The APB on HPV with Christiane Farkouh-Karoleski, MD and Eleonora Teplinsky, MD
From the Show: Valley Health System - NJ
Summary:
Air Date: 6/2/22
Duration: 10 Minutes
Who knew that a vaccine can prevent cancer just like a vaccine prevent the flu? Human Papiloma Virus (HPV) is a common virus you can get through skin-to-skin contact. It is also the most common sexually transmitted infection (STI). This conversation is about body parts, physical encounters, warts, your immune system, and cancer. We'll talk about how getting vaccinated against HPV will decrease your risk for future cancers.
Transcription:
Scott Webb: HPV is common, but it's also preventable thanks to a vaccine. And joining me today to discuss the prevalence of HPV, the forms of cancer that can result from undiagnosed and untreated HPV and the importance of the HPV vaccine for our kids are Dr. Christiane Farkouh, she's the Director of Pediatrics for the Valley Hospital and Associate Director of Neonatology for the Valley Medical Group; and Dr. Eleonora Teplinsky, she's the Head of Breast Medical Oncology at Valley Mount Sinai Comprehensive Cancer Care.
Welcome to Conversations Like No Other, presented by Valley Health System in Ridgewood, New Jersey. Our podcast goes beyond broad everyday topics to discuss very real and very specific subjects impacting men, women, and children. We think you'll enjoy our fresh take. Thanks for listening. I'm Scott Webb.
Doctors, it's so great to have your time. We're going to have a really interesting conversation today. We're going to talk about HPV and cancer and vaccines and so on. So we've got a lot to get to, and I really do appreciate your time. Dr. Farkouh, I'm going to start with you. What are the symptoms of HPV?
Dr. Christiane Farkouh: Really for many, there may not even be symptoms. But probably commonly what people kind of associate with HPV are warts. So we know them as genital warts, but they can also be on any other part of the body as well.
Scott Webb: Yeah, even for a lay person like me, that's the one thing I do know is about warts. And Dr. Teplinsky, what tests can we take, right, if we suspect that we have HPV or we speak with our provider? And how is it diagnosed?
Dr. Eleonora Teplinsky: So really, diagnosing HPV is limited to testing cervical specimen. So that's going to be done through a Pap smear as well as a dedicated HPV test. But again, that's going to be done at your exam with your gynecologist. HPV also increases our risk for different types of head and neck cancers and so if someone is suspected of having a head and neck cancer, then, you know, we do a biopsy and you can test HPV on that biopsy specimen.
Scott Webb: Yeah. And sticking with you, when we think about treatment for HPV, what are the treatment options? Is it curable? And I think maybe the million-dollar question for most people would be is it preventable?
Dr. Eleonora Teplinsky: Most of HPV will kind of go away on its own. A crazy statistic is that by the age of 50, four out of five, women will be diagnosed with HPV. And many of them may not have even known it, because our body can really clear the virus on its own. However, in about 10% of women with HPV, they develop kind of a long-lasting HPV infection that then increases our risk of developing cervical cancer or other cancers associated with the HPV virus.
Scott Webb: Did I hear that right? Did you say four out of five?
Dr. Eleonora Teplinsky: Yeah. It's a very, very high statistic.
Scott Webb: Yeah, it really is. I'm wondering, Dr. Farkouh, what your thoughts on that are? You know, it's sort of alarming when you hear those types of numbers, those odds, four out of five. What are your thoughts on that?
Dr. Christiane Farkouh: It is alarming and it is, you know, quite shocking really when you think about this. But to keep in mind that, you know, HPV is quite common, and there are many types. There's over a hundred types of HPV types that are out there. Not all are associated with cancer, though. That's, I think, why we don't hear so much of this. But it is quite prevalent and it is out there and easily transmissible through sexual contact and skin-to-skin contact.
Scott Webb: Yeah, it is easily transmissible. So let's stay there. Can someone still get HPV even if there is no vaginal penetration? And what about oral and anal sex?
Dr. Christiane Farkouh: You absolutely can get HPV if there is no vaginal penetration. And oral and anal sex have both also been kind of risk factors for transmitting HPV. And that's why it kind of relates to not just cervical cancer, but we're also seeing anal cancers, vaginal cancers, vulvar cancers, penile cancers, and throat cancers that are associated with HPV as well. But the most common is cervical cancer.
