell-Freeman, Timothy J. Bungum, Jennifer R. Pharr

Environmental & Global Health Faculty Research

Vaccines are one of the most successful interventions in the history of public health. They are largely responsible for the near eradication of several diseases. However, some people are vaccination averse which can lead to vaccine hesitancy. Vaccine hesitant parents are those that refuse or delay getting their children vaccinated despite the availability of vaccination services. This phenomenon often occurs despite parent’s belief that vaccines are effective. The purpose of this review was to exam available literature to identify predictors of vaccine hesitancy among parents and parental rationale for vaccine hesitancy

Multi-Subunit Sars-Cov-2 Vaccine Design Using Evolutionarily Conserved T- And B- Cell Epitopes, Burkitkan Akbay, Syed Hani Abidi, Mahmoud A A. Ibrahim, Zhussipbek Mukhatayev, Syed Ali

Department of Biological & Biomedical Sciences

The SARS-CoV-2 pandemic has created a public health crisis worldwide. Although vaccines against the virus are efficiently being rolled out, they are proving to be ineffective against certain emerging SARS-CoV-2 variants. The high degree of sequence similarity between SARS-CoV-2 and other human coronaviruses (HCoV) presents the opportunity for designing vaccines that may offer protection against SARS-CoV-2 and its emerging variants, with cross-protection against other HCoVs. In this study, we performed bioinformatics analyses to identify T and B cell epitopes originating from spike, membrane, nucleocapsid, and envelope protein sequences found to be evolutionarily conserved among seven major HCoVs. Evolutionary conservation of …

Forum 10: Covid Vaccines: How Did You Get Here?, David Dobrzykowski, Sarah Nurre Pinkley

Vaccine Course

We consider the supply chains for the distribution of the COVID-19 vaccine and other routine vaccines. We first outline new product development, manufacturing flow management, order fulfillment and vaccine distribution. Next, we focus on the vaccine supply chains in low and middle-income countries. We discuss the cold supply chain and challenges in these countries. Lastly, we discuss current drone delivery capabilities and how drones are being used to delivery the COVID-19 vaccine.

Meeting Minutes, Wku Council Of Academic Deans

Council of Academic Deans

Meeting regarding post-COVID instructional modality and international travel.

Forum 8: Logistics And The Vaccine, Ashlea Milburn

Vaccine Course

This presentation summarizes the goals of the COVID-19 vaccination program and provides an overview of its status as of May 2021. Next, the logistics requirements of Community Vaccination Centers (CVCs), which are common venues for mass vaccine dispensing, are presented. According to this dispensing method, people travel to where the vaccine is being administered (people-to-shots). Finally, the logistics requirements of an alternative dispensing method that brings the vaccine to people in their homes (shots-to-people) are addressed. This dispensing method can increase vaccine access for homebound individuals.

Forum 6: Humanistic Health And The History Of Vaccine Hesitancy: Lessons From Then And Now, Casey Kayser, Kaitlyn Akel

Vaccine Course

Kayser introduces and defines humanistic health, focusing on the need for this approach in healthcare, the qualities of practitioners who practice humanistic medicine, and the outcomes it provides for patients and practitioners alike. She discusses why COVID-19 has laid bare the need for humanistic approaches, and how they help us to understand issues surrounding the virus and the vaccine. Akel discusses parallels between historical vaccine hesitancy and that during the COVID-19 pandemic. She illustrates the public health significance of vaccination as a public health intervention as well as what professionals in the field are doing to measure and intervene on …

Forum 5: Understanding Vaccine Efficacy And Effectiveness: A Statistician's Perspective/Open Access Stem Research, Jyotishka Datta, Angie Ohler

Vaccine Course

In the first part of this presentation, Jyotishka Datta discusses the concepts and calculations behind the efficacy and effectiveness for vaccines from a statistician’s perspective, as well as the different factors contributing to it. Prof. Datta also offers a brief tour through the history of vaccines in preventing infectious diseases and the development of statistical tools such as randomized controlled trials. Lastly, Prof. Datta discusses the direct and indirect effects, the inherent uncertainties involved with the efficacy and efficiency numbers and remark on their comparison. In the second part of this presentation, Angie Ohler discusses the vital role of open …

Vaccine Forum Syllabus, Lynda Coon

Vaccine Course

This forum zooms in on the race to develop a vaccine for the COVID-19 Coronavirus through a diversity of academic and professional disciplines: medicine, medical history, sociology, statistics, social media studies, public health, immunology, political science, industrial engineering, supply chain management, and chemical engineering. In so doing, the forum’s instructors situate the COVID-19 vaccine within a broader narrative of the science of immunization, the history of vaccines, the social and economic inequalities produced by deploying a vaccine, and the challenges presented to the global supply chain.