Scott Webb: Right, that's the most common. And we definitely want people to know that there are other types of cancers and some of these numbers, four out of five women, over, you know, a hundred types of HPV. Some really great information, somewhat alarming information, but it's so great to have experts on to kind of talk through this.
So, Dr. Teplinsky, I think I know the answer to this, but if someone has HPV, will they sort of automatically get cancer if they have warts? Does that mean they're going to get cancer? Kind of have you take on the cancer question, if you will. What's the connection between HPV and cancer?
Dr. Eleonora Teplinsky: What happens is, as I mentioned, that in majority of cases, our body is able to clear HPV infection on its own. But in a few patients, you know, the body cannot clear HPV. And what happens is the virus itself actually starts turning our normal cells into abnormal cancerous cells. And that really is the link between HPV and cancer. We very often think of HPV with cervical cancer and essentially almost all cervical cancer is caused by the HPV virus, which is why when we think about the vaccine, it really can be prevented with the administration of the HPV vaccine. However, HPV is not just linked with cervical cancer. It is also associated with cancer of the vulva, the vagina, the penis, the anus, and the oropharynx, which is really that head and neck area.
Scott Webb: Yeah. So I want to drill down just a little bit more, you know, because I think that, you know, maybe one of the issues that folks might have with HPV is that there's so many types and some can lead to cancer and some won't. And so, what would be your best advice? I am guessing it's to speak with a provider, see a specialist and so on. But maybe you can kind of take us through this, how maybe something that seems maybe innocuous initially can lead to these, you know, severe consequences and what should we do about it.
Dr. Eleonora Teplinsky: Well, I think that partly we don't actually know which people are going to be able to clear the HPV virus and which are not. And so the most important thing is really to make sure that you are seeing your gynecologist as recommended for regular pelvic exams and Pap smears and HPV testing. You know, very often, people kind of fall off the screening schedule. We've seen this a lot with the COVID-19 pandemic. And so it's really, really important to be getting monitored to make sure that that HPV infection isn't now turning into abnormal cells, something that we can detect on the Pap smear.
Scott Webb: Yeah, I see what you mean and glad you brought up COVID, because we're going to talk about specifically this vaccine, but vaccines in general. You know, there's been a lot of information, misinformation, a lot of folks delaying care, delaying their regular visits and so on. And we know with most things in medicine, but things that can affect us as patients, you know, cancer is something we want prevented if we can, but obviously diagnose it and treat it as early as possible. So, Dr. Farkouh, let's talk a little bit about vaccines and talk about this vaccine in particular for HPV. How does it work?
Dr. Christiane Farkouh: The HPV vaccines work like other vaccines against viral infection in stimulating the body to produce antibodies, that when the body in the future encounters HPV, can bind to that virus and then prevent it from infecting cells.
Scott Webb: Yeah. And how effective is it at preventing? Are we talking about a hundred percent or is that just wishful thinking?
Dr. Christiane Farkouh: That's a good question. It is very effective, because the kind of measurable outcome is cervical cancers or kind of abnormal cells or abnormal tests that may signify a risk for cervical cancer. You may not really see the results of, you know, the vaccine for years, but from countries where this has been in place and we are seeing here as well a reduction in signs of early cancer, the reduction in the incidence of genital warts, as well as a decreased need for invasive procedures, like the Pap or biopsies or colposcopies to look for cervical cancer.
Dr. Eleonora Teplinsky: So if I can add to that, we know that, you know, since 2006, when HPV vaccines were first used in the United States, we've seen, you know, a significant decline in infections with HPV types that cause most of our cancers and genital warts, so that rate of infection has actually dropped by 88% among teen girls. And then, among young adult women, it has dropped by 81%. And then finally, the last statistic, which I think is really impressive that when you look at among vaccinated women, the percentage of cervical pre-cancers that's caused by the HPV types most often linked to cervical cancer has dropped by 40%. And those are statistics from the CDC.
Scott Webb: Yeah, those are really encouraging numbers. I love hearing that. And Dr. Farkouh, you know, it sounded like you were saying basically that you may be vaccinated now, but you might not find out the real benefits of that until later. But I'm sure a lot of us, and I'm a parent myself, I have a 19-year-old and, you know, if we don't believe that our child is having sex, do we need to get them vaccinated? Is that something that should wait until we're sure or they're sure? Or is it better to just be prepared?
Dr. Christiane Farkouh: You know, that's a great question. And I think many, many parents have that same kind of question. I'm a parent of two teenagers myself, and I think I even asked my kid's pediatrician the same question. I think the reality is we want to get this to our kids as early as possible and during the recommended period of time. And for girls, that could be as early as nine, but certainly between nine and fourteen, and then really up until age 45. But the earlier it is, the more effective it will be at preventing the virus from even getting hold in the body.
Scott Webb: You know, and I'm not sure which one of you wants to take this one, but when we think about boys and not having a cervix and cervical cancers seemingly being most serious and the most worrisome as sort of an outcome or result of having HPV, do they really need to be vaccinated? I understand the girls, of course. But I'm sure a lot of parents would ask the same question, "Well, he's a boy. He doesn't have a cervix. He's not going to get cervical cancer." Maybe Dr. Teplinsky, you can take this one.
Dr. Eleonora Teplinsky: Sure. I think that's a very common question and, you know, I'll actually get it from my patients, you know, asking you about their children. But the bottom line is that we're again not just talking about cervical cancer here, we're talking about other cancers that are just as important. The oropharynx, the anus, the penile cancers, all of those are linked with HPV as well. And so we want to make sure that we are reducing the risk of those cancers. But also if we vaccinate boys and young adult men, then we are decreasing the risk of transmission of HPV. And so that's contributing to decreasing the rates of HPV and subsequently cancer on a whole in the population.
Scott Webb: Yeah. That's exactly what I was thinking. I was like, you know, 'Yeah, sure, they don't have a cervix, but there's other types of cancer of course," and just sort of being able to stop the spread of HPV and just get everybody vaccinated. And we've had obviously a lot of conversations about the effectiveness of vaccines over the last couple of years and definitely the case with HPV. So this has been some great information today. As we wrap up here, Dr. Farkouh, what would be your final thoughts and takeaways on HPV, the role of vaccines in preventing it and so on.
Dr. Christiane Farkouh: I think that HPV vaccines are really just amazing in the sense that here we have something that protects against the virus that we know puts people at risk for potentially developing cancers later in life. You know, cancer is not something that anyone really should ever have to experience. And here we have something that can prevent it. And as a pediatrician, to realize we could start early with our children as young as adolescence and protect them for their future for decades to come, I think, that's really a win for everybody and something that I would really encourage and advocate, not just for my own children, but for our children all across the world.
Scott Webb: Yeah, I couldn't agree more, having been in the room when my children have received those vaccines. And Dr. Teplinsky, I'm going to give you the final word here. I don't want to put any doctors out of business, of course, but if we can prevent the spread of HIV, prevent cervical cancer and other types of cancer related to it, that's a good thing for all of us. Unfortunately, there will always be other cancers for oncologists to have to treat and deal with. But what are your final thoughts and takeaways as we think about HPV, preventing it, cancer and everything else?
Dr. Eleonora Teplinsky: So, first of all, believe me, I'd love to be out of business, because we got rid of all the cancer. That would be great.
Scott Webb: I hear you.
Dr. Eleonora Teplinsky: But, you know, what I'll add to all of this is that, you know, we didn't touch too much on the vaccine safety and it has been proven in numerous studies to be safe. And there is a lot of misinformation out there right now, you know, especially recently with the COVID-19 vaccine. And there's just a, you know, prevalence in misinformation and even a disinformation. And what I would say is that, you know, for parents listening who are unsure, you know, make sure that you have a trusted healthcare team that you can go to with your concerns, because we do see a lot online that sometimes makes us question things. And so making sure that you have a pediatrician, a gynecologist, trusted healthcare professionals, that you can bring your concerns and really have an open and honest conversation with before you make a decision for your child is really important.
Scott Webb: Yeah, it definitely is. And that's a perfect way to end. You know, what else would we want from a vaccine, right? Other than to be safe and effective and maybe put some oncologists out of business, you know, in the process. Nothing personal. So this has been really great. A lot of information, really educational. I'm sure listeners will really appreciate this. So thank you both, and you both stay well
Dr. Christiane Farkouh: Thank you.
Dr. Eleonora Teplinsky: Thank you.