Eradicating Polio In Pakistan: A Systematic Review Of Programs And Policies, Anushka Ataullahjan, Hanaa Ahsan, Sajid Bashir Soofi, Atif Habib, Zulfiqar Ahmed Bhutta

Woman and Child Health

Introduction: Established in 1994, Pakistan's polio program demonstrated early success. However, despite over 120 supplementary immunization activities in the last decade, polio eradication efforts in Pakistan have been unable to achieve their objective of halting polio transmission. Variable governance, and inconsistent leadership and accountability have hindered the success of the polio program and the quality of the campaigns. Insecurity and terrorism has interrupted polio activities, and community fears and misbeliefs about polio vaccinations continue to persist.
Areas covered: The article consists of a systematic review of the barriers and facilitators associated with the delivery of polio eradication activities …

Forum 1: Social Inequality, Justice, And Vaccine Intent And Distribution In The United States, Grant Drawve, Kevin Fitzpatrick, Casey Harris

Vaccine Course

The key issues for the distribution of the COVID vaccine are shared. These issues include funding, racial and ethnic disparities, supply and logistics, communication and trust, federal, state and local roles, and coverage and costs.

Hpv Vaccine Hesitancy, Ellen Fountain

Health, Human Performance and Recreation Undergraduate Honors Theses

Human papillomavirus (HPV) is a virus spread through close contact, often sexual contact. Those infected will be at high risk of developing HPV-related cancers later in life. In 2006, the HPV vaccine was approved for use in the United States, but many were, and continue to be, hesitant to vaccinate their children. While other factors come into play, many times there are misconceptions contributing to hesitancy and ultimate refusal of the vaccine. The goal of this analysis is to review these factors and misconceptions and explore education-based interventions designed to minimize HPV vaccine hesitancy.

Exploring Equity In Health And Poverty Impacts Of Control Measures For Sars-Cov-2 In Six Countries, Sedona Sweeney, Theo Prudencio Juhani Capeding, Rosalind Eggo, Maryam Huda, Mark Jit, Don Mudzengi, Nichola R. Naylor, Simon Procter, Matthew Quaife, Lela Serebryakova

Community Health Sciences

Background: Policy makers need to be rapidly informed about the potential equity consequences of different COVID-19 strategies, alongside their broader health and economic impacts. While there are complex models to inform both potential health and macro-economic impact, there are few tools available to rapidly assess potential equity impacts of interventions.
Methods: We created an economic model to simulate the impact of lockdown measures in Pakistan, Georgia, Chile, UK, the Philippines and South Africa. We consider impact of lockdown in terms of ability to socially distance, and income loss during lockdown, and tested the impact of assumptions on social protection coverage …

Vaccine Hesitancy & Study Of Attitudes And Barriers Towards The Influenza Vaccine In Public Health Students At Liberty University, Mikayla Zook

Senior Honors Theses

Every year 2.5 million deaths worldwide are prevented because of vaccinations. Vaccine hesitancy is defined as delayed acceptance or refusal of vaccination and is a global threat to public health. Attitudes and barriers towards vaccines vary and change from group to group. Eighty-five percent of surveyed public health students at Liberty University did not receive the seasonal influenza vaccine. Their attitudes and barriers included: “I did not have time to receive a flu vaccination”, “I believe that as a result of the flu shot, I may actually get the flu”, and “I do not believe I am in danger of …

H1n1 Influenza Virus (Swine Flu): A Comprehensive Insight Into Escalating Catch-22 Scenarios, Muhammad Shahzaib, Ehsan Ul Haq

The University of Louisville Journal of Respiratory Infections

Introduction: Viruses have always been a major cause of various disastrous pandemics in mankind’s history. H1N1 became a threat when its original strain was first discovered back in the swine flu pandemic of 2009. It became highly catastrophic on a large scale because none of the therapeutic interventions and methodologies that were already present at the time were effective against the virus.