Scott Webb: And for more information or to make an appointment, please reach out to your pediatrician. And for more information about today's topic, please email This email address is being protected from spambots. You need JavaScript enabled to view it. . And if you found this podcast helpful, please do share it on your social media and maybe with some family and friends.
And thanks for listening to Conversations Like No Other, presented by Valley Health System in Ridgewood, New Jersey. I'm Scott Webb. Stay well.
Scott Webb: HPV is common, but it's also preventable thanks to a vaccine. And joining me today to discuss the prevalence of HPV, the forms of cancer that can result from undiagnosed and untreated HPV and the importance of the HPV vaccine for our kids are Dr. Christiane Farkouh, she's the Director of Pediatrics for the Valley Hospital and Associate Director of Neonatology for the Valley Medical Group; and Dr. Eleonora Teplinsky, she's the Head of Breast Medical Oncology at Valley Mount Sinai Comprehensive Cancer Care.
Welcome to Conversations Like No Other, presented by Valley Health System in Ridgewood, New Jersey. Our podcast goes beyond broad everyday topics to discuss very real and very specific subjects impacting men, women, and children. We think you'll enjoy our fresh take. Thanks for listening. I'm Scott Webb.
Doctors, it's so great to have your time. We're going to have a really interesting conversation today. We're going to talk about HPV and cancer and vaccines and so on. So we've got a lot to get to, and I really do appreciate your time. Dr. Farkouh, I'm going to start with you. What are the symptoms of HPV?
Dr. Christiane Farkouh: Really for many, there may not even be symptoms. But probably commonly what people kind of associate with HPV are warts. So we know them as genital warts, but they can also be on any other part of the body as well.
Scott Webb: Yeah, even for a lay person like me, that's the one thing I do know is about warts. And Dr. Teplinsky, what tests can we take, right, if we suspect that we have HPV or we speak with our provider? And how is it diagnosed?
Dr. Eleonora Teplinsky: So really, diagnosing HPV is limited to testing cervical specimen. So that's going to be done through a Pap smear as well as a dedicated HPV test. But again, that's going to be done at your exam with your gynecologist. HPV also increases our risk for different types of head and neck cancers and so if someone is suspected of having a head and neck cancer, then, you know, we do a biopsy and you can test HPV on that biopsy specimen.
Scott Webb: Yeah. And sticking with you, when we think about treatment for HPV, what are the treatment options? Is it curable? And I think maybe the million-dollar question for most people would be is it preventable?
Dr. Eleonora Teplinsky: Most of HPV will kind of go away on its own. A crazy statistic is that by the age of 50, four out of five, women will be diagnosed with HPV. And many of them may not have even known it, because our body can really clear the virus on its own. However, in about 10% of women with HPV, they develop kind of a long-lasting HPV infection that then increases our risk of developing cervical cancer or other cancers associated with the HPV virus.
Scott Webb: Did I hear that right? Did you say four out of five?
Dr. Eleonora Teplinsky: Yeah. It's a very, very high statistic.
Scott Webb: Yeah, it really is. I'm wondering, Dr. Farkouh, what your thoughts on that are? You know, it's sort of alarming when you hear those types of numbers, those odds, four out of five. What are your thoughts on that?
Dr. Christiane Farkouh: It is alarming and it is, you know, quite shocking really when you think about this. But to keep in mind that, you know, HPV is quite common, and there are many types. There's over a hundred types of HPV types that are out there. Not all are associated with cancer, though. That's, I think, why we don't hear so much of this. But it is quite prevalent and it is out there and easily transmissible through sexual contact and skin-to-skin contact.
Scott Webb: Yeah, it is easily transmissible. So let's stay there. Can someone still get HPV even if there is no vaginal penetration? And what about oral and anal sex?
Dr. Christiane Farkouh: You absolutely can get HPV if there is no vaginal penetration. And oral and anal sex have both also been kind of risk factors for transmitting HPV. And that's why it kind of relates to not just cervical cancer, but we're also seeing anal cancers, vaginal cancers, vulvar cancers, penile cancers, and throat cancers that are associated with HPV as well. But the most common is cervical cancer.
Scott Webb: Right, that's the most common. And we definitely want people to know that there are other types of cancers and some of these numbers, four out of five women, over, you know, a hundred types of HPV. Some really great information, somewhat alarming information, but it's so great to have experts on to kind of talk through this.
So, Dr. Teplinsky, I think I know the answer to this, but if someone has HPV, will they sort of automatically get cancer if they have warts? Does that mean they're going to get cancer? Kind of have you take on the cancer question, if you will. What's the connection between HPV and cancer?
Dr. Eleonora Teplinsky: What happens is, as I mentioned, that in majority of cases, our body is able to clear HPV infection on its own. But in a few patients, you know, the body cannot clear HPV. And what happens is the virus itself actually starts turning our normal cells into abnormal cancerous cells. And that really is the link between HPV and cancer. We very often think of HPV with cervical cancer and essentially almost all cervical cancer is caused by the HPV virus, which is why when we think about the vaccine, it really can be prevented with the administration of the HPV vaccine. However, HPV is not just linked with cervical cancer. It is also associated with cancer of the vulva, the vagina, the penis, the anus, and the oropharynx, which is really that head and neck area.
Scott Webb: Yeah. So I want to drill down just a little bit more, you know, because I think that, you know, maybe one of the issues that folks might have with HPV is that there's so many types and some can lead to cancer and some won't. And so, what would be your best advice? I am guessing it's to speak with a provider, see a specialist and so on. But maybe you can kind of take us through this, how maybe something that seems maybe innocuous initially can lead to these, you know, severe consequences and what should we do about it.
Dr. Eleonora Teplinsky: Well, I think that partly we don't actually know which people are going to be able to clear the HPV virus and which are not. And so the most important thing is really to make sure that you are seeing your gynecologist as recommended for regular pelvic exams and Pap smears and HPV testing. You know, very often, people kind of fall off the screening schedule. We've seen this a lot with the COVID-19 pandemic. And so it's really, really important to be getting monitored to make sure that that HPV infection isn't now turning into abnormal cells, something that we can detect on the Pap smear.
Scott Webb: Yeah, I see what you mean and glad you brought up COVID, because we're going to talk about specifically this vaccine, but vaccines in general. You know, there's been a lot of information, misinformation, a lot of folks delaying care, delaying their regular visits and so on. And we know with most things in medicine, but things that can affect us as patients, you know, cancer is something we want prevented if we can, but obviously diagnose it and treat it as early as possible. So, Dr. Farkouh, let's talk a little bit about vaccines and talk about this vaccine in particular for HPV. How does it work?
Dr. Christiane Farkouh: The HPV vaccines work like other vaccines against viral infection in stimulating the body to produce antibodies, that when the body in the future encounters HPV, can bind to that virus and then prevent it from infecting cells.
Scott Webb: Yeah. And how effective is it at preventing? Are we talking about a hundred percent or is that just wishful thinking?
Dr. Christiane Farkouh: That's a good question. It is very effective, because the kind of measurable outcome is cervical cancers or kind of abnormal cells or abnormal tests that may signify a risk for cervical cancer. You may not really see the results of, you know, the vaccine for years, but from countries where this has been in place and we are seeing here as well a reduction in signs of early cancer, the reduction in the incidence of genital warts, as well as a decreased need for invasive procedures, like the Pap or biopsies or colposcopies to look for cervical cancer.
Dr. Eleonora Teplinsky: So if I can add to that, we know that, you know, since 2006, when HPV vaccines were first used in the United States, we've seen, you know, a significant decline in infections with HPV types that cause most of our cancers and genital warts, so that rate of infection has actually dropped by 88% among teen girls. And then, among young adult women, it has dropped by 81%. And then finally, the last statistic, which I think is really impressive that when you look at among vaccinated women, the percentage of cervical pre-cancers that's caused by the HPV types most often linked to cervical cancer has dropped by 40%. And those are statistics from the CDC.
Scott Webb: Yeah, those are really encouraging numbers. I love hearing that. And Dr. Farkouh, you know, it sounded like you were saying basically that you may be vaccinated now, but you might not find out the real benefits of that until later. But I'm sure a lot of us, and I'm a parent myself, I have a 19-year-old and, you know, if we don't believe that our child is having sex, do we need to get them vaccinated? Is that something that should wait until we're sure or they're sure? Or is it better to just be prepared?
Dr. Christiane Farkouh: You know, that's a great question. And I think many, many parents have that same kind of question. I'm a parent of two teenagers myself, and I think I even asked my kid's pediatrician the same question. I think the reality is we want to get this to our kids as early as possible and during the recommended period of time. And for girls, that could be as early as nine, but certainly between nine and fourteen, and then really up until age 45. But the earlier it is, the more effective it will be at preventing the virus from even getting hold in the body.