Methods: A vast amount of literature and research is available regarding H1N1 influenza from different reputable sources online. The data were gathered with the contrasting and relative situations of 1918 and 2009 pandemics in mind. The overall extracted …

Food Insecurity Measurement And Prevalence Estimates During The Covid-19 Pandemic In A Repeated Cross-Sectional Survey In Mexico, Pablo Gaitán-Rossi, Mireya Vilar-Compte, Graciela Teruel, Rafael Pérez-Escamilla

Department of Public Health Scholarship and Creative Works

Objective: To validate the telephone modality of the Latin American and Caribbean Food Security Scale (ELCSA) included in three waves of a phone survey to estimate the monthly household food insecurity prevalence during the COVID-19 pandemic in Mexico. Design: We examined the reliability and internal validity of the ELCSA scale in three repeated waves of cross-sectional surveys with Rasch models. We estimated the monthly prevalence of food insecurity in the general population and in households with and without children and compared them with a national 2018 survey. We tested concurrent validity by testing associations of food insecurity with socio-economic status …

Direct And Indirect Effect Of 10 Valent Pneumococcal Vaccine On Nasopharyngeal Carriage In Children Under 2 Years Of Age In Matiari, Pakistan, Muhammad Imran Nisar, Sheraz Ahmed, Fyezah Jehan, Shahira Shahid, Sadia Shakoor, Furqan Kabir, Aneeta Hotwani, Sahrish Munir, Sajid Muhammad, Farah Khalid, Syed Asad Ali, Anita K. M. Zaidi, Najeeha Talat Iqbal

Department of Paediatrics and Child Health

Background: Pakistan introduced Ten-valent pneumococcal-conjugate-vaccine PCV10 in 2012 as a 3 + 0 schedule without catch-up.
Methods: Children <2 years old in Matiari, Sindh provided nasopharyngeal swabs between 2014 and 2018, which were cultured for pneumococcus and serotyped through multiplex PCR at the Aga Khan University Hospital. Carriage rates over time for Vaccine-Type (VT) and Non-VT (NVT) serotypes were used to estimate direct, indirect, total and overall effects of vaccination. Regression analysis was used to determine factors associated with VT carriage.
Results: Pneumococcus was detected in 2370/3140 (75%). VT carriage decreased overall, 16.1-9.6% (p-trend <0.001); vaccinated (all 3 doses of PCV10 received) 11.3-8.1% (p-trend 0.031) and unvaccinated (no PCV10 dose received) 17.4-10.3% (p-trend 0.003) with a decline in serotypes 6B, 9V/9A and 19F. Immunization increased from 41.0% to 68.4% (p-trend 0.001). Direct effect of vaccine was 32.8% (95% CI 14.7-47.0%) and indirect effect 44.6%(95% CI 40.6-48.6%). Factors associated with decreased VT colonization were education 1-5 years (aOR 0.7, 95%CI 0.6-1.0), history of difficulty breathing (aOR 0.7, 95%CI 0.5-1.0), exposure to smoke (aOR 0.8, 95% CI 0.6-1.0), child fully immunized (aOR 0.7, 95%CI 0.5-1.0) and enrolled in 3rd (aOR 0.6, 95%CI 0.4-0.8) and 4th (aOR 0.6, 95%CI 0.5-0.9) year of the study whereas history of runny nose (aOR 1.5, 95% CI 1.2-1.9) was positively associated.
Conclusions: Decrease in VT pneumococcal carriage in vaccinated and unvaccinated children indicates herd immunity. Sustained increase in vaccine coverage and close long-term surveillance is warranted.

Adios 2020 And Welcome 2021, Srinivasan Ragothaman

Creative Work

This is a short ballad about current health policy and practice regarding the Coronavirus. As vaccines are being administered, this poem points out that light is at the end of the tunnel. At the same time it urges caution, vigilance, masking and common sense. It praises science and scientists. It also calls for unity, cooperation and healing!