Scott Webb: You know, and I'm not sure which one of you wants to take this one, but when we think about boys and not having a cervix and cervical cancers seemingly being most serious and the most worrisome as sort of an outcome or result of having HPV, do they really need to be vaccinated? I understand the girls, of course. But I'm sure a lot of parents would ask the same question, "Well, he's a boy. He doesn't have a cervix. He's not going to get cervical cancer." Maybe Dr. Teplinsky, you can take this one.
Dr. Eleonora Teplinsky: Sure. I think that's a very common question and, you know, I'll actually get it from my patients, you know, asking you about their children. But the bottom line is that we're again not just talking about cervical cancer here, we're talking about other cancers that are just as important. The oropharynx, the anus, the penile cancers, all of those are linked with HPV as well. And so we want to make sure that we are reducing the risk of those cancers. But also if we vaccinate boys and young adult men, then we are decreasing the risk of transmission of HPV. And so that's contributing to decreasing the rates of HPV and subsequently cancer on a whole in the population.
Scott Webb: Yeah. That's exactly what I was thinking. I was like, you know, 'Yeah, sure, they don't have a cervix, but there's other types of cancer of course," and just sort of being able to stop the spread of HPV and just get everybody vaccinated. And we've had obviously a lot of conversations about the effectiveness of vaccines over the last couple of years and definitely the case with HPV. So this has been some great information today. As we wrap up here, Dr. Farkouh, what would be your final thoughts and takeaways on HPV, the role of vaccines in preventing it and so on.
Dr. Christiane Farkouh: I think that HPV vaccines are really just amazing in the sense that here we have something that protects against the virus that we know puts people at risk for potentially developing cancers later in life. You know, cancer is not something that anyone really should ever have to experience. And here we have something that can prevent it. And as a pediatrician, to realize we could start early with our children as young as adolescence and protect them for their future for decades to come, I think, that's really a win for everybody and something that I would really encourage and advocate, not just for my own children, but for our children all across the world.
Scott Webb: Yeah, I couldn't agree more, having been in the room when my children have received those vaccines. And Dr. Teplinsky, I'm going to give you the final word here. I don't want to put any doctors out of business, of course, but if we can prevent the spread of HIV, prevent cervical cancer and other types of cancer related to it, that's a good thing for all of us. Unfortunately, there will always be other cancers for oncologists to have to treat and deal with. But what are your final thoughts and takeaways as we think about HPV, preventing it, cancer and everything else?
Dr. Eleonora Teplinsky: So, first of all, believe me, I'd love to be out of business, because we got rid of all the cancer. That would be great.
Scott Webb: I hear you.
Dr. Eleonora Teplinsky: But, you know, what I'll add to all of this is that, you know, we didn't touch too much on the vaccine safety and it has been proven in numerous studies to be safe. And there is a lot of misinformation out there right now, you know, especially recently with the COVID-19 vaccine. And there's just a, you know, prevalence in misinformation and even a disinformation. And what I would say is that, you know, for parents listening who are unsure, you know, make sure that you have a trusted healthcare team that you can go to with your concerns, because we do see a lot online that sometimes makes us question things. And so making sure that you have a pediatrician, a gynecologist, trusted healthcare professionals, that you can bring your concerns and really have an open and honest conversation with before you make a decision for your child is really important.
Scott Webb: Yeah, it definitely is. And that's a perfect way to end. You know, what else would we want from a vaccine, right? Other than to be safe and effective and maybe put some oncologists out of business, you know, in the process. Nothing personal. So this has been really great. A lot of information, really educational. I'm sure listeners will really appreciate this. So thank you both, and you both stay well
Dr. Christiane Farkouh: Thank you.
Dr. Eleonora Teplinsky: Thank you.
Scott Webb: And for more information or to make an appointment, please reach out to your pediatrician. And for more information about today's topic, please email This email address is being protected from spambots. You need JavaScript enabled to view it. . And if you found this podcast helpful, please do share it on your social media and maybe with some family and friends.
And thanks for listening to Conversations Like No Other, presented by Valley Health System in Ridgewood, New Jersey. I'm Scott Webb. Stay well